College of American Pathologists
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  Need CP practice? CPIP keeps skills current


CAP Today




May 2009
Feature Story

Mariann Stephens

Thomas M. Sodeman, MD, was faced with an offer he couldn’t refuse when CAP president Jared N. Schwartz, MD, PhD, asked him in 2008 to chair the CAP Clinical Pathology Resource Committee. Dr. Sodeman, who had at that time just completed his term as CAP president, had been talking for years about a continuing medical education course for anatomic pathologists who have responsibility for the clinical laboratory. Newly retired then as chair of laboratory medicine at North Shore Long Island Jewish Health System, he had the time to collaborate on a CME course in clinical pathology, starting with an educational tool that would allow anatomic pathologists to experience decisionmaking on the clinical side. The result, one year later, is the CAP Clinical Pathology Improvement Program, or CPIP, an online, hands-on, interactive CME course using actual case studies.

The CPIP will appeal to anatomic pathologists who have responsibilities in the clinical laboratory and to all pathologists who are preparing for Maintenance of Certification examinations. It will also interest residents who are preparing for their American Board of Pathology examinations in clinical pathology. And it is likely to engage almost any pathologist, Dr. Sodeman says: “Pathologists are curious people and this is their sort of thing. If you give them a case scenario, they’re going to want to work their way through it.”

The program will provide cases in practical clinical pathology and over the course of time will cover the eight major areas of the ABP examination: chemistry, hematology, coagulation, immunology, transfusion medicine, microbiology, molecular genetic pathology, and laboratory management. The semiannual courses will generally cover five of the eight subject areas so all topics are addressed within the year.

The Clinical Pathology Resource Committee will launch the first online offering in July; the second course is planned for December. Pathologists and residents can enroll by calling the CAP contact center (800-323-4040) or online at (on the Education Programs tab). Multiple subscriptions can be ordered at a cost savings for pathologists and residents. Pathologists who received their CP certificates during or after 2006 must earn 70 category 1 CME credits every two years, 56 of which must be in their practice area. CPIP participants can earn up to five CME credits annually for completing the two courses.

Dr. Sodeman is also a member of the CAP Membership Development Committee, Diagnostic Intelligence and Health Information Technology Committee, and the Ad Hoc Committee on Lab Quality and Improvements for the 21st Century. He has been selected to receive this fall the CAP Pathologist of the Year Award, and he agreed this spring to talk with CAP TODAY about the CPIP launch.

Why is it important that pathologists enroll in the CPIP?

In both CP and AP, the discipline is evolving and it is a challenge to stay current. As clinical and anatomic pathology have moved forward, technical knowledge and clinical applications have increased dramatically. We can try to drive people to be extremely knowledgeable on the technical side, but that isn’t the intent of this program. That’s what residency does; as a resident, you learn how to do all the technical aspects, and because you’re a physician it’s assumed you have an understanding of the clinical applications. Our intent is to bring everybody up to date on the clinical applications.

The growing demand for maintenance of certification requires that those who practice predominantly in one area of pathology attempt to maintain knowledge throughout the fields they are expected to represent. For those residents who are completing their training now, MOC will require an exam at the end of 10 years, and the intent of the exam is to determine that individuals have remained current. If you’re in an environment where you practice mostly anatomic pathology, the goal of this program is to offer you case scenarios that will focus on current activities in all the fields of clinical pathology.

How is the course set up?

We’re not trying teach the ‘techie’ side of clinical pathology; we’re trying to build skills on the clinical side. So the case studies have been designed as consultative case scenarios. A problem is presented to the pathologist. Information is revealed sequentially, as it would be in the laboratory, and the pathologist works through a series of prompts to make a final recommendation. It really is a clinically based program, not a technically based program. That’s not to say you don’t have to understand the technology to adequately answer some of the questions, but this is set up as an Internet-based program that first gives a case scenario, the pathologist is asked a question, and that leads to additional information and an answer. The answer will provide additional feedback that may then require you to ask for more information, such as choosing the next correct step or action, like ordering a followup test. Ultimately, the path will lead to a conclusion representing the most logical next step.

It’s Internet based, so as you go through the course, you’ll be able to stop and go to a link for additional background. We can link to a slide—a peripheral blood slide or a protein electrophoresis pattern perhaps. And, of course, there is immedi­ate feedback.

The topics in the first mailing include HIPAA, which is a laboratory management topic, along with chemistry, medical microbiology, transfusion medicine, and hematology.

The plan is five basic case scenarios, though the number of cases will depend on the questions. If it turns out that one area may be better with one long case scenario and another may be better with three or four shorter cases, we’ll do that. For example, the first management topic is HIPAA, and it turns out it is much better to give four short HIPAA case scenarios than one long one. We’ll give them a classic case—say a hospital administrator calls up and wants information on a patient who is the wife of a board member. What is your first step? There are four possible answers to that and only one is correct. That takes you to a discussion of the HIPAA regulations and another series of questions. One problem with Internet-based learning is that it can get boring. This adds an interactive element and should be sufficiently dynamic to hold the learner’s interest.

How much time will be required to complete each course?

That will depend on the person’s knowledge and the length of the questions. We have estimated about 2.5 hours.

What skill in clinical pathology is the most challenging to teach?

For most pathologists, it’s not the knowledge base—most of them have the knowledge base. It’s how to use it. The most difficult piece is how to approach the decisions that should be derived from the information at hand. For instance, in the HIPAA case I described, how do you direct a hospital administrator to the right place without getting into an argument or an embarrassing situation? The clinical cases are structured to direct the physician to the most appropriate answer.

Will much of the management section focus on ways to finesse difficult situations?

As they move through, they will get a sense of how to manage the situations, yes, but we also hope to bring new knowledge. This program is not intended to rehash the old stuff, though some of that will be in it, but to bring forward some of the more cutting-edge issues. The cases will be a mixture of both.

Who should enroll in the CPIP?

It’s open to everyone, but we’re targeting the physician who is practicing both anatomic and clinical pathology as well as residents preparing for their boards. The intent is to reinforce clinical pathology knowledge in someone who is practicing clinical pathology on a limited basis.

You’re planning to use genuine case studies. Where will they come from?

The committee will write up the first ones from their own practices, but we have to begin to get people interested in the program so they will submit cases from their own experience. We hope people who have interesting cases will be willing to present them. We have a standard Word document template to put them in. Pathologists will be able to submit the cases for the committee to review, and we hope to build a bank. Then we can expand the number of course offerings.

I think we’ll get a lot of cases. I was at a meeting this weekend and asked four people; they all volunteered. Everybody has an interesting case they want to share. Developing these things takes a lot of time, but one of the wonderful things about the College membership is its willingness to dedicate considerable personal time to the profession. In a program like this one, we are highly dependent on pathologists giving personal time to developing case scenarios. We welcome case scenarios from everyone.

The focus will be on problems that occur within the laboratory, whether they are clinical in nature or are clinical problems that require a strong knowledge of technology. For example, Robert Farnham, MD, is working on a thyroid case where the lab didn’t have the right reference range for the right age group and therefore the clinician used the data inappropriately.

Another example is a microbiology case in which the pathologist must decide what steps to take when there is an unusual susceptibility test result on a positive blood culture. The pathologist will receive pertinent information just as in the lab, such as a Gram stain image, a susceptibility profile, the results of special tests with explanations, as well as the next steps to take per Clinical and Laboratory Standards Institute guidelines. In a similar fashion, a hemoglobin abnormality is explored in detail. The pathologist will have the family history, whole blood smear images, lab reports, and ancillary test results such as hemoglobin electrophoresis patterns. The case will provide detailed discussions of result interpretations.

Clinical pathology is often a judgment call. Do you foresee controversy?

The committee reviews every case scenario; we have a chance to see what the author has selected. There is a certain element of opinion, unlike a technical issue involving an analyte and technical process. It’s likely there will be debate on some of these questions because of their clinical nature; for example, there is likely to be a difference of opinion on the HIPAA question I described. The author of a question may be challenged on his or her selection of answer. When you get to a clinical issue, there are always some branches in there and questions about selecting the right branch to pursue. It’s good for those who do not practice a lot of clinical pathology to appreciate the challenges; we see that as a plus.

When did the CPIP get its start?

It’s a program we thought of way back during the strategic planning for my presidency, in 2004 and 2005. That was a long time ago; we just didn’t get around to it. Jared Schwartz was extremely interested in the program, so he appointed me as committee chair and now we’re going to bring it forward.

Our biggest concern is that some anatomic pathologists won’t realize they’d better do this. Ultimately, even the older pathologists who have lifelong board certification are likely to be required to participate in an MOC process. Insurance companies and hospital privileges will drive that because the general concern of the public is to see that the physician is up to date. Even pathologists who have been out there for some time may in the end be required to demonstrate their knowledge through examination. If that is the case, this type of program will give them the basic information they’re likely to need

How will the CPIP contribute to improvements in daily practice?

Participants will improve their diagnostic and laboratory management skills and their ability to make optimal use of the clinical presentation and findings in arriving at a diagnosis. They will learn how to ask the right questions in a clinical consultation and recognize information about abnormal results that is most useful to report to clinicians. And pathologists will refine their ability to recognize multiple paths that can lead to the same outcome and apply that skill in recommending actions most likely to improve patient outcomes. They will learn to think through a clinical case in terms of a series of events—given one result, what is the next diagnostic step? What is the best course of action from there? If it is positive, or negative, what do I tell the physician or patient? Which logical path will identify the best treatment alternatives?

Mariann Stephens is a writer in La Grange Park, Ill. Members of the CAP Clinical Pathology Resource Committee, in addition to its chair, Dr. Sodeman, are Robert Farnham III, MD, Michael Petzar, MD, Sandra Richter, MD, Lynne Uhl, MD, and Jeremy Patrick Crim, MD. To enroll, or if you have questions about the Clinical Pathology Improvement Program, call the CAP customer contact center at 800-323-4040 option 1#.

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