Pediatric Pathology Supplemental Guide

Supplemental Guide:
Pediatric Pathology

November 2020

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Pediatric Pathology Supplemental Guide

TABLE OF CONTENTS

PEDIATRIC AND PERINATAL PATHOLOGY GROSSING

INTRA-OPERATIVE CONSULTATION
AUTOPSY
REPORTING, INCLUDING SURGICAL PATHOLOGY, CYTOPATHOLOGY, AND AUTOPSY
KNOWLEDGE OF PEDIATRIC AND PERINATAL DISEASES
CLINICAL REASONING
PATIENT SAFETY AND QUALITY IMPROVEMENT (QI)
SYSTEMS NAVIGATION FOR PATIENT-CENTERED CARE
PHYSICIAN ROLE IN HEALTH CARE SYSTEM
ACCREDITATION, COMPLIANCE, AND QUALITY
UTILIZATION
EVIDENCE-BASED PRACTICE AND SCHOLARSHIP
REFLECTIVE PRACTICE AND COMMITMENT TO PERSONAL GROWTH
PROFESSIONAL BEHAVIOR AND ETHICAL PRINCIPLES
ACCOUNTABILITY AND CONSCIENTIOUSNESS
SELF-AWARENESS AND HELP-SEEKING
PATIENT- AND FAMILY-CENTERED COMMUNICATION
INTERPROFESSIONAL AND TEAM COMMUNICATION
COMMUNICATION WITHIN HEALTH CARE SYSTEMS

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Pediatric Pathology Supplemental Guide

Milestones Supplemental Guide

This document provides additional guidance and examples for the Pediatric Pathology Milestones. This is not designed to indicate
any specific requirements for each level, but to provide insight into the thinking of the Milestone Work Group.

Included in this document is the intent of each Milestone and examples of what a Clinical Competency Committee (CCC) might
expect to be observed/assessed at each level. Also included are suggested assessment models and tools for each subcompetency,
references, and other useful information.

Review this guide with the CCC and faculty members. As the program develops a shared mental model of the Milestones, consider
creating an individualized guide (Supplemental Guide Template available) with institution/program-specific examples, assessment
tools used by the program, and curricular components.

Additional tools and references, including the Milestones Guidebook, Clinical Competency Committee Guidebook, and Milestones
Guidebook for Residents and Fellows, are available on the Resources page of the Milestones section of the ACGME website.

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 Pediatric Pathology Supplemental Guide

Patient Care 1: Pediatric and Perinatal Pathology Grossing (Examine, Describe, Triage, Sample, and Document)
Overall Intent: To perform gross examination of routine and complex pediatric and perinatal specimens for optimal patient care
Milestones Examples
Level 1 Performs gross examination of routine ● Receives oriented skin ellipse from operating room, correctly inks and preserves
specimens, with direct supervision orientation; submits cassettes based on standard grossing protocols
Level 2 Performs gross examination of complex ● Receives tumor specimen, triages for cytogenetic studies, submits pilot section, and
specimens, with direct supervision submits cassettes based on standard grossing protocols
Level 3 Performs gross examination of complex ● Receives Wilms tumor, photographs, inks, maps, and samples specimen, according to
specimens and identifies when additional consensus protocols; discusses intra-operative findings with surgeon with attending
sampling is necessary for diagnosis or staging, guidance
with indirect supervision
Level 4 Independently performs gross ● Receives osteosarcoma resection, photographs, inks, submits margins, cuts longitudinal
examination of complex specimens section, decalcifies, and maps specimen; discusses gross margins and orientation with
surgeon, independently
Level 5 Serves as an expert resource for gross ● Serves as a resource for faculty members and co-fellows for dissecting explanted
examination and applies innovative approaches complex congenital heart disease specimens
of grossing to demonstrate innovative pathology
in unique specimens
Assessment Models or Tools ● Case based discussions
● Clinical-Pathologic conferences
● Direct observation
● Presentations
● Review of gross descriptions and photographs
Curriculum Mapping ●
Notes or Resources ● Kaplan CG. Color Atlas of Gross Placental Pathology. 2nd ed. New York, NY: Springer
Science+Business Media; 2006.

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● Lester SC. Manual of Surgical Pathology. 2nd ed. Philadelphia, PA: Elsevier Saunders;
2005.

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Patient Care 2: Intra-Operative Consultation (Frozen Sections, Rapid Onsite Evaluation of Fine Needle Aspiration)
Overall Intent: To select, perform, and interpret common and complex pediatric intra-operative consultations
Milestones Examples
Level 1 Selects tissue and prepares quality ● Receives lymph node for intra-operative consultation (IOC); selects appropriate tissue,
slides for common and complex pediatric cases, performs touch prep/freezes, cuts, stains, and prepares readable slides, with direct
with direct supervision supervision

Develops differential diagnosis of common ● Lists a differential diagnosis of reactive versus malignant disorders of lymph nodes
pediatric specimens and recognizes broad
diagnostic categories (i.e., benign versus
malignant, normal versus abnormal)
Level 2 Selects tissue and prepares quality ● Selects appropriate lymph node tissue, performs touch prep/freezes, cuts, stains, and
slides for common pediatric cases, with indirect prepares readable slides, with indirect supervision
supervision, and complex pediatric cases, with
● Orients and cuts seromuscular biopsy for Hirschsprung disease with direct supervision
direct supervision

Interprets common pediatric cases

independently and develops differential for ● Differentiates inflammatory/reactive bone lesions from malignant neoplastic disorders
complex pediatric cases with guidance independently
● Lists a differential diagnosis of spindle cell soft tissue tumors with guidance
Level 3 Selects tissue and prepares quality ● Selects appropriate lymph node tissue, performs touch prep/freezes, cuts, stains and
slides for common pediatric cases, prepares readable slides, independently
independently, and complex pediatric cases,
● Orients and cuts margins of partial nephrectomy/wedge resections for bilateral treated
with indirect supervision
Wilms tumor with nephrogenic rests with indirect supervision

Interprets common pediatric cases

● Interprets margins for partial nephrectomy/wedge resections for bilateral treated Wilms
independently and complex cases with
guidance

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 Pediatric Pathology Supplemental Guide

tumor with nephrogenic rests with guidance

● Lists a differential diagnosis of spindle cell soft tissue tumors independently
Level 4 Independently selects tissue and ● Independently orients and cuts margins of partial nephrectomy/wedge resections for
prepares quality slides for common and bilateral treated Wilms tumor with nephrogenic rests
complex pediatric cases

Independently interprets common and complex

● Interprets margins for bilateral Wilms tumor resections, independently
pediatric cases
Level 5 Serves as an expert resource for ● Serves as a consultant for faculty members and co-fellows for technical and diagnostic
intraoperative consultations performance of intra-operative consultation
Assessment Models or Tools ● Case based discussions
● Direct observation
● Frozen/permanent correlation
● Presentations
● Slide review
Curriculum Mapping ●
Notes or Resources ● Marchevsky AM, Balzer B, Abdul-Karim FW. Intraoperative Consultation: A Volume in the
Series: Foundations in Diagnostic Pathology. 1st ed. Philadelphia, PA: Elsevier Saunders;
2014.
● Taxy JB, Husain AN, Montag AG. Biopsy Interpretation: The Frozen Section (Biopsy
Interpretation Series). 1st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.

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Patient Care 3: Autopsy

Overall Intent: To perform the technical aspects of an autopsy
Milestones Examples
Level 1 Performs standard autopsy, with direct ● Performs autopsy and placental exam in intact non-dysmorphic fetus with direct
supervision supervision; submits cassettes based on standard sampling protocols

Obtains clinical history from electronic health

record (EHR) and/or other sources
Level 2 Performs standard autopsy with indirect ● With direct supervision, performs autopsy on older child with neoplastic disease, and in
supervision and performs complex autopsy with addition to standard sampling, triages and samples tissue based on autopsy findings
direct supervision

Reviews clinical history and summarizes

● Performs standard fetopsy and placental exam with indirect supervision
pertinent findings
Level 3 Independently performs standard ● With indirect supervision, performs internal and external examination on an infant with
autopsy and performs complex autopsy with multiple congenital anomalies; samples based on autopsy findings and triages tissue for
indirect supervision molecular, genetic, and research testing

Reviews clinical history, summarizes pertinent

findings, and identifies relevant clinical
questions for standard cases
Level 4 Independently performs standard and ● Independently dissects and classifies complex post-operative anatomy in repaired
complex autopsy congenital anomalies

Reviews clinical history, summarizes pertinent

findings, and identifies relevant clinical

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 Pediatric Pathology Supplemental Guide

questions for complex cases

Level 5 Serves as an expert resource for ● Serves as an expert resource for faculty members and co-fellows for dissection in
complex techniques in autopsy complex, rare, and unique autopsy cases

Serves as an expert resource for identifying and

interpreting clinical questions in complex cases
Assessment Models or Tools ● Autopsy log
● Case based discussions
● Clinical pathologic conferences
● Direct observation
● Presentations
● Review of reports and photographs
Curriculum Mapping ●
Notes or Resources ● Bharati S, Lev M. The Pathology of Congenital Heart Disease: A Personal Experience
with More Than 6,300 Congenitally Malformed Hearts. Armonk, NY: Futura Publishing
Company; 1996.
● Gilbert-Barness E, Debich-Spicer DE, Steffensen TS. Handbook of Pediatric Autopsy
Pathology. New York, NY: Springer; 2013.
● Local/institutional autopsy dissection procedure manual

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Patient Care 4: Reporting, including Surgical Pathology, Cytopathology, and Autopsy

Overall Intent: To draft clear and concise reports that include all the relevant information
Milestones Examples
Level 1 Composes reports on routine cases, ● Composes a report for a singleton placenta with acute chorioamnionitis, using Amsterdam
with guidance, including synoptics and guidelines, with guidance
amended/addended reports, when applicable
● Creates an addended report when additional cytogenetic studies become available, with
guidance
Level 2 Independently composes reports on ● Independently writes a report for a thyroglossal duct cyst
routine cases
● Independently writes a report for a singleton placenta with acute chorioamnionitis, using
Amsterdam guidelines
Level 3 Composes reports on complex cases ● Develops a surgical pathology report for a neuroblastic tumor resection, including College
with integration of clinical and ancillary (e.g., of American Pathologists (CAP) synoptic templates and International Neuroblastoma
molecular, cytogenetic, flow cytometric) Pathology Classification, with guidance
information, including language of uncertainty,
● Writes a report that interprets pathologic findings in light of discordant imaging, with
with guidance
assistance
Level 4 Independently composes reports on ● Independently develops a surgical pathology report for a neuroblastic tumor resection,
complex cases with integration of clinical and including CAP synoptic templates and International Neuroblastoma Pathology
ancillary information, including language of Classification
uncertainty
● Independently reports an undifferentiated round cell sarcoma with negative molecular
data, reflecting ambiguous final classification
Level 5 Serves as a resource for composition of ● Drafts a report reconciling multiple discordant results and/or opinions, including those
reports on complex cases with integration of received from outside expert consultants
clinical and ancillary information, including
language of uncertainty
Assessment Models or Tools ● Attending evaluation during daily sign-out
● Chart review or other system documentation

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 Pediatric Pathology Supplemental Guide

● Consensus conference presentations

● Review of reports
Curriculum Mapping ●
Notes or Resources ● CAP. Cancer Protocol Templates. www.cap.org/cancerprotocols. 2020.
● Khong YT, Mooney EE, Ariel I, et al. Sampling and definitions of placental lesions:
Amsterdam placental working group consensus statement. Arch Pathol Lab Med.
2016;140(7):698-713. https://www.archivesofpathology.org/doi/10.5858/arpa.2015-0225-
CC?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. 2020.
● Nakhleh RE, Myers JL, Allen TC, et al. Consensus statement on effective communication
of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and
cytopathology from the College of American Pathologists and Association of Directors of
Anatomic and Surgical Pathology. Arch Pathol Lab Med. 2012;136(2):148-154.
https://www.archivesofpathology.org/doi/10.5858/arpa.2011-0400-SA?url_ver=Z39.88-
2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. 2020.
● Rosai J, Bonfiglio TA, Carson JM, et. al. Standardization of the surgical pathology report.
Mod Pathol. 1992;5(2):197-199.
● Smith SM, Yearsley M. Constructing comments in a pathology report: advice for the
pathology resident. Arch Pathol Lab Med. 2016;140(10):1023-1024.
https://www.archivesofpathology.org/doi/10.5858/arpa.2016-0220-ED?url_ver=Z39.88-
2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. 2020.

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 Pediatric Pathology Supplemental Guide

Medical Knowledge 1: Knowledge of Pediatric and Perinatal Diseases

Overall Intent: To demonstrate knowledge of perinatal and pediatric diseases and its application to common and complex clinical cases
Milestones Examples
Level 1 Demonstrates basic medical knowledge ● Understands how Hirschsprung disease is defined and the role of the pathologist in its
acquired through pathology education in diagnosis
residency

Demonstrates basic knowledge of

● Understands how histochemical and immunohistochemical stains aid in the diagnosis of
histochemistry, immunohistochemistry, and
Hirschsprung disease
molecular techniques
Level 2 Demonstrates advanced knowledge of ● Describes the setting and types of diagnostic procedures used to evaluate Hirschsprung
common pediatric neoplastic and non-neoplastic disease
diseases

Demonstrates advanced knowledge of

histochemistry, immunohistochemistry, and
molecular techniques ● Orders calretinin and/or acetylcholinesterase

Level 3 Applies advanced knowledge of ● Identifies the pathologic features of uncommon Hirschsprung disease variants
uncommon pediatric neoplastic and non-
neoplastic diseases

Applies advanced knowledge of histochemistry,

immunohistochemistry, and molecular ● Interprets calretinin and/or acetylcholinesterase to diagnose Hirschsprung disease
techniques
Level 4 Integrates advanced knowledge of ● Reviews prior pathology and clinical data in the context of current literature to advise
uncommon pediatric neoplastic and non- surgeon on the possibility of a previous incomplete pull-through for Hirschsprung disease
neoplastic diseases, with reference to literature

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Integrates advanced knowledge of

histochemistry, immunohistochemistry, and
● Interprets calretinin and/or acetylcholinesterase to craft nuanced diagnosis of
molecular techniques with reference to literature
Hirschsprung disease variants in the context of current literature
Level 5 Demonstrates expertise and teaches ● Teaches residents best practice guidelines for sampling and reporting in Hirschsprung
pediatric pathology disease

Demonstrates expertise and teaches

histochemistry, immunohistochemistry, and
● Contributes to the literature in immunohistochemistry and other modalities in the diagnosis
molecular techniques
of Hirschsprung disease
Assessment Models or Tools ● Case-based discussions
● Clinical pathologic conferences
● Direct observation
● Presentations
● Review of drafted reports
● Unknown slide conferences
Curriculum Mapping ●
Notes or Resources ● Gilbert-Barness E, Kapur RP, Oligny LL, Siebert JR, Optiz JM. Potter’s Pathology of the
Fetus, Infant and Child. 2nd ed. Philadelphia, PA: Mosby Elsevier; 2007.
● Khong TY, Mooney EE, Nikkels PGJ, Morgan TK, Gordijn SJ, editors. Pathology of
Placenta: A Practical Guide. Switzerland: Springer; 2019.
● Stocker JT, Dehner LP, Husain AN. Stocker and Dehner’s Pediatric Pathology. 3rd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2011.

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Medical Knowledge 2: Clinical Reasoning

Overall Intent: To approach a diagnostic work-up in an informed and logical manner using appropriate resources to guide decisions
Milestones Examples
Level 1 Demonstrates a basic framework for ● Reviews a radiology report and hospital discharge note for an autopsy to begin
clinical reasoning developing a differential diagnosis

Identifies appropriate resources to inform ● Navigates electronic health record (EHR), laboratory information system (LIS), internet,
clinical reasoning and literature to locate necessary information
Level 2 Demonstrates clinical reasoning to ● Traces the evolution of a suspected fatal diagnosis throughout an intensive care unit
determine relevant information (ICU) course, ignoring extraneous information to identify guiding questions prior to
beginning an autopsy

● Is aware of and uses appropriate algorithms, consensus guidelines, and published

Selects relevant resources based on scenario to
literature
inform decisions
Level 3 Synthesizes information to inform ● Integrates imaging modality reports, death note, and internal and external exam findings
clinical reasoning, with assistance at autopsy to craft a narrative of cause of death in an oncology autopsy case

Seeks and integrates evidence-based ● Uses published literature and recommendations to correctly classify a neuroblastic tumor
information to inform diagnostic decision making
in complex cases, with assistance
Level 4 Independently synthesizes information ● Gathers and interprets cath, echo, and cardiac surgical operative notes to guide precise
to inform clinical reasoning in complex cases dissection of complex congenital heart disease autopsy case

Independently seeks out, analyzes, and applies ● Uses PubMed to identify novel molecular alterations to assist in the diagnosis of an
relevant original research to diagnostic decision undifferentiated soft tissue sarcoma
making in complex clinical cases

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 Pediatric Pathology Supplemental Guide

Level 5 Demonstrates intuitive approach to ● Serves as a resource for faculty members and co-fellows for narrative building and
clinical reasoning for complex cases integration of clinical, gross, and microscopic findings for unique/complex cases
Assessment Models or Tools ● Case-based discussions
● Clinical pathologic conferences
● Direct observation
● Presentations
● Review of drafted reports
● Unknown slide conferences
Curriculum Mapping ●
Notes or Resources ● Archie JG, Collins JS, Lebel RR. Quantitative standards for fetal and neonatal autopsy.
Am J Clin Pathol. 2006;126(2):256-265. https://watermark.silverchair.com/ajcpath126-
0256.pdf?
token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAmkwggJlBgk
qhkiG9w0BBwagggJWMIICUgIBADCCAksGCSqGSIb3DQEHATAeBglghkgBZQMEAS4w
EQQMW8jz7BzYHdxX-bGcAgEQgIICHF3bl2WIgGFx92k-
anqdhUVWVMxyZu7ibCmNgLiIcv4VkBhGbR-
DRW3mJlG1LcHG3EWN5Odw6UrwDMBbd85JTWIrXFxTxa60LmvV8kW_khW5x592CY
mcu1bY-
5sx42jNaVgP0og4YOKKYgnJG1iISHTBX_9fii7EkU9N0oOPOJaYFggVSioPck0p9vv_Y6w
d3XVz-
I5oV8X34AEl5VUH9w8NBRRIvRiv_ciH7cCVu1Z7YgMHOgmoRnlRpmkJ9rr5IHx3QfzNidy
5u6bSsArweqS-Nep44u3geFtB8ZHenBzVH6P6LZbW5t5gVDCuoE2ulsCLfny-
Li7JJuyTXZlClQ82VIWhNu9NMRobsKpMyUD4K_ftYAo7ww-
Xav8HH1HRTDGNTeTzJKK55ygJuncTJhLuxlL92fzEXjv27ysocGkcN2YqczniHvIpIMJw7N
aeTMS9jDarW3KBE-MGgZi2Lct6kjPYxwKmpBtLHuhTAYCjB2kiXG-
xlGTlmEiWCjbct7Kqzk940-wF4bcivVVO_t6KLUPxyqVS2DDPuGJpyU3P-ms-
Zh3SFJS3NS99zJuSQuB_il_XvD2MFi_6b_DLaBn3Ao9uu5BbGLnV5hoprjPrT-
QBfRdWsQLEGFgmzZhNNxgd96tZMqx6x9NLP28tIn5esd504gmFjPL9Y9bYsDYyCBQe3
pxeG9UKlyMqRxOaXtRhhCZVoMTVgUkO6g. 2020.

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● Clinical reasoning relies on appropriate foundational knowledge that requires the trainee
to apply that knowledge in a thoughtful, deliberate and logical fashion to clinical cases to
inform clinical care
● CAP. Biomarker Reporting Templates. https://www.cap.org/search?q=Biomarker
%20reporting. 2020.
● CAP. Cancer Protocol Templates. https://www.cap.org/protocols-and-guidelines/cancer-
reporting-tools/cancer-protocol-templates. 2020.
● Gilbert-Barness E, Debich-Spicer DE. Handbook of Pediatric Autopsy Pathology. Totowa,
NJ: Springer Science & Business Media; 2008.
● Institutional EMR training (i.e. note filtering, graphing of longitudinal laboratory data, chart
search functionality)
● Iobst WF, Trowbride R, Philibert I. Teaching and assessing critical reasoning through the
use of entrustment. J Grad Med Educ. 2013;5(3):517-518.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3771188/. 2020.
● Medical literature databases: PubMed, Google Scholar

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Systems-Based Practice 1: Patient Safety and Quality Improvement (QI)

Overall Intent: To engage in the analysis and management of patient safety events, including relevant communication with patients,
families, and health care professionals; to conduct a QI project
Milestones Examples
Level 1 Demonstrates knowledge of common ● Has basic knowledge of patient safety events, reporting pathways, and QI strategies, but
patient safety events has not yet participated in such activities

Demonstrates knowledge of how to report

patient safety events

Demonstrates knowledge of basic QI

methodologies and metrics
Level 2 Identifies system factors that lead to ● Identifies and reports a patient safety issue (real or simulated), along with system factors
patient safety events contributing to that issue

Reports patient safety events through ● Is aware of improvement initiatives within their scope of practice
institutional reporting systems (simulated or
actual)

● Attend departmental QI and patient safety activities such as huddles, QI reviews

Describes departmental and institutional QI
initiatives
Level 3 Participates in analysis of patient safety ● Reviews a patient safety event (e.g., preparing for morbidity and mortality (M and M)
events (simulated or actual) presentations, joining a root cause analysis group) and has participated in communication
with clinicians about such an event
● Participates in a simulated exercise to report a safety event to a family
Participates in disclosure of patient safety
events to clinicians and/or patients and families

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(simulated or actual)

Participates in departmental and institutional QI ● Participates in a QI project, though they may not have yet designed a QI project
initiatives
Level 4 Conducts analysis of patient safety ● Collaborates with a team to lead the analysis of a patient safety event and can
events and offers error prevention strategies competently communicate with the clinician and/or family about those events
(simulated or actual)

Discloses patient safety events to clinicians

and/or patients and families (simulated or
actual)

Demonstrates the skills required to identify,

develop, implement, and analyze a QI project
● Initiates and completes a QI project, including communication with stakeholders
Level 5 Actively engages teams and processes ● Competently assumes a leadership role at the departmental or institutional level for
to modify systems to prevent patient safety patient safety and/or QI initiatives, possibly even being the person to initiate action or call
events attention to the need for action

Role models or mentors others in the disclosure

of patient safety events

Creates, implements, and assesses QI

initiatives at the institutional or community level
Assessment Models or Tools ● Direct observation
● E-module multiple choice tests

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● Medical record (chart) audit

● Multisource feedback
● Portfolio
● Reflection
● Simulation
Curriculum Mapping ●
Notes or Resources ● ABPath approved Patient Safety Courses: American Society for Clinical Pathology
(ASCP), College of American Pathologists (CAP), National Association of Medical
Examiners (NAME), Society for Pediatric Pathology, United States and Canadian
Academy of Pathology (USCAP)
● Institute of Healthcare Improvement. http://www.ihi.org/Pages/default.aspx. 2020.

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Systems-Based Practice 2: Systems Navigation for Patient-Centered Care

Overall Intent: To effectively navigate the health care system, including the interdisciplinary team and other care providers, to adapt care to
a specific patient population to ensure high-quality patient outcomes
Milestones Examples
Level 1 Demonstrates knowledge of case ● Identifies the members of the interprofessional team, including histotechnologists,
coordination laboratory technicians, pathologist assistants, consultants, other specialty physicians,
nurses, and consultants, and describes their roles but is not yet routinely using team
members or accessing all available resources

● Lists the essential components of an effective sign-out and care transition including
Identifies key elements for safe and effective sharing information necessary for successful on-call/off-call transitions such as surgical
transitions of care and hand-offs cases in operating room requiring frozen sections, end of service delayed cases, pending
intradepartmental or external consultations

● Identifies components of social determinants of health and how they impact the delivery of
patient care
Demonstrates knowledge of population and
community health needs and disparities
Level 2 Coordinates care of patients/specimens ● Contacts interprofessional team members for routine cases, but requires supervision to
in routine cases effectively using ensure all necessary referrals, testing, and care transitions
interprofessional teams

Performs safe and effective transitions of

● Performs a routine case sign-out but still needs direct supervision to identify and
care/hand-offs in routine situations
appropriately triage cases or calls (priority versus non-priority case or call) and
anticipatory guidance

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Identifies pathology’s role in population and ● Identifies different populations within own cases and/or the local community
community health needs and inequities for the
● Knows which patients are at high risk for specific health outcomes related to health
local population
literacy concerns, cost of testing or therapy, etc.
Level 3 Coordinates care of patients/specimens ● At interdisciplinary tumor boards (e.g., solid organ or hematopoietic malignancies),
in complex cases effectively using engages in appropriate discussion of patient care testing options and impact on therapy
interprofessional teams for complex pathologic cases

Performs safe and effective transitions of ● Appreciates the need for and uses local resources when coordinating pathology case
care/hand-offs in complex situations transfer from an outside institution; coordinates specimen handling, ordering of needed
tests/stains, and courier schedules

● Aware of community service and public health opportunities requiring pathology expertise
Identifies opportunities for pathology to
participate in community and population health ● Recognizes the need to report a reportable disease to appropriate health authorities
Level 4 Models effective coordination of patient- ● Role models and educates students and junior team members regarding the engagement
centered care among different disciplines and of appropriate interprofessional team members, as needed for each patient and/or case,
specialties and ensures the necessary resources have been arranged

Models and advocates for safe and effective ● Role models, initiates, and coordinates effective transition of care such as cases pending
transitions of care/hand-offs within and across for sign-out, intra-operative frozen sections or consultations
health care delivery systems
● Proactively calls the clinical team to provide preliminary findings for rush cases and
unexpected findings to ensure the patient gets appropriate follow-up

Recommends and/or participates in changing ● Performs quality reviews and correlations between current findings and previous
and adapting practice to provide for the needs cytology/fine needle aspiration or previous biopsies to assure appropriate follow-up
of communities and populations
● Is aware of and actively considers increased risk of an infection that is endemic to the
country of origin of a local immigrant population

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Level 5 Analyzes the process of care ● Works with hospital or ambulatory site team members or leadership to analyze care
coordination and leads in the design and coordination and laboratory services in that setting, and takes a leadership role in
implementation of improvements designing and implementing changes to improve the care coordination and laboratory
workflow/menu process and design

● Works with a QI mentor to identify better hand-off tools for on-call pathology services or to
Improves quality of transitions of care within and
improve teaching sessions
across health care delivery systems to optimize
patient outcomes

Leads innovations and advocates for ● Designs a social determinants of health curriculum to help others learn to identify local
populations and communities with health care resources and barriers to care and laboratory testing; effectively uses resources, such as
inequities telehealth and telepathology for proactive outreach programs in referring laboratories and
institutions
Assessment Models or Tools ● Case management quality metrics
● Chart review
● Direct observation
● Multisource feedback
● Pathology report review
Curriculum Mapping ●
Notes or Resources ● Aller RD. Pathology's contributions to disease surveillance: sending our data to public
health officials and encouraging our clinical colleagues to do so. Archives of Path Lab
Med. 2009;133(6):926-932. https://www.archivesofpathology.org/doi/10.1043/1543-2165-
133.6.926?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed.
2020.
● Centers for Disease Control and Prevention (CDC). Population Health Training in Place
Program (PH-TIPP). https://www.cdc.gov/pophealthtraining/whatis.html. 2020.

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● CAP Competency Model for Pathologists.

https://learn.cap.org/content/cap/pdfs/Competency_Model.pdf. 2020.
● Kaplan KJ. In Pursuit of Patient-Centered Care. http://tissuepathology.com/2016/03/29/in-
pursuit-of-patient-centered-care/#axzz5e7nSsAns. 2020.

Systems-Based Practice 3: Physician Role in Health Care System

Overall Intent: To understand the physician role in the complex health care system and how to optimize the system to improve patient care
and the health system’s performance
Milestones Examples
Level 1 Identifies key components of the ● Recognizes the multiple, often competing forces, in the health care system (e.g., names

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complex health care system (e.g., hospital, systems and providers involved test ordering and payment)
reference lab, finance, personnel, technology)

Describes basic health payment systems (e.g.,

● Recognizes there are different payment systems, such as Medicare, Medicaid, the
government, private, public, uninsured care)
Veterans Affairs (VA), and commercial third-party payers,
and practice models
● With direct supervision, completes a report following a routine patient specimen and
applies appropriate coding in compliance with regulations
Level 2 Describes how components of a ● Understands the impact of health plans on testing workflow and reimbursement;
complex health care system are interrelated, demonstrates knowledge that is theoretical, but is not yet able to apply this knowledge to
and how this impacts patient care the care of patients without some direct attending input and/or prompting

Documents testing detail and explains the ● Completes a report following a routine patient specimen and applies appropriate coding in
impact of documentation on billing and compliance with regulations, with oversight
reimbursement
Level 3 Discusses how individual practice ● Understands, accesses, and analyzes own individual performance data; relevant data
affects the broader system (e.g., test utilization, may include:
turnaround time)
o Autopsy Case Log

o Consultation logs (e.g., on-call cases)

o Grossing log

Engages with clinicians and/or patients in

shared decision making, such as use of ● Uses shared decision making and adapts the choice of the most cost-effective testing
preauthorization for complex testing depending on the relevant clinical needs

Level 4 Manages various components of the ● Works collaboratively with the institution to improve patient resources or design the
complex health care system to provide efficient institution’s testing needs assessment, or develop/implement/assess the resulting action
and effective patient care and transition of care plans

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 Pediatric Pathology Supplemental Guide

Practices and advocates for cost effective ● Works with the obstetrics team to determine the most appropriate labs to be ordered for
patient care with consideration of the limitations mothers with stillbirth
of each patient’s payment model
Level 5 Advocates for or leads systems change ● Performs a LEAN analysis of laboratory practices to identify and modify areas of
that enhances high-value, efficient, and effective improvement to make laboratory testing more efficient
patient care and transition of care

Participates in health policy advocacy activities

● Participates in state and national lobbying for Centers for Medicare & Medicaid Services
(CMS) payment reform, public health initiatives, or expanding access to care
Assessment Models or Tools ● Audit of testing usage
● Direct observation
● QI project
● Review of billing code assignment to pathology cases (real or simulated)
Curriculum Mapping ●
Notes or Resources ● Agency for Healthcare Research and Quality. Major Physician Measurement Sets.
https://www.ahrq.gov/talkingquality/measures/setting/physician/measurement-sets.html.
2020.
● Children’s Hospital Association. Resource Library.
https://www.childrenshospitals.org/Resources. 2020.
● The Commonwealth Fund. Health System Data Center.
http://datacenter.commonwealthfund.org/?_ga=2.110888517.1505146611.1495417431-
1811932185.1495417431#ind=1/sc=1. 2020.
● Dzau VJ, McClellan M, Burke S, et al. Vital directions for health and health care: priorities
from a National Academy of Medicine Initiative. NAM Perspectives. Discussion Paper,
National Academy of Medicine, Washington, DC. https://nam.edu/vital-directions-for-

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Pediatric Pathology Supplemental Guide

health-health-care-priorities-from-a-national-academy-of-medicine-initiative/. 2020.
● Gross DJ, Kennedy M, Kothari T, et al. The Role of the Pathologist in Population Health.
Arch Pathol Lab Med. 2019;143(5):610-620.
https://www.archivesofpathology.org/doi/10.5858/arpa.2018-0223-CP?url_ver=Z39.88-
2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. 2020.
● The Kaiser Family Foundation. www.kff.org. 2020.

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 Pediatric Pathology Supplemental Guide

Systems-Based Practice 4: Accreditation, Compliance, and Quality

Overall Intent: To gain in-depth knowledge of the components of laboratory accreditation, regulatory compliance, and quality management
Milestones Examples
Level 1 Demonstrates knowledge that ● Attends departmental quality assurance/quality control meetings, M and M conferences
laboratories must be accredited and accreditation/regulatory summation meetings
● Understands that there are different accrediting bodies for laboratories (CAP, Joint
Commission on Accreditation of Healthcare Organizations (Joint Commission), etc.) with
overlapping and differing requirements

● Understands that daily histology and immunohistochemistry quality control sheets are
Discusses the need for quality control and mandated for each case
proficiency testing
Level 2 Demonstrates knowledge of the ● Is aware of potential regulatory violations or deficiencies in anatomic pathology
components of laboratory accreditation and laboratories
regulatory compliance (e.g., Clinical Laboratory
Improvement Amendments), either through
training or experience

Interprets quality data and charts and trends,

including proficiency testing results, with
supervision ● Assesses quality of quality control slides for immunohistochemical stains
● Compares frozen section to final diagnosis for own cases
● Fills out daily histology quality control sheets for own cases
Level 3 Identifies the differences between ● Discusses the differences between federally and state-mandated laboratory regulation
accreditation and regulatory compliance; and specialty specific best practices
discusses the process for achieving
accreditation and maintaining regulatory
compliance

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 Pediatric Pathology Supplemental Guide

Demonstrates knowledge of the components of

a laboratory quality management plan

● Actively participates in quality assurance activities, including mandatory second reviews,

reconciliation of outside consultant reports, and consensus conferences
● Actively participate in regular laboratory quality management duties
● Review QI reports, participates in QI committees
Level 4 Participates in an internal or external ● Performs mock or self-inspection, or external inspection with faculty members
laboratory inspection

Reviews the quality management plan to

● Assists in troubleshooting quality control or proficiency testing failures (e.g., HistoQIP)
identify areas for improvement
Level 5 Serves as a resource for accreditation ● Serves on a committee for a regional or national accreditation agency
at the regional or national level

Creates and follows a comprehensive quality

● Oversees laboratory quality management in concert with the medical director
management plan
Assessment Models or Tools ● Direct observation
● Documentation of inspector training and participation
● Participation in laboratory management meetings
● Presentation at M and conferences
● Rotation evaluations
Curriculum Mapping ●
Notes or Resources ● CAP. Inspector Training Options. https://www.cap.org/laboratory-

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Pediatric Pathology Supplemental Guide

improvement/accreditation/inspector-training. 2020.

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 Pediatric Pathology Supplemental Guide

Systems-Based Practice 5: Utilization

Overall Intent: To optimize utilization of tests to ensure both high-quality patient outcomes and stewardship of health care resources
Milestones Examples
Level 1 Identifies general pediatric pathology ● Identifies key elements of ordering practices
work practices and workflow (e.g., molecular
● Understands turnaround time for routine histology, expedited (i.e., stat) cases, routine and
diagnostic, histology, immunohistochemistry
stat immunostains, and additional testing modalities
stains, chemical tests, administrative support)
● Understands the role of CPT codes in pathology billing on a basic level
Level 2 Explains rationale for test/resource ● Identifies appropriate or inappropriate ordering and overutilization
utilization patterns in own practice setting
● Discusses financial implications of inappropriate ordering and overutilization
● Understands the implications of inappropriate stat requests on overtime for laboratory
staff members
Level 3 Identifies opportunities to optimize ● Collaborates with departmental leadership to intervene in inappropriate or overutilization
utilization of pathology resources situations
● Addresses use of specific tests instead of a complete panel
● Understands the difference between clinical diagnostic and research tumor sequencing
Level 4 Initiates efforts to optimize utilization ● Identifies faculty member and co-fellow overutilization of cytogenetic studies, removes up
front ordering of stains with low diagnostic yield
● Orders immunohistochemical stains based on carefully considered differential diagnosis
to optimize patient care and cost effectiveness
● Discusses with the oncologist the boundaries between clinically relevant and research
testing
Level 5 Completes a utilization review, ● Independently or as a collaborator, conducts a utilization review on patterns of ordering
implements change, and reviews effectiveness immunohistochemical stains for evaluation of small round cell tumors, identifies
inappropriate ordering and overutilization in the context of evidence-based best practices,
and engages stakeholders in interventions to modify and improve utilization practices and
stewardship of resources

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 Pediatric Pathology Supplemental Guide

● Publishes results of utilization review on a focused topic

Assessment Models or Tools ● Direct observation
● Faculty evaluations of fellow
● Participation in laboratory management and finance meetings
● Planning and completion of a utilization review
Curriculum Mapping ●
Notes or Resources ● Bejjanki H, Mramba LK, Beal SG, et al. The role of a best practice alert in the electronic
medical record in reducing repetitive lab tests. Clinicoecon Outcomes Res. 2018;10:611-
618. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6181108/. 2020.
● Harb R, Hajdasz D, Landry ML, Sussman LS. Improving laboratory test utilisation at the
multihospital Yale New Haven Health System. BMJ Open Qual. 2019;8(3):e000689.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768328/. 2020.
● Kowbecka DM, Ronksley PE, McKay JA, et al. Influence of educational, audit and
feedback, system based, and incentive and penalty interventions to reduce laboratory test
utilization: a systematic review. Clin Chem Lab Med. 2015;53(2):157-183.
https://www.degruyter.com/view/j/cclm.2015.53.issue-2/cclm-2014-0778/cclm-2014-
0778.xml. 2020.
● Lewandrowski K. Managing utilization of new diagnostic tests. Clin Leadersh Manag Rev.
2003;17(6):318-324.
https://www.researchgate.net/publication/8945324_Managing_utilization_of_new_diagnos
tic_tests. 2020.
● Seattle Children's Hospital. Patient-centered Laboratory Utilization Guidance Services.
http://www.schplugs.org/. 2020.
● Ulbright TM, Tickoo SK, Berney DM, Srigley JR, Members of the ISUP
Immunohistochemistry in Diagnostic Urologic Pathology Group. Best practices
recommendations in the application of immunohistochemistry in testicular tumors: Report
from the International Society of Urological Pathology Consensus Conference. Am J
Surg Pathol. 2014;38(8):e50-e59.

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Pediatric Pathology Supplemental Guide

https://journals.lww.com/ajsp/Abstract/2014/08000/Best_Practices_Recommendations_in
_the_Application.4.aspx. 2020.
● Verna R, Velazquez AB, Laposata M. Reducing diagnostic errors worldwide through
diagnostic management teams. Ann Lab Med. 2019;39(2):121-124.
https://synapse.koreamed.org/DOIx.php?id=10.3343/alm.2019.39.2.121. 2020.

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 Pediatric Pathology Supplemental Guide

Practice-Based Learning and Improvement 1: Evidence-Based Practice and Scholarship

Overall Intent: To incorporate evidence into clinical practice and contribute to the body of knowledge in pediatric and perinatal pathology
Milestones Examples
Level 1 Demonstrates how to access and select ● Understands and accesses national research databases, journals, protocols, and
applicable evidence textbooks relevant to pediatric pathology

Is aware of the need for patient privacy, ● Identifies the need for an Institutional Review Board (IRB) approval when collecting cases
autonomy, and consent as applied to clinical for a possible research project
research
Level 2 Identifies and applies the best available ● Uses national research databases, journals, protocols, and textbooks relevant to pediatric
evidence to guide diagnostic work-up of simple pathology
cases

Develops knowledge of the basic principles of

● Drafts an IRB protocol with attending oversight
research (demographics, Institutional Review
Board, human subjects), including how research
is evaluated, explained to patients, and applied
to patient care
Level 3 Identifies and applies the best available ● Uses national research databases, journals, protocols, and textbooks relevant to pediatric
evidence to guide diagnostic work-up of pathology in order to guide ordering molecular testing or sequencing for unusual pediatric
complex cases tumors

Applies knowledge of the basic principles of ● Drafts an IRB protocol with minimal oversight
research such as informed consent and
● Completes research project and submits an abstract for a national meeting
research protocols to clinical practice, with
supervision
Level 4 Critically appraises and applies ● Appropriately researches the primary literature to explain rare molecular findings
evidence to guide care, even in the face of

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 Pediatric Pathology Supplemental Guide

conflicting data

Proactively and consistently applies knowledge

of the basic principles of research such as
● Independently designs a research project, including IRB submission
informed consent and research protocols to
clinical practice ● Submits a paper for publication
Level 5 Teaches others to critically appraise ● Moderates a discussion with clinicians over disparate molecular, morphologic, and
and apply evidence for complex cases; and/or immunohistochemical findings of a tumor to formulate the best course forward based on
participates in the development of guidelines the primary literature

Suggests improvements to research regulations ● Submits a grant proposal

and/or substantially contributes to the primary
literature through basic, translational, or clinical
research
Assessment Models or Tools ● Direct observation
● Participation in IRB
● Presentation, including at national meetings
● Research portfolio
Curriculum Mapping ●
Notes or Resources ● Academic journal submission guidelines
● CITI Program. Research Ethics and Compliance Training.
https://about.citiprogram.org/en/homepage/. 2020.
● Local IRB guidelines
● Local/institutional medical library website/database subscriptions
● National Institutes of Health. Write Your Application. https://grants.nih.gov/grants/how-to-

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Pediatric Pathology Supplemental Guide

apply-application-guide/format-and-write/write-your-application.htm. 2020.
● U.S. National Library of Medicine. PubMed Tutorial.
https://www.nlm.nih.gov/bsd/disted/pubmedtutorial/cover.html. 2020.

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 Pediatric Pathology Supplemental Guide

Practice-Based Learning and Improvement 2: Reflective Practice and Commitment to Personal Growth
Overall Intent: To seek clinical performance information with the intent to improve care; reflects on all domains of practice, personal
interactions, and behaviors; develop clear objectives and goals for improvement
Milestones Examples
Level 1 Accepts responsibility for personal and ● Is aware of need to improve and receptive to constructive feedback
professional development by establishing goals
● Humbly acts on input and is appreciative and not defensive

Identifies the gap(s) between expectations and

● Critically reads evaluations to become aware of strengths and weaknesses
actual performance
● Performs self-assessment

Actively seeks opportunities to improve

● Asks for resources for suggested reading
Level 2 Demonstrates openness to receiving ● Increasingly able to identify performance gaps in terms of diagnostic skills and daily work;
performance data and feedback in order to uses feedback from others
inform goals

Analyzes and reflects on the factors which

● After working with an attending for a week, asks about performance and opportunities for
contribute to gap(s) between expectations and
improvement
actual performance

Designs and implements a learning plan, with

assistance ● Uses feedback with a goal of improving communication skills with technologists,
peers/colleagues, and staff the following week
● Starts a reading plan to improve medical knowledge
Level 3 Seeks performance data and feedback ● Takes input from technologists, peers/colleagues, and supervisors to gain complex insight
with humility into personal strengths and areas to improve

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 Pediatric Pathology Supplemental Guide

Institutes behavioral change(s) to narrow the ● Actively seeks feedback from the pathologist assistant to improve handling of complex
gap(s) between expectations and actual specimens
performance

Independently creates and implements a

● Independently develops a reading program for a major pediatric pathology textbook and
learning plan
demonstrates weekly progress towards that goal
Level 4 Actively and consistently seeks ● Is perceived by all staff members to be humble, open to learning, and receptive to
performance data and feedback with humility constructive criticism

Critically evaluates the effectiveness of ● Consistently identifies ongoing gaps and chooses areas for further development
behavioral changes in narrowing the gap(s)
● Consistently makes a learning plan for each rotation
between expectations and actual performance

Uses performance data to measure the

effectiveness of the learning plan and improves ● Uses results from pediatric in-service exam to target areas of weakness via slide study
it when necessary sets, directed reading, and discussions with faculty member experts
Level 5 Models seeking performance data and ● Actively discusses learning goals with supervisors and colleagues
accepting feedback with humility

Coaches others in reflective practice

● Encourages other learners on the team to consider how their behavior affects the rest of
the team

Facilitates the design and implementing of ● Offers self-designed performance improvement plan to fellowship program director and
learning plans for others other colleagues

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 Pediatric Pathology Supplemental Guide

Assessment Models or Tools ● Direct observation

● Multisource feedback
● Pediatric in-service exam
● Portfolio
● Review of learning plan
● Self-reflection
● Semi-annual performance reviews
Curriculum Mapping ●
Notes or Resources ● Burke AE, Benson B, Englander R, Carraccio C, Hicks PJ. Domain of competence:
practice-based learning and improvement. Acad Pediatr. 2014;14: S38-S54.
https://www.academicpedsjnl.net/article/S1876-2859(13)00333-1/fulltext. 2020.
● Hojat M, Veloski JJ, Gonnella JS. Measurement and correlates of physicians' lifelong
learning. Academic Medicine. 2009;84(8):1066-1074.
https://journals.lww.com/academicmedicine/fulltext/2009/08000/Measurement_and_Correl
ates_of_Physicians__Lifelong.21.aspx. 2020.
● Lockspeiser TM, Schmitter PA, Lane JL, Hanson JL, Rosenberg AA, Park YS. Assessing
residents’ written learning goals and goal writing skill: validity evidence for the learning
goal scoring rubric. Academic Medicine. 2013;88(10):1558-1563.
https://journals.lww.com/academicmedicine/fulltext/2013/10000/Assessing_Residents__W
ritten_Learning_Goals_and.39.aspx. 2020.

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 Pediatric Pathology Supplemental Guide

Professionalism 1: Professional Behavior and Ethical Principles

Overall Intent: To recognize and address lapses in ethical and professional behavior, demonstrates ethical and professional behaviors, and
use appropriate resources for managing ethical and professional dilemmas
Milestones Examples
Level 1 Demonstrates knowledge of the ethical ● Identifies and describes potential triggers for professionalism lapses, describes when and
principles underlying informed consent, how to appropriately report professionalism lapses, and outlines strategies for addressing
surrogate decision making, advance directives, common barriers to reporting
confidentiality, error disclosure, stewardship of
limited resources, and related topics

Describes when and how to appropriately report

professionalism lapses, including strategies for ● Discusses the basic principles underlying ethics (beneficence, nonmaleficence, justice,
addressing common barriers; identifies and autonomy) and professionalism (professional values and commitments), and how they
describes potential triggers for professionalism apply in various situations (e.g., informed consent process)
lapses
● Obtains informed consent for procedures
Level 2 Analyzes straightforward situations ● Demonstrates professional behavior in routine situations and uses ethical principles to
using ethical principles analyze straightforward situations, and can acknowledge a lapse without becoming
defensive, making excuses, or blaming others

● Apologizes for the lapse when appropriate and taking steps to make amends if needed
Demonstrates insight into professional behavior
in routine situations; takes responsibility for ● Articulates strategies for preventing similar lapses in the future
one’s own professionalism lapses
● Monitors and responds to fatigue, hunger, stress, etc. in self and team members
● Recognizes and responds effectively to the emotions of others
Level 3 Recognizes the need and uses relevant ● Analyzes complex situations, such as how the clinical situation evokes strong emotions,
resources to seek help in managing and conflicts (or perceived conflicts) among patients/providers/staff members or between
resolving complex ethical situations professional values; navigates a situation while not at personal best (due to fatigue,
hunger, stress), or the system poses barriers to professional behavior (e.g., inefficient

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 Pediatric Pathology Supplemental Guide

workflow, inadequate staffing, conflicting policies)

● Recognizes own limitations and seeks resources to help manage and resolve complex
ethical situations such as:
o consulting with a genetic counselor about the implications of genetic testing

o requesting an ethics consult

● Analyzes difficult real or hypothetical ethics and professionalism case scenarios or

situations, recognizes own limitations, and consistently demonstrates professional
Demonstrates professional behavior in complex behavior
or stressful situations
Level 4 Independently resolves and manages ● Actively seeks to consider the perspectives of others
complex ethical situations
● Models respect for patients and expects the same from others

Recognizes situations that may trigger

● Recognizes and utilizes appropriate resources for managing and resolving ethical
professionalism lapses and intervenes to
dilemmas (e.g., ethics consultations, literature review, risk management/legal
prevent lapses in self and others
consultation)
Level 5 Identifies and seeks to address system- ● Coaches others when their behavior fails to meet professional expectations, either in the
level factors that induce or exacerbate ethical moment or after the moment
problems or impede their resolution

Coaches others when their behavior fails to

● Identifies and seeks to address system-wide factors or barriers to promoting a culture of
meet professional expectations
ethical and professional behavior through participation in a work group, committee, or task
force (e.g., ethics committee or an ethics sub-committee, risk management committee,
root cause analysis review, patient safety or satisfaction committee, professionalism work
group, IRB, trainee grievance committee, etc.)
Assessment Models or Tools ● Direct observation

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 Pediatric Pathology Supplemental Guide

● Multisource feedback
● Oral or written self-reflection
● Simulation
Curriculum Mapping ●
Notes or Resources ● American Medical Association. Ethics. https://www.ama-assn.org/delivering-care/ama-
code-medical-ethics. 2020.
● Brissette MD, Johnson K, Raciti PM, et al. Perceptions of unprofessional attitudes and
behaviors: implications for faculty role modeling and teaching professionalism during
pathology residency. Arch Pathol Lab Med. 2017;141:1349-1401.
https://www.archivesofpathology.org/doi/10.5858/arpa.2016-0477-CP. 2020.
● Byyny RL, Papadakis MA, Paauw DS. Medical Professionalism Best Practices. Menlo
Park, CA: Alpha Omega Alpha Medical Society; 2015.
https://alphaomegaalpha.org/pdfs/2015MedicalProfessionalism.pdf. 2019.
● Conran RM, Powell SZ, Domen RE, et al. Development of professionalism in graduate
medical education: a case-based educational approach from the College of American
Pathologists’ Graduate Medical Education Committee. 2018;5: 2374289518773493.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039899/. 2020.
● Domen RE, Johnson K, Conran RM, et al. Professionalism in pathology: a case-based
approach as a potential education tool. Arch Pathol Lab Med. 2017;141:215-219.
https://www.archivesofpathology.org/doi/10.5858/arpa.2016-0217-CP?url_ver=Z39.88-
2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. 2020.
● Domen RE, Talbert ML, Johnson K, et al. Assessment and management of
professionalism issues in pathology residency training: results from surveys and a
workshop by the graduate medical education committee of the College of American
Pathologists. Acad Pathol. 2015; 2:2374289515592887.
https://journals.sagepub.com/doi/10.1177/2374289515592887. 2020.
● Levinson W, Ginsburg S, Hafferty FW, Lucey CR. Understanding Medical
Professionalism. 1st ed. New York, NY: McGraw-Hill Education; 2014.

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 Pediatric Pathology Supplemental Guide

Professionalism 2: Accountability and Conscientiousness

Overall Intent: To take responsibility for one’s own actions and the impact on patients and other members of the health care team
Milestones Examples
Level 1 Responds promptly to instructions, ● Responds promptly to reminders from program administrator to complete work hour logs
requests, or reminders to complete tasks and or evaluations
responsibilities
● Timely attendance at conferences
● Responds promptly to requests to complete preliminary anatomic diagnosis report on an
autopsy
Level 2 Takes ownership and performs tasks ● Completes autopsy reports in a timely manner and recognizes when it will be difficult to
and responsibilities in a timely manner with complete that task (e.g., going out of town, awaiting brain cutting) and knows deadline for
attention to detail autopsy completion during vacation time
● Completes cases (any) in a timely manner, with attention to detail, including reporting of
all immunohistochemical stains
● Completes and documents safety modules, procedure review, and licensing requirements
(e.g., administrative duties and tasks)
Level 3 Recognizes situations that may impact ● Appropriately notifies colleagues on day service about overnight call events during
own ability to complete tasks and transition of care or hand-off in order to avoid patient safety issues and compromise of
responsibilities in a timely manner and patient care
describes the impact on team
● Completes tasks in stressful situations and preempts issues that would impede
completion of tasks (e.g., notifies attending of multiple competing demands on call,
appropriately triages tasks, and asks for assistance from other colleagues, if needed)
Level 4 Anticipates and intervenes in situations ● Identifies issues that could impede other colleagues from completing tasks and provides
that may impact others’ ability to complete tasks leadership to address those issues
and responsibilities in a timely manner
● Takes responsibility for potential adverse outcomes from mishandled specimen and
professionally discusses with the interprofessional team
Level 5 Takes ownership of system outcomes, ● Sets up a meeting with the lead technologist to streamline an ordering process and
and implements new strategies when necessary follows through with a system-based solution

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 Pediatric Pathology Supplemental Guide

● Writes specimen hand-off policy

Assessment Models or Tools ● Compliance with deadlines and timelines
● Direct observation
● Multisource feedback
● Quality metrics of turnaround time on cases
● Self-evaluations and reflective tools
Curriculum Mapping ●
Notes or Resources ● Code of conduct from fellow/resident institutional manual
● Institutional/shared calendaring, email, checklist, and handoff tools

Professionalism 3: Self-Awareness and Help-Seeking

Overall Intent: To identify, use, manage, improve, and seek help for personal and professional well-being for self and others
Milestones Examples
Level 1 Recognizes limitations in the ● Accepts feedback and exhibits positive responses to criticism
knowledge/skills/ behaviors of self or team, with
assistance

Recognizes status of personal and professional

well-being, with assistance ● Aware of institutional training to identify and prevent physician burnout
● Understands the need for community and personal support while in training
● Aware of institutional wellness resources
Level 2 Independently recognizes limitations in ● Identifies possible sources of personal stress or lack of clinical knowledge and
the knowledge/skills/ behaviors of self or team independently seeks help
and seeks help when needed

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 Pediatric Pathology Supplemental Guide

Independently recognizes status of personal ● Uses institutional wellness resources

and professional well-being and seeks help
● Completes institutional training to identify and prevent physician burnout
when needed
Level 3 Proposes and implements a plan to ● With supervision, designs debriefing session for team following stressful series of frozen
remediate or improve the knowledge/ sections
skills/behaviors of self or team, with assistance

Proposes and implements a plan to optimize

personal and professional well-being, with ● With supervision, assists in developing a plan to address stress and burnout, for self or
assistance team
● Discusses a change in rotation schedule due to personal life stressor that impacts
performance
Level 4 Independently develops and ● Independently develops personal learning or action plans for continued personal and
implements a plan to remediate or improve the professional growth, and limits stress and burnout for self or team
knowledge/skills/ behaviors of self or team
● Leads a debriefing session for team members following emotionally difficult autopsy

Independently develops and implements a plan

● Implements a change in rotation schedule due to personal life stressor that impacts
to optimize personal and professional well-being
performance
● Organizes hobbies, community activities and family life around rotation schedule
Level 5 Serves as a resource or consultant for ● Mentors colleagues in self-awareness, work-life balance, and burnout awareness and
developing a plan to remediate or improve the prevention
knowledge/ skills/behaviors

Coaches others when responses or limitations

● Mentors colleagues to minimize lapses in professional attitudes and interpersonal
in knowledge/skills do not meet professional

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 Pediatric Pathology Supplemental Guide

expectations communication in response to stress

Assessment Models or Tools ● Direct observation
● Group interview or discussions for team activities
● Individual interview
● Institutional online training modules
● Participation in institutional well-being programs
● Self-assessment and personal learning plan
Curriculum Mapping ●
Notes or Resources ● ACGME. Tools and Resources. https://www.acgme.org/What-We-Do/Initiatives/Physician-
Well-Being/Resources. 2020.
● Conran RM, Powell SZ, Domen RE, et al. Development of professionalism in graduate
medical education: a case-based educational approach from the College of American
Pathologists’ Graduate Medical Education Committee. Acad Pathol.
2018;5:2374289518773493. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039899/.
2020.
● Hicks PJ, Schumacher D, Guralnick S, Carraccio C, Burke AE. Domain of competence:
personal and professional development. Acad Pediatr. 2014;14(2 Suppl):S80-97.
https://linkinghub.elsevier.com/retrieve/pii/S1876-2859(13)00332-X. 2020.
● Joseph L, Shaw PF, Smoller BR. Perceptions of stress among pathology residents:
survey results and some strategies to reduce them. Am J Clin Pathol. 2007;128(6):911-
919. https://academic.oup.com/ajcp/article/128/6/911/1764982. 2020.
● Local resources, including Employee Assistance

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Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication

Overall Intent: To deliberately use language and behaviors to form constructive relationships with patients, to identify communication
barriers including self-reflection on personal biases, and minimize them in the doctor-patient relationships; organize and lead communication
around shared decision making
Milestones Examples
Level 1 Uses language and nonverbal behavior ● Self-monitors and controls tone, non-verbal responses, and language and asks questions
to demonstrate respect and establish rapport to invite patient/family participation

Identifies common barriers to effective ● Avoids medical jargon when talking to patients
communication (e.g., language, disability) while
● Makes sure communication is at the appropriate level to be understood by a layperson
accurately communicating own role within the
health care system ● Identifies self as pediatric pathology fellow when discussing a pathology report or
performing a fine needle aspiration
Level 2 Establishes a relationship in ● Prior to a fine needle aspiration, organizes and initiates the informed consent process,
straightforward encounters using active listening actively listens to concerns about the procedure, and clearly answers questions
and clear language

Identifies complex barriers to effective

● Uses translation service to share autopsy findings with family members
communication (e.g., health literacy, cultural)
● Tailors discussion of pathology report findings to the family’s educational level
Level 3 Sensitively and compassionately ● Discusses and writes autopsy reports with the family in mind as an audience; avoids
delivers medical information, with supervision emotionally fraught language, with supervision
● Discusses surgical pathology reports sensitively with patients when asked, with
supervision

● When prompted, acknowledges personal “desire to please” and recognizes tendency to

When prompted, reflects on personal biases
give concrete answers when none are available
while attempting to minimize communication

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barriers
Level 4 Independently, sensitively, and ● Sensitively handles fetopsy remains; tactfully writes reports resulting from a potentially
compassionately delivers medical information avoidable peripartum death
and acknowledges uncertainty and conflict
● Participates in the sharing of autopsy findings in face of family anger or medical error

Independently recognizes personal biases while

● Writes reports with nuance, acknowledging personal “desire to please” and does not give
attempting to proactively minimize
concrete answers when none are available
communication barriers
● Recognizes individual cognitive biases (anchoring, confirmation bias) in diagnostic
pathology
Level 5 Mentors others in the sensitive and ● Leads the sharing of autopsy findings in face of family anger or medical error
compassionate delivery of medical information
● Models writing autopsy reports, or surgical pathology report comments, which
acknowledge potential clinical mismanagement
Models self-awareness while teaching a ● Serves on hospital committees or initiatives to improve communication and handle error
contextual approach to minimize communication disclosure
barriers
● Runs resident teaching sessions with mock pathologist-patient information disclosure
Assessment Models or Tools ● Direct observation
● Pathology draft report review
● Self-assessment including self-reflection exercises
● Simulation
Curriculum Mapping ●
Notes or Resources ● Dintzis SM. Improving pathologist’s communication skills. AMA J Ethics. 2016;18(8):802-
808. https://journalofethics.ama-assn.org/article/improving-pathologists-communication-
skills/2016-08. 2020.
● Dintzis SM, Stetsenko GY, Sitlani CM, et al. Communicating pathology and laboratory
errors: anatomic pathologists’ and laboratory medical directors’ attitudes and experiences.

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Am J Clin Pathol. 2011;135(5):760-765.

https://academic.oup.com/ajcp/article/135/5/760/1766306. 2020.
● Laidlaw A, Hart J. Communication skills: an essential component of medical curricula.
Part I: Assessment of clinical communication: AMEE Guide No. 51. Med Teach.
2011;33(1):6-8. https://www.tandfonline.com/doi/full/10.3109/0142159X.2011.531170.
2020.
● Symons AB, Swanson A, McGuigan D, Orrange S, Akl EA. A tool for self-assessment of
communication skills and professionalism in residents. BMC Med Educ. 2009;9:1.
https://bmcmededuc.biomedcentral.com/articles/10.1186/1472-6920-9-1. 2020.

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Interpersonal and Communication Skills 2: Interprofessional and Team Communication

Overall Intent: To effectively communicate with the health care team, including both inter- and intra-departmental and consultants, in both
straightforward and complex situations
Milestones Examples
Level 1 Uses language that values all members ● Shows respect in health care team communications through words and actions such as in
of the health care team requests for intraoperative consultation or clinical consultation for fine needle aspirations
● Uses respectful communication with clerical and technical staff members
● Listens to and considers others’ points of view, is nonjudgmental and actively engaged,
and demonstrates humility

● Understands constructive feedback from the team can help improve future
Describes the utility of constructive feedback
communications
Level 2 Communicates information effectively ● Verifies understanding of own communications within the health care team (i.e., closed-
with all health care team members loop communications, restating for critical values and unexpected diagnoses, follows up in
laboratory with technologists)
● Demonstrates active listening by fully focusing on the speaker, actively showing verbal
and non-verbal signs

● Asks for feedback from the pathologist’s assistant regarding communication and
Solicits feedback on performance as a member documentation related to a complex specimen hand-off
of the health care team
Level 3 Uses active listening to adapt ● Verifies understanding by clinical physician of an unexpected diagnosis
communication style to fit team needs
● Requests a verbal read-back of frozen section results from surgeon

Integrates feedback from team members to

● Modifies documentation of on-call specimen triage in response to prior feedback
improve communication

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Level 4 Coordinates recommendations from ● Offers suggestions to negotiate or resolve conflicts among health care team members
different members of the health care team to
optimize patient care

Communicates feedback and constructive

criticism to superiors ● Respectfully points out error in pathology report or missed diagnosis identified on
secondary review for conference presentation to attending physician
Level 5 Models flexible communication ● Serves as a role model in communication with all health care team members, resolution of
strategies that value input from all health care conflicts, and providing feedback
team members, resolving conflict when needed

Facilitates regular health care team-based

● Organizes a team meeting to discuss and resolve potentially conflicting points of view on
feedback in complex situations
a diagnostic approach
Assessment Models or Tools ● Direct observation
● Medical multisource feedback
● Record (chart) review
● Simulation
Curriculum Mapping ●
Notes or Resources ● Brissette MD, Johnson K, Raciti PM, et al. Perceptions of unprofessional attitudes and
behaviors: implications for faculty role modeling and teaching professionalism during
pathology residency. Arch Pathol Lab Med. 2017;141:1394-1401.
https://www.archivesofpathology.org/doi/10.5858/arpa.2016-0477-CP. 2020.
● Conran RM, Powell SZ, Domen RE, et al. Development of professionalism in graduate
medical education: a case-based educational approach from the College of American
Pathologists’ Graduate Medical Education Committee. 2018;5: 2374289518773493.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039899/. 2020.

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● Green M, Parrott T, Cook G., Improving your communication skills. BMJ. 2012;344:e357.
https://www.bmj.com/content/344/bmj.e357. 2020.
● Henry SG, Holmboe ES, Frankel RM. Evidence-based competencies for improving
communication skills in graduate medical education: a review with suggestions for
implementation. Med Teach. 2013;35(5):395-403.
https://www.tandfonline.com/doi/full/10.3109/0142159X.2013.769677. 2020.
● Nakhleh RE, Myers JL, Allen TC, et al. Consensus statement on effective communication
of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and
cytopathology from the College of American Pathologists and Association of Directors of
Anatomic and Surgical Pathology. Arch Pathol Lab Med. 2012;136(2):148-154.
https://www.archivesofpathology.org/doi/10.5858/arpa.2011-0400-SA?url_ver=Z39.88-
2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed. 2020.
● Roth CG, Eldin KW, Padmanabhan V, Freidman EM. Twelve tips for the introduction of
emotional intelligence in medical education. Med Teach. 2019;41(7):1-4.
https://www.tandfonline.com/doi/full/10.1080/0142159X.2018.1481499. 2020.

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Interpersonal and Communication Skills 3: Communication within Health Care Systems

Overall Intent: To effectively communicate within and across health care systems using a variety of methods
Milestones Examples
Level 1 Safeguards patient personal health ● Identifies when it is acceptable to include protected health information in various forms of
information by communicating through communication
appropriate means as required by institutional
policy (e.g., patient safety reports, cell
phone/pager usage)

Identifies institutional and departmental

structure for communication of issues
● Knows the organizational structure and options for reporting concerns
Level 2 Selects forms of communication based ● Immediately pages pathology attending when previewing a case and diagnosing invasive
on context and urgency of the situation fungal disease
● Sends secure email to pathology attending when there has been a routine autopsy
notification

● Recognizes when a communication breakdown has happened and respectfully brings the
Respectfully communicates concerns about the
issue to the attention of a faculty member
system
Level 3 Communicates while ensuring security ● Demonstrates adept use of institutional paging, secure messaging, EHR-based
of personal health information, with supervision messaging, and secure texting platforms to communicate patient results, with supervision

Uses institutional structure to effectively ● Knows when to direct concerns locally, departmentally, or institutionally
communicate clear and constructive
suggestions to improve the system ● Improves methods for communicating system-wide call schedules, conference
scheduling, etc.
Level 4 Independently communicates while ● Independently demonstrates adept use of institutional paging, secure messaging, EHR-

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ensuring security of personal health information based messaging, and secure texting platforms to communicate patient results

Initiates conversations on difficult subjects with ● Participates in task force to update policy for sharing abnormal results
appropriate stakeholders to improve the system
● Communicates opportunities to departmental informatician or hospital information
technology (IT) for improvement in the LIS/EHR interface
Level 5 Guides departmental or institutional ● Leads a task force established by the hospital QI committee to develop a plan to improve
communication around policies and procedures house staff secure messaging utilization
regarding the security of personal health
information

Facilitates dialogue regarding systems issues

among larger community stakeholders ● Works with information systems to implement improvements in the LIS/EHR interface
(institution, health care system, field)
Assessment Models or Tools ● Chart review for documented communications
● Multisource feedback
● Observation of sign-outs, observation of requests for consultations
● Participation in departmental and institutional meetings
Curriculum Mapping ●
Notes or Resources ● Bierman JA, Hufmeyer KK, Liss DT, Weaver AC, Heiman HL. Promoting responsible
electronic documentation: validity evidence for a checklist to assess progress notes in the
electronic health record. Teach Learn Med. 2017;29(4):420-432.
https://www.tandfonline.com/doi/full/10.1080/10401334.2017.1303385. 2020.
● Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving
communication between clinicians. Jt Comm J Qual Patient Saf. 2006;32(3):167-175.
https://www.jointcommissionjournal.com/article/S1553-7250(06)32022-3/fulltext. 2020.

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To help programs transition to the new version of the Milestones, the original Milestones 1.0 have been mapped to the new
Milestones 2.0. Below it is indicated where the subcompetencies are similar between versions. These are not exact matches but
include some of the same elements. Not all subcompetencies map between versions. Inclusion or exclusion of any subcompetency
does not change the educational value or impact on curriculum or assessment. 
Milestones 1.0 Milestones 2.0
PC1: Procedure: Surgical Pathology Grossing PC1: Pediatric and Perinatal Pathology Grossing (Examine,
Describe, Triage, Sample, and Document)
PC2: Procedure: Intra-operative Consultation/Frozen PC2: Intra-Operative Consultation (Frozen Sections, Rapid Onsite
Section Evaluation of Fine Needle Aspiration)
PC3: Procedure: Autopsy  PC3: Autopsy
PC4: Reporting  PC4: Reporting, including Surgical Pathology, Cytopathology, and
Autopsy
MK1: Knowledge of Perinatal and Pediatric Disease  MK1: Knowledge of Pediatric and Perinatal Diseases
MK2: Application of Knowledge of Perinatal and Pediatric MK2: Clinical Reasoning
Disease to Clinical Situations 
MK3: Application of Clinical Laboratory Testing  MK2: Clinical Reasoning
SBP1: Regulatory and Compliance: Accreditation SBP4: Accreditation, Compliance, and Quality
Management
SBP2: Health Care teams SBP2: Systems Navigation for Patient-Centered Care
ICS2: Interprofessional and Team Communication
SBP3: Lab Management: Resource Utilization (personnel SBP 3: Physician Role in Health Care System
and finance) SBP5: Utilization
PBLI1: Evidence-based Utilization PBLI1: Evidence-Based Practice and Scholarship
SBP5: Utilization
PBLI2: Process Improvement and Patient Safety SBP1: Patient Safety and Quality Improvement (QI) 
PROF1: Receiving and Providing Feedback PBLI2: Reflective Practice and Commitment to Personal Growth 
PROF2: Accountability, Honesty, and Integrity PROF1: Professional Behavior and Ethical Principles
PROF2: Accountability and Conscientiousness
PROF3: Self-Awareness and Help-Seeking
PROF3: Cultural Competency SBP2: Systems Navigation for Patient-Centered Care
ICS1: Patient and Family-Centered Communication
ICS1: Communication with Health Care Providers, Families, ICS1: Patient and Family-Centered Communication
and Patients (as applicable) ICS2: Interprofessional and Team Communication 
ICS2: Personnel Management and Conflict Resolution ICS2: Interprofessional and Team Communication 
ICS3: Communication within Health Care Systems

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Available Milestones Resources

Clinical Competency Committee Guidebook, updated 2020 -

https://www.acgme.org/Portals/0/ACGMEClinicalCompetencyCommitteeGuidebook.pdf?ver=2020-04-16-121941-380

Clinical Competency Committee Guidebook Executive Summaries, New 2020 - https://www.acgme.org/What-We-

Do/Accreditation/Milestones/Resources - Guidebooks - Clinical Competency Committee Guidebook Executive Summaries

Milestones Guidebook, updated 2020 - https://www.acgme.org/Portals/0/MilestonesGuidebook.pdf?ver=2020-06-11-100958-330

Milestones Guidebook for Residents and Fellows, updated 2020 -

https://www.acgme.org/Portals/0/PDFs/Milestones/MilestonesGuidebookforResidentsFellows.pdf?ver=2020-05-08-150234-750

Milestones for Residents and Fellows PowerPoint, new 2020 -https://www.acgme.org/Residents-and-Fellows/The-ACGME-for-

Residents-and-Fellows

Milestones for Residents and Fellows Flyer, new 2020 https://www.acgme.org/Portals/0/PDFs/Milestones/ResidentFlyer.pdf

Implementation Guidebook, new 2020 - https://www.acgme.org/Portals/0/Milestones%20Implementation%202020.pdf?ver=2020-05-20-

152402-013

Assessment Guidebook, new 2020 - https://www.acgme.org/Portals/0/PDFs/Milestones/Guidebooks/AssessmentGuidebook.pdf?

ver=2020-11-18-155141-527

Milestones National Report, updated each Fall -

https://www.acgme.org/Portals/0/PDFs/Milestones/2019MilestonesNationalReportFinal.pdf?ver=2019-09-30-110837-587 (2019)

Milestones Bibliography, updated twice each year - https://www.acgme.org/Portals/0/PDFs/Milestones/MilestonesBibliography.pdf?

ver=2020-08-19-153536-447

Developing Faculty Competencies in Assessment courses - https://www.acgme.org/Meetings-and-Educational-Activities/Other-

Educational-Activities/Courses-and-Workshops/Developing-Faculty-Competencies-in-Assessment

Assessment Tool: Direct Observation of Clinical Care (DOCC) - https://dl.acgme.org/pages/assessment

Assessment Tool: Teamwork Effectiveness Assessment Module  (TEAM) - https://dl.acgme.org/pages/assessment

Learn at ACGME has several courses on Assessment and Milestones - https://dl.acgme.org/

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