Pathology Competencies for Medical Education and Educational Cases

Abstract

Current medical school curricula predominantly facilitate early integration of basic science principles into clinical practice to strengthen diagnostic skills and the ability to make treatment decisions. In addition, they promote life-long learning and understanding of the principles of medical practice. The Pathology Competencies for Medical Education (PCME) were developed in response to a call to action by pathology course directors nationwide to teach medical students pathology principles necessary for the practice of medicine. The PCME are divided into three competencies: 1) Disease Mechanisms and Processes, 2) Organ System Pathology, and 3) Diagnostic Medicine and Therapeutic Pathology. Each of these competencies is broad and contains multiple learning goals with more specific learning objectives. The original competencies were designed to be a living document, meaning that they will be revised and updated periodically, and have undergone their first revision with this publication. The development of teaching cases, which have a classic case-based design, for the learning objectives is the next step in providing educational content that is peer-reviewed and readily accessible for pathology course directors, medical educators, and medical students. Application of the PCME and cases promotes a minimum standard of exposure of the undifferentiated medical student to pathophysiologic principles. The publication of the PCME and the educational cases will create a current educational resource and repository published through Academic Pathology.

Background

Becoming a competent physician requires the ability to gain a broad foundation of knowledge, skills, and attitudes essential for independent medical practice. Essential in this is the understanding of the normal and pathological processes of each organ system, the ability to apply disease mechanisms to describe the pathobiology, and the ability to continually improve the diagnostic acumen and optimal treatment decisions through lifelong learning. The initial project to develop pathology competencies was described in the article “National Standards in Pathology Education,” ¹ where over 60 pathology course directors and department chairs submitted pathology course objectives that were extensively revised and peer-reviewed, then posted on the Association of Pathology Chairs (APC) Website in 2014, where they were available for both course directors and medical students. A website externally linked from the APC Website was maintained where anyone could leave a comment regarding the competencies. This project, the pathology competencies for medical education (PCME), was initiated and supported by the Undergraduate Medical Education Committee of the APC. ²

Most medical schools have transitioned to an integrated organ–based curriculum, ¹ where individual courses are no longer taught as distinct disciplines. The manner in which medical students are taught has also changed. The lecture format has largely been replaced with multiple types of active learning, including integrated small group discussions, team-based learning exercises, and flipped classrooms. Pathology course directors have a new challenge in education that has vastly transformed from the classic 1910 Abraham Flexner module of basic science education with individual basic science and clinical skills courses followed by 2 years of clinical practice apprenticeships ³ to an integrated and interdisciplinary medical school curriculum. In this transformation, individual disciplines are no longer presented as stand-alone courses, and the exponential expanse of medical knowledge requires an ever-changing and comprehensive understanding of pathobiology by the competent practicing physician. The importance of understanding pathobiology is underscored by the significant amount of questions included on the current US Medical Licensing Examination (USMLE), where pathobiology is tested in both Steps 1 and 3 of the licensing examinations. ⁴ Every medical student must master disease processes and therapeutics in order to become a competent intern, resident, and fully practicing physician. As stated in the current standard 7 of the Liaison Committee on Medical Education (LCME) publication “structures and functions of a medical school,” ⁵ there are important elements that must be understood including: (1) recognize and interpret symptoms and signs of disease and (2) develop differential diagnoses and treatment plans.

Pathology has a central role to assist students and physicians in (1) understanding the mechanisms of disease that lead to the signs and symptoms that must be recognized in patients, (2) forming a differential diagnosis, and (3) applying laboratory medicine that allows physicians to rule in or out individual diagnoses and make appropriate diagnostic and treatment decisions. This is in line with the Carnegie Foundation’s report calling for a new reform of learning that is “learner centered” ⁶ and for learning outcomes to be tied to competencies.

The goal of this endeavor is 3-fold: (1) to revise the previously Website-published pathology competencies as these must be a living document, meaning revised regularly to keep pace with current medical practice and understanding, to highlight the essential (or minimum) for all medical students to understand for the practice of medicine and remain current with medical practice; (2) to emphasize laboratory medicine, which is often not taught, or at best only superficially taught, in many medical school curricula; and (3) to develop a shared resource of pathology competencies and educational cases highlighting the competencies for pathology faculty, educators, and students, which are developed by or with pathologists, peer-reviewed, and represent foundational understanding of pathobiology essential for clinical practiec that can easily be adapted into any curriculum.

Pathology Competencies for Medical Education

The PCME have detailed learning objectives under each goal that direct medical students and course directors to important facets of each learning goal that can be individually applied by learners. The competencies are divided into 3 sections—disease mechanisms and processes, organ system pathology, and diagnostic medicine and therapeutic pathology—and allow flexibility for each learning institution and learner to apply the learning goals and objectives in a way that can keep the unique design of each curriculum or learning plan. The competencies are purposefully kept broad as they represent the minimum requirements of what pathology course directors across the nation have agreed upon to prepare medical students for entry into any residency program and for the subsequent contemporary practice of medicine. ¹

The learning objectives of the competencies are meant to be a living document, being continually commented upon by pathologists, medical educators, and medical students, and revised accordingly after review by an editorial group. The topics, goals, and learning objectives, as well as the comments submitted on the PCME website before November 2016, have been extensively reviewed by the original editorial group to ensure the learning objectives are current with the changing and expanding medical knowledge. Compared with the original competencies, additional sections have been developed, learning objectives have been revised, the format has been standardized, and new introductions for each section have been added. The revised competencies are found in the following pages of this article.

Educational Cases

Following publication of the original PCME, the Undergraduate Medical Educators Section (UMEDS) of APC began developing educational cases for the pathology competencies that are current, peer-reviewed, and highlight the pathology competencies in learning cases that can easily be adapted to multiple types of educational modalities. Some of the original cases were posted on the PCME website.

The format of the cases has evolved from the original cases posted on the PCME website to the present format of educational cases that are presented in this special edition of Academic Pathology. The educational cases reference the PCME from the following pages, and address at least 1 primary learning objective, but may have 1 or more secondary learning objective(s). The pathology competencies and learning objectives are clearly indicated in the beginning of each case so that the focus of the educational case is evident. Key elements of the current format include clinical presentation, discussion questions or points, learning points, and references. The clinical presentation may include images or laboratory data for the patient’s presentation. The discussion questions or points are questions or statements that promote clinical reasoning followed by detailed explanations of the pathology, medicine, or therapeutics brought up in the discussion point or question. The learning points at the end of the case highlight the main teaching points from the preceding discussion. Thus, the cases demonstrate the application of medical reasoning to clinical scenarios that allow the learner to understand and apply diagnostic principles, incorporating morphologic findings and laboratory values with discussion of the laboratory medicine essentials for accurate diagnosis and treatment. References are included in each case and will allow the reader to review the original sources used to create the learning case or gain additional in-depth information. Thus, the educational cases are written in a style that can be easily used or adapted to multiple educational formats, such as small group discussions or flipped classrooms.

Discussion

Development of the PCME and the educational cases that support the individual learning objectives is a tremendous undertaking. On the broadest level, this effort supports the LCME standard 7, which requires all medical school curricula to prepare the undifferentiated medical student with sufficient breadth and depth of knowledge for the contemporary practice of medicine. This very broad view is the level at which the objectives were originally created, intended to be the minimum-level objectives course directors nationally felt were needed for adequate understanding for the practice of medicine. In addition, the PCME can be used by individual medical schools to gain leverage for additional curriculum development, especially in laboratory medicine, which is often only minimally taught, and to help expose students to pathology as a clinical specialty. Having a national repository of competencies that is peer-reviewed allows use of learning objectives and educational cases in individual curricula, potentially relieving some of the load on pathology course directors to continually update curricula to keep up with the exponential expanse of knowledge, laboratory testing, and treatment options. And lastly, a national repository of learning objectives and cases can potentially be used to support pathology exposure in integrated curricula to ensure exposure to a minimum amount of pathology for all students. We invite our audience to comment on the depth and breadth of the competencies found on the following pages.

The primary audience for the educational cases is our pathology educators, especially since not all pathology course directors are pathologists. The cases are peer-reviewed, appropriately referenced, and can be used as teaching material by faculty and students. Discussions that follow each discussion point should be broad enough to give faculty who may use these educational cases a deeper understanding of the pathobiology behind the learning objectives needed to teach or explain the concepts to the students. Here we emphasize that the discussions should explain the basic science and medicine behind each objective at a deeper level than the bare minimum of the objectives. As educators, we must be able to explain and build on basic knowledge concepts for our students, tying the information together in a tightly woven fabric across disciplines. In addition, the discussions should explain the clinical reasoning behind each of the discussion points. Thus the educational cases are not intended to be a bare-bones review, but rather a fuller discussion building on concepts and explaining the thought process that will allow our students to become critical thinkers and apply new knowledge in the future. Having said this, the cases may be adapted to different levels or types of learners during different parts of the curriculum. For example, a case may present a simple benign lesion at a basic level where the intent is to highlight histologic features that help to differentiate between benign and malignant processes, however, another case may cover that same lesion in a different scenario to highlight clinical or diagnostic aspects of that specific disease.

Examples of educational cases can be found in the following pages for a variety of objectives from the three pathology competencies. The educational cases allow for individual use of the cases as students for primary learning or inclusion in medical school curricula in an adaptable format for a variety of teaching venues including laboratories, small group discussions or Team-Based-Learning. The educational cases are intended to facilitate knowledge integration and retention essential for clinical practice. Moving forward, we invite the broader community to submit educational cases to Academic Pathology to grow this national resource.

Conclusion

The educational cases highlight principles of the 3 competencies—(1) disease mechanisms and processes, (2) organ system pathology, and (3) diagnostic medicine and therapeutic pathology—and are presented in a way to help the development of clinical reasoning and the application of basic science into medicine, as well as increase the diagnostic acumen and treatment of disease. Continuing to build and review the PCME and create educational cases to highlight what we as a pathology education community feel is essential knowledge for the practice of medicine requires broader input.

We encourage readers to comment on the pathology competencies to further shape what we as pathologists feel is essential for medical education. Comments regarding the PCME can be sent to Jen Norman, in the APC office, at [e-mail]. As stated above, the competencies are a living document requiring periodic updates. Comments will be reviewed and revised competencies will be published. In addition, we invite readers to submit educational cases directly to Academic Pathology, following the submission guidelines found on the Academic Pathology website.

We are grateful to Academic Pathology that the PCME and educational cases will be published as an easily accessible resource for educators and students.