Hematopathology Entrustable Professional Activity 1: Guide selection of diagnostic tests and triage and allocate specimens for ancillary studies.

Skills:

• Ordering ancillary workup necessary for diagnosis and management for lymphoid and myeloid neoplasia and non-neoplastic causes of adenopathy and blood count abnormalities
• Stewardship of limited tissue
• Providing test utilization consultation, including intervention in inappropriate test ordering, and identifying potential areas of test overutilization

Knowledge Areas:

• Pathogenesis, clinical correlation and prognostic significance; diagnostic and relevant clinical practice guidelines for hematolymphoid neoplasia, congenital, infectious, and other specific nonneoplastic entities
• Flow cytometry immunophenotyping panels, immunohistochemical stains, cytogenetic analysis, including karyotyping and fluorescence in situ hybridization (FISH) and molecular ancillary testing

Example Scenarios:

• Determine appropriate immunohistochemical stains to order when limited material available. Determine correct flow cytometry panel to perform when limited material available.
• Triage cerebrospinal fluid or fine needle aspiration/core biopsy material to appropriate diagnostic assays, including morphology (cytologic or cell blocks), flow cytometry immunophenotyping, cytogenetic and molecular analysis.
• Discuss inappropriate flow cytometry immunophenotyping orders with ordering provider.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1 and 4: Interdisciplinary Consultation, Specimen Handling and Triaging
• Medical Knowledge 5 and 6: Selection of Molecular and Cytogenetics Testing and Interpretation of Reports, Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 3 and 5: Physician Role in Health Care System, Utilization
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship, Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 2 and 3: Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 2: Identify and communicate critical values and clinically urgent results

Skills:

• Rendering clinically urgent diagnoses triggered by microscopic or ancillary test review of any specimen type
• Communication of critical values, including interdisciplinary communication
• Documentation of clinically urgent communication

Knowledge Areas:

• Disease mechanisms and clinical course of acute leukemias, consumptive coagulopathies, and systemic infections; morphologic/immunophenotypic recognition of these entities as applicable, and confirmatory testing for these entities as applicable
• Concept and rationale of critical laboratory results
• Principles and techniques of transition of care/handoffs

Example Scenarios:

• Identify and communicate acute promyelocytic leukemia, thrombotic thrombocytopenic purpura, hemophagocytic lymphohistiocytosis, blasts in cerebrospinal fluid, organisms in cerebrospinal fluid.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1: Interdisciplinary Consultation
• Medical Knowledge 6: Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 1 and 2: Patient Safety and Quality Improvement (levels 1-3), Systems Navigation for Patient-Centered Care
• Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 1, 2 and 3: Patient and Family-Centered Communication, Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 3: Complete workup and diagnostic reporting of a simple hematolymphoid diagnosis

Skills:

• Ordering appropriate initial and, if indicated, next round ancillary studies based on clinical setting and differential diagnosis. Integrating ancillary studies including immunohistochemistry, flow cytometry immunophenotyping, cytogenetics, fluorescence in situ hybridization, targeted molecular studies
• Providing a preliminary report to the patient-facing team
• Writing succinct and complete final report including any indicated synoptic reporting

Knowledge Areas:

• Acute leukemias, classic myeloproliferative neoplasms, B cell lymphomas, involving bone marrow aspirate and core, lymph node, extranodal tissue, peripheral blood and body fluids
• Indications for and interpretation of immunohistochemistry, flow cytometry immunophenotyping, cytogenetics, fluorescence in situ hybridization, and targeted molecular studies

Example Scenarios:

• Order and interpret lymphoma staging studies with appropriate flow cytometry immunophenotyping, immunohistochemistry, and fluorescence in situ hybridization studies as indicated. Initial diagnosis of small B-cell lymphomas. Work up large B-cell lymphoma and classic Hodgkin lymphoma.
• Provide verbal and/or written preliminary reports to colleagues and to the patient-facing team, including discussion of level of uncertainty and significance of pending studies.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1 and 2 (levels 1-3): Interdisciplinary Consultation, Reporting
• Medical Knowledge 4, 5 and 6(levels 1-3): Morphologic Interpretation and Diagnosis, Selection of Molecular and Cytogenetics Testing and Interpretation of Reports, Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 3 and 5: Physician Role in Health Care System, Utilization (levels 1-3)
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship (levels 1-2), Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 2 and 3: Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 4: Complete workup and diagnostic reporting of a complex or rare hematolymphoid diagnosis.

Skills:

• Ordering appropriate initial and, if indicated, next round ancillary studies based on clinical setting and differential diagnosis. Integrating ancillary studies including immunohistochemistry, flow cytometry immunophenotyping, cytogenetics, fluorescence in situ hybridization, targeted molecular studies
• Providing a preliminary report to the patient-facing team
• Writing succinct and complete final report including any indicated synoptic reporting
• Integrating relevant literature/references and/or expert consultation
• Recognizing areas of diagnostic challenge where a definitive diagnosis cannot be reached with the given material and communicating effectively to the clinician

Knowledge Areas:

• Pathogenesis, clinical correlation and prognostic significance; diagnostic and relevant clinical practice guidelines for hematolymphoid neoplasia, congenital, infectious, and other specific nonneoplastic entities
• Flow cytometry immunophenotyping panels, immunohistochemical stains, cytogenetic analysis, including karyotyping and fluorescence in situ hybridization and molecular ancillary testing
• Indications for and interpretation of next generation sequencing panel testing, fluorescence in situ hybridization testing, and esoteric/sendout testing; techniques and technical limitations of ancillary studies

Example Scenarios:

• Perform complete diagnostic workup of myelodysplastic syndromes, myelodysplastic/myeloproliferative neoplasms, T/NK cell lymphomas, gray zone lymphomas, histiocytic and dendritic cell neoplasms and nodular lymphocyte predominant Hodgkin lymphoma.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1 and 2 (levels 3-5): Interdisciplinary Consultation, Reporting
• Medical Knowledge 4, 5 and 6 (levels 3-5): Morphologic Interpretation and Diagnosis, Selection of Molecular and Cytogenetics Testing and Interpretation of Reports, Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 3 and 5: Physician Role in Health Care System, Utilization (levels 3-5)
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship (levels 3-5), Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 2 and 3: Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 5: Select a flow immunophenotyping panel and compose an interpretive report.

Skills:

• Design/select appropriate flow cytometric initial and follow-up immunophenotyping panels based on clinical and/or morphologic information
• Gate and analyze raw flow immunophenotyping data
• Recognize common technical and gating errors in flow cytometry and know how to avoid them
• Accurately describe and interpret a flow cytometric immunophenotype
• Incorporate flow cytometry data into clinical and morphologic context

Knowledge Areas:

• Flow cytometry techniques, including specimen processing and analysis, as well as pitfalls in analysis and interpretation

Example Scenarios:

• Design/pick an appropriate flow cytometry panel for a low cellularity cerebrospinal fluid specimen in a patient with known lymphoma history.
• Recognize typical and atypical immunophenotypic patterns for chronic lymphocytic leukemia.
• Distinguish between hematogones (normal B-lineage precursors) and leukemic B-lymphoblasts.
• Assign lineage to an acute leukemia. Recognize reactive and neoplastic T antigen abnormalities.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1 and 2: Interdisciplinary Consultation, Reporting
• Medical Knowledge 3 and 6: Interpretation of Flow Cytometry, Clinical Reasoning in Hematopathology and Hematology
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship, Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 2 and 3: Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 6: Interpret hematology/coagulation tests and provide consultation.

Skills:

• Answer clinical questions regarding test selection (pre-analytic) and patient results (post-analytic)
• Provide interpretative report for hemoglobin analysis and other tests (e.g., hypercoagulation panel)
• Automated hematology analyzers, coagulation testing, red cell disorder testing, hemoglobin analyses

Knowledge Areas:

• Algorithmic and/or panel testing approaches for evaluation of bleeding disorders and hypercoagulable states
• Knowledge of congenital and acquired hemostatic disorders and their management. 
• Categories of anticoagulant therapies, and the indications and laboratory methods of monitoring them
• Clinical significance and methods of diagnosing common hemoglobinopathies and thalassemias

Example Scenarios:

• Provide interpretation of hemoglobin electrophoresis analysis in the context of peripheral blood findings and clinical scenario.
• A diagnostic approach to the evaluation of hemolytic anemias, congenital or acquired. Work up von Willebrand disease, factor deficiencies, and inhibitors.
• Guide and interpret testing for lupus anticoagulant testing, protein C or S deficiency. Consult on management of heparin, direct thrombin inhibitors, anti-Xa inhibitors.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1 and 2: Interdisciplinary Consultation, Reporting
• Medical Knowledge 1,2 and 6: Interpretation of Hematology and Coagulation Testing, Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 3 and 5: Physician Role in Health Care System, Utilization
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship, Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 2 and 3: Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 7: Provide guidance on testing parameters and limitations for routine hematology, ancillary, or coagulation testing.

Skills:

• Provide guidance on appropriate testing based on the clinical question and specimen and test characteristics
• Troubleshoot discrepant/unusual/unreportable results and provide recommendations to laboratory staff and/or ordering provider
• Develop laboratory protocols/procedures for commonly occurring test issues

Knowledge Areas:

• Appropriate indications, technical requirements and techniques for routine and special hematology testing, special testing, flow cytometry immunophenotyping, cytogenetics, fluorescence in situ hybridization, immunohistochemistry, single and panel molecular testing, coagulation studies

Example Scenarios:

• Troubleshoot and provide guidance on effects of interfering substances (eg elevated bilirubin, hyperlipidemia, cryoglobulins, anticoagulation medication) on automated hematology and coagulation testing.
• Evaluate automated hematology analyzer flagging criteria, manual differential/pathologist review criteria. 
• Detect and resolve platelet clumping (pseudo-thrombocytopenia).

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1 and 4: Interdisciplinary Consultation, Specimen Handling and Triaging
• Medical Knowledge 5 and 6: Selection of Molecular and Cytogenetics Testing and Interpretation of Reports, Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 3 and 5: Physician Role in Health Care System, Utilization
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship, Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 2 and 3: Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 8: Present at interdisciplinary conferences and effectively communicate in a consultative role.

Skills:

• Interdisciplinary communication and presentation skills
• Able to state and support degree of confidence of diagnosis, and specify additional studies that could clarify the diagnosis

Knowledge Areas:

• Pathologic features that inform staging, prognostication or prediction of treatment response
• Ongoing clinical trials at institution that may require additional ancillary studies or reporting of specific features

Example Scenarios:

• Actively participate in multidisciplinary tumor boards.
• Present at morbidity and mortality conferences.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1: Interdisciplinary Consultation
• Medical Knowledge 6: Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 2: Systems Navigation for Patient-Centered Care
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship, Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 1, 2 and 3: Patient and Family-Centered Communication, Interprofessional and Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 9: Maintain and improve quality of care on the hematopathology service and in the hematology laboratory.

Skills:

• Identify and evaluate potential safety/quality issues in the hematopathology service/hematology laboratory and propose changes as needed
• Maintain appropriate and up-to-date hematology laboratory testing menus, flow cytometry panels, immunohistochemical stains, and fluorescence in situ hybridization and molecular tests if appropriate (in-house and reference testing)
• Apply root cause analysis and performance improvement tools (Lean, Six Sigma, Plan Do Study Act cycle) to the hematopathology service/hematology laboratory

Knowledge Areas:

• Be aware of applicable hematology, anatomic pathology, and flow cytometry laboratory accreditation requirements
• Stay up to date with new clinically relevant hematology tests and ancillary diagnostic tests

Example Scenarios:

• Monitor sendout test request patterns to prioritize new hematology test or molecular tests for in house validation.
• Identify a recurring slide quality issue, communicate the issue to the appropriate section supervisor, and provide feedback on whether changes to workflow are satisfactory.
• Evaluate, choose, and validate a new hematology laboratory or hematopathology service test, instrument or assay, such as an immunohistochemistry assay or flow cytometry panel.
• Participate in proficiency testing and sign off on protocol changes in the hematology lab, such as coagulation test, flow cytometry, or immunohistochemistry.

ACGME Hematopathology Milestones version 2.0:

• Patient Care 1: Interdisciplinary Consultation
• Medical Knowledge 6: Clinical Reasoning in Hematopathology and Hematology
• Systems Based Practice 1, 2, 3 and 4: Patient Safety and Quality Improvement, Systems Navigation for Patient-Centered Care, Physician Role in Health Care System, Accreditation, Compliance, and Quality
• Practice-Based Learning and Improvement 1 and 2: Evidence-Based Practice and Scholarship, Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 1, 2 and 3: Patient and Family-Centered Communication, Interprofessional/Team Communication, Communication within Health Care Systems

Hematopathology Entrustable Professional Activity 10: Perform bone marrow aspiration and biopsy.

Skills:

• Provide informed consent, administer local anesthetic, identify correct needle placement, sterile technique, identify bone spicules, document procedure.
• Collect and triage material for flow immunophenotyping, cytogenetic studies, and other studies in appropriate media as clinically indicated

Knowledge Areas:

• Components of informed consent, collection requirements for ancillary testing, anatomy/landmarks of the posterior superior iliac crest, appropriate post-procedural care

Example Scenarios:

• Diagnostic bone marrow biopsy and aspirate in a patient with unexplained cytopenias, with material sent for cytogenetics and flow immunophenotyping

ACGME Hematopathology Milestones version 2.0:

• Patient Care 3 and 4: Bone Marrow Aspiration and Biopsy, Specimen Handling and Triaging
• Medical Knowledge 6 (levels 1-3): Clinical Reasoning in Hematopathology and Hematology
• Practice-Based Learning and Improvement 2 Reflective Practice and Commitment to Personal Growth
• Professionalism 1, 2 and 3: Professional Behavior and Ethical Principles, Accountability and Conscientiousness, Self-Awareness and Help-Seeking
• Interpersonal and Communication Skills 1, 2 and 3: Patient- and Family-Centered Communication, Interprofessional and Team Communication, Communication within Health Care Systems

K White, J Qualtieri, EL Courville, RC Beck, B Alobeid, DR Czuchlewski, J Teruya-Feldstein, LA Soma, S Prakash, D Gratzinger. Entrustable Professional Activities in Hematopathology Pathology Fellowship Training: Consensus Design and Proposal. Academic Pathology. January 2021. doi:10.1177/2374289521990823