Evaluation of different testing methods for identification of RhIG in red blood cell antibody detection.

BACKGROUND: RhIG has had great success in protecting fetuses from potential harm; however, little work has been done to demonstrate how long RhIG reactivity is detected in the mother after administration when using common red blood cell antibody detection methods. STUDY DESIGN AND METHODS: A retrospective investigation was performed examining positive antibody identification panels due to RhIG. These panels were run on solid-phase (SP) testing. The time to a positive result, length of detection, and positive strength of reactivity (PSR) were evaluated. Additionally, a comparative study was performed evaluating how sensitive SP, gel (GT), and tube testing (TT) were at detecting RhIG using serially diluted plasma samples spiked with different RhIG formulas. RESULTS: Retrospectively, most antibody identification panels by SP were positive 3.5 months after RhIG administration and demonstrated a strong PSR. The longest recorded positive panel was present at 4.5 months. RhIG administered intramuscularly could not be detected until several hours after injection. The comparative study showed that SP was the most sensitive method while GT and TT were comparable to one another in detecting RhIG. SP also recorded strong PSR at very low concentrations of RhIG. GT and TT recorded weak PSR even with higher concentrations of RhIG. CONCLUSION: SP is the most sensitive testing method and has the ability to detect RhIG 4 to 5 months after administration. TT and GT have the ability to detect RhIG up to 3 to 4 months after administration. Different RhIG formulas may show slightly different lengths of detection.

A national survey of eating disorder training.

OBJECTIVE: Eating disorders (EDs) result in the highest mortality rate of all psychiatric disorders, and in the United States, approximately one in twenty females suffers from an eating disorder. However, training provided within residency programs to address the needs of these patients is sparse. The objective of this study was to conduct a national survey that assesses the amount of EDs training for trainees across five ACGME accredited specialties: internal medicine, pediatrics, family medicine, psychiatry, and child and adolescent psychiatry. The results of the survey will be used to develop strategies to improve eating disorder education among residents. METHOD: Eight hundred eighty training coordinators were contacted using information available on the ACGME website and asked to complete the survey. RESULTS: Of the 637 responding programs, 514 did not offer any scheduled or elective rotations for EDs. Of the 123 programs offering rotations, only 42 offered a formal, scheduled rotation. Child and adolescent psychiatry offered the most clinical experiences, and pediatric programs offered the greatest number of didactic hours on EDs. DISCUSSION: Training in EDs is limited. Simulated patient encounters, massive open online courses, web-based curricula, dedicated rotations and clinical experiences, didactic curricula, and brief-training programs may help to improve eating disorder diagnostic and treatment skills among trainees.

Immune functional assay for immunosuppressive management in post-transplant malignancy.

Immunosuppression management in post-transplant malignancy is challenging because of a lack of objective immunologic assessment tools. The ImmuKnow assay measures the ATP level from CD4 T cells, quantifying cell-mediated immunity and providing an insight into the immune status of transplant recipients. Its potential use in patients with post-transplant de novo malignancy was evaluated. Thirteen adult transplant patients with de novo malignancy were divided into survivors (n = 9) and non-survivors (n = 4) after malignancy treatment. Tacrolimus and the ImmuKnow levels were monitored before, during, and after malignancy treatment. The ImmuKnow level in non-survivors group was significantly lower before and after malignancy treatment compared to survivors group (p = 0.013 and 0.0014 respectively). In survivor group, the ImmuKnow level was significantly decreased during malignancy treatment (p = 0.019) but recovered to the initial level after the treatment. However, in non-survivor group, the ImmuKnow level remained suppressed throughout the observed period despite a reduction in immunosuppressive drug levels. The ImmuKnow assay can be an objective means evaluating immune status of patients with de novo malignancy. The ImmuKnow assay can express the degree of immune suppression induced by chemotherapeutic or radiation therapy and may be a useful tool in optimizing the timing of re-introduction of immunosuppression after malignancy treatment.

An examination of professional and ethical issues in the fellowship application process in pathology.

Approximately 34 medical specialty and subspecialty fellowship programs in the United States have formalized the application process through the National Resident Matching Program. This approach sets standards for the application process, offers a formalized match similar to that for residency programs, functions within a specific timeline, and establishes binding rules of behavior for both applicants and programs. For fellowship programs that operate outside the National Resident Matching Program, such as those in pathology, no published guidelines exist to help programs and applicants address the many questions and problems that can arise. As a result, programs are free to set their own timelines for interviews, application requirements, contract negotiations and finalizations, and other details. Consequently, applicants often feel pressured to apply earlier and earlier in their residency for competitive fellowship programs, are often required to fill out multiple unique applications, may feel no "loyalty" toward honoring an acceptance without a contract, and often feel disenfranchised by the whole process. This article addresses professional and ethical aspects of the current application process and offers possible solutions for improving it.

Optimizing donor scheduling before recruitment: An effective approach to increasing apheresis platelet collections.

BACKGROUND/AIMS: Typical approach for increasing apheresis platelet collections is to recruit new donors. Here, we investigated the effectiveness of an alternative strategy: optimizing donor scheduling, prior to recruitment, at a hospital-based blood donor center. METHODS: Analysis of collections, during the 89 consecutive months since opening of donor center, was performed. Linear regression and segmented time-series analyses were performed to calculate growth rates of collections and to test for statistical differences, respectively. RESULTS: Pre-intervention donor scheduling capacity was 39/month. In the absence of active donor recruitment, during the first 29 months, the number of collections rose gradually to 24/month (growth-rate of 0.70/month). However, between month-30 and -55, collections exhibited a plateau at 25.6 ± 3.0 (growth-rate of -0.09/month) (p<0.0001). This plateau-phase coincided with donor schedule approaching saturation (65.6 ± 7.6% schedule booked). Scheduling capacity was increased by following two interventions: adding an apheresis instrument (month-56) and adding two more collection days/week (month-72). Consequently, the scheduling capacity increased to 130/month. Post-interventions, apheresis platelet collections between month-56 and -81 exhibited a spontaneous renewed growth at a rate of 0.62/month (p<0.0001), in absence of active donor recruitment. Active donor recruitment in month-82 and -86, when the donor schedule had been optimized to accommodate further growth, resulted in a dramatic but transient surge in collections. CONCLUSION: Apheresis platelet collections plateau at nearly 2/3rd of the scheduling capacity. Optimizing the scheduling capacity prior to active donor recruitment is an effective strategy to increase platelet collections at a hospital-based donor center.

Due Process in Medical Education: Legal Considerations.

Throughout the medical education continuum, some students encounter difficulty in meeting academic or professional standards that leads to remediation or dismissal. Termination of a student without due process may lead to litigation by deprivation of a student's property or liberty interest. This article outlines the concept of procedural and substantive due process as applied to litigated student dismissal cases in undergraduate and graduate medical education. Determination of the amount of due process owed is based on whether the dismissal is academic or nonacademic. The decision to dismiss a student where the entire student record has been reviewed, due process provided, and the institution complied with its own policies is usually upheld by the courts in litigation.

The Recent Pathology Residency Graduate Job Search Experience: A Synthesis of 5 Years of College of American Pathologists Job Market Surveys.

CONTEXT: - Pathology residents and fellows tailor their training and job search strategies to an actively evolving specialty in the setting of scientific and technical advances and simultaneous changes in health care economics. OBJECTIVE: - To assess the experience and outcome of the job search process of pathologists searching for their first non-fellowship position. DESIGN: - The College of American Pathologists (CAP) Graduate Medical Education Committee has during the past 5 years sent an annual job search survey each June to CAP junior members and fellows in practice 3 years or less who have actively searched for a non-fellowship position. RESULTS: - Job market indicators including job interviews, job offers, positions accepted, and job satisfaction have remained stable during the 5 years of the survey. Most survey respondents who had applied for at least 1 position had accepted a position at the time of the survey, and most applicants who had accepted a position were satisfied or very satisfied. However, most attested that finding a non-fellowship position was difficult. Despite a perceived push toward subspecialization in surgical pathology, the reported number of fellowships completed was stable. Respondent demographics were not associated with job search success with 1 significant exception: international medical school graduate respondents reported greater perceived difficulty in finding a position, and indeed, fewer reported having accepted a position. CONCLUSIONS: - Pathology residents and fellows seeking their first position have faced a relatively stable job market during the last 5 years, with most accepting positions with which they were satisfied.

Development of Professionalism in Graduate Medical Education: A Case-Based Educational Approach From the College of American Pathologists' Graduate Medical Education Committee.

Professionalism and physician well-being are important topics in academic medicine. Lapses in professional judgment may lead to disciplinary action and put patient's health at risk. Within medical education, students and trainees are exposed to professionalism in the institution's formal curriculum and hidden curriculum. Development of professionalism starts early in medical school. Trainees entering graduate medical education already have developed professional behavior. As a learned behavior, development of professional behavior is modifiable. In addition to role modeling by faculty, other modalities are needed. Use of case vignettes based on real-life issues encountered in trainee and faculty behavior can serve as a basis for continued development of professionalism in trainees. Based on the experience of program directors and pathology educators, case vignettes were developed in the domains of service, research, and education and subdivided into the areas of duty, integrity, and respect. General and specific questions pertaining to each case were generated to reinforce model behavior and overcome professionalism issues encountered in the hidden curriculum. To address physician burnout, cases were generated to provide trainees with the skills to deal with burnout and promote well-being.

Forensic Pathology Education in Pathology Residency: A Survey of Current Practices, a Novel Curriculum, and Recommendations for the Future.

Forensic pathology is a fundamental part of anatomic pathology training during pathology residency. However, the lack of information on forensic teaching suggests the highly variable nature of forensic education. A survey of pathology residency program directors was performed to determine key aspects of their respective forensic rotations and curriculum. A total of 38.3% of programs from across the country responded, and the survey results show 5.6% don't require a forensic pathology rotation. In those that do, most forensic pathology rotations are 4 weeks long, are done at a medical examiner's office, and require set prerequisites. A total of 21.1% of responding programs have residents who are not receiving documented evaluations for this rotation. While 39.6% of programs have a defined forensics curriculum, as many as 15% do not. Furthermore, nearly 43% of programs place no limit on counting forensic autopsies when applying for pathology board examinations. Our survey confirmed the inconsistent nature of forensic pathology training in resident education. Additionally, our curriculum was reorganized to create a more robust educational experience. A pre- and post-forensic lecture quiz and Resident In-Service Examination scores were analyzed to determine our curriculum's impact and effectiveness. Analysis of our pre- and post-lecture quiz showed an improved overall average as well as an increase in Resident In-Service Examination scores, indicating improved general forensic pathology knowledge. Using this knowledge, along with changes in our curriculum, we generated a number of recommendations for improving forensic pathology education in pathology residency.

Employer Expectations for Newly Trained Pathologists: Report of a Survey From the Graduate Medical Education Committee of the College of American Pathologists.

CONTEXT: -Multiple sources have identified challenges that training programs face in preparing graduates for the "real world" practice of pathology, and many training programs have sought to decrease the gap between skills acquired during training and those required in practice. However, there exists the possibility that some of the difficulty experienced by newly trained pathologists and employers might arise from differences between employer expectations of new hires and what applicants expect from their first job. OBJECTIVE: -To define the constellation of skills and attributes employers prioritize when hiring newly trained pathologists. DESIGN: -A survey of fellows of the College of American Pathologists in practice for 5 or more years in the United States was administered and the results were analyzed. RESULTS: -A total of 630 pathologists who were responsible for hiring a new-in-practice pathologist completed the survey. Regardless of practice setting, certain skills and attributes were rated critically important in new hires, including ethics/integrity, work ethic, and professionalism. Seventy-one percent reported having some difficulty hiring entry-level pathologists and cited inadequate training/experience during residency, and applicants having unrealistic expectations regarding work load/hours as the most common reasons. CONCLUSIONS: -Prospective employers not only expect well-developed diagnostic skills in their job applicants, but also require evidence of a strong work ethic and outstanding professionalism. Successful applicants must display willingness to assume responsibilities and flexibility regarding existing and new responsibilities. A secondary but important finding of this survey was that most jobs are garnered through word-of-mouth recommendations; therefore, it is crucial for pathologists-in-training to hone their networking skills.

Perceptions of Unprofessional Attitudes and Behaviors: Implications for Faculty Role Modeling and Teaching Professionalism During Pathology Residency.

CONTEXT: - Changes occurring in medicine have raised issues about medical professionalism. Professionalism is included in the Core Competencies and Milestones for all pathology residents. Previous studies have looked at resident professionalism attitudes and behaviors in primary care but none have looked specifically at pathology. OBJECTIVE: - To examine behavior and attitudes toward professionalism within pathology and to determine how professionalism is taught in residency programs. DESIGN: - Surveys were sent to all College of American Pathologists junior members and all pathology residency program directors, and responses were compared. RESULTS: - Although no single behavior received the same professionalism rating among residents and program directors, both groups identified the same behaviors as being the most unprofessional: posting identifiable patient information or case images to social media, making a disparaging comment about a physician colleague or member of the support staff on social media or in a public hospital space, and missing work without reporting the time off. Faculty were observed displaying most of these behaviors as often or more often than residents by both groups. The most common means to teach professionalism in pathology residencies is providing feedback as situations arise and teaching by example. Age differences were found within each group and between groups for observed behaviors and attitudes. CONCLUSIONS: - As teaching by example was identified as a common educational method, faculty must be aware of the role their behavior and attitudes have in shaping resident behavior and attitudes. These results suggest a need for additional resources to teach professionalism during pathology residency.

Entrustable Professional Activities for Pathology: Recommendations From the College of American Pathologists Graduate Medical Education Committee.

Competency-based medical education has evolved over the past decades to include the Accreditation Council for Graduate Medical Education Accreditation System of resident evaluation based on the Milestones project. Entrustable professional activities represent another means to determine learner proficiency and evaluate educational outcomes in the workplace and training environment. The objective of this project was to develop entrustable professional activities for pathology graduate medical education encompassing primary anatomic and clinical pathology residency training. The Graduate Medical Education Committee of the College of American Pathologists met over the course of 2 years to identify and define entrustable professional activities for pathology graduate medical education. Nineteen entrustable professional activities were developed, including 7 for anatomic pathology, 4 for clinical pathology, and 8 that apply to both disciplines with 5 of these concerning laboratory management. The content defined for each entrustable professional activity includes the entrustable professional activity title, a description of the knowledge and skills required for competent performance, mapping to relevant Accreditation Council for Graduate Medical Education Milestone subcompetencies, and general assessment methods. Many critical activities that define the practice of pathology fit well within the entrustable professional activity model. The entrustable professional activities outlined by the Graduate Medical Education Committee are meant to provide an initial framework for the development of entrustable professional activity-related assessment and curricular tools for pathology residency training.

Professionalism in Pathology: A Case-Based Approach as a Potential Educational Tool.

CONTEXT: -Professionalism issues in residency training can be difficult to assess and manage. Generational or role-based differences may also exist between faculty and residents as to what constitutes unprofessional behavior and how to manage it. OBJECTIVE: -To examine and compare how faculty and residents would approach the same 5 case scenarios detailing various aspects of unprofessional behavior. DESIGN: -Five case scenarios highlighting various unprofessional behaviors were presented in a workshop at an annual meeting of pathology department chairs, residency program directors, and undergraduate pathology medical educators (ie, pathologists involved in medical student pathology education). The same cases were presented to a cohort of pathology residents currently in training. A standard set of responses were offered to the participants, polling results were collected electronically, and results were compared. RESULTS: -Faculty and residents were fairly consistent within their respective groups. In a subset of cases, faculty were more likely to favor working with the individual in the scenario, whereas resident respondents were more likely to favor either no response or a severe response. Generational or role-based differences were also potentially evident. CONCLUSIONS: -Assessing expectations and differences around professionalism for both faculty and residents should be considered as part of any educational and management approach for professionalism. Although a level of generational differences appears to be evident in this study regarding the recognition and management of unprofessional behavior, there was also agreement in some cases. Further exploration into the discrepant responses between faculty and residents may prove useful in developing educational, assessment, and remediation resources.

The Ethics of Ambiguity: Rethinking the Role and Importance of Uncertainty in Medical Education and Practice.

Understanding and embracing uncertainty are critical for effective teacher-learner relationships as well as for shared decision-making in the physician-patient relationship. However, ambiguity has not been given serious consideration in either the undergraduate or graduate medical curricula or in the role it plays in patient-centered care. In this article, the author examines the ethics of ambiguity and argues for a pedagogy that includes education in the importance of, and tolerance of, ambiguity that is inherent in medical education and practice. Common threads running through the ethics of ambiguity are the virtue of respect, and the development of a culture of respect is required for the successful understanding and implementation of a pedagogy of ambiguity.

The Pathologist as Poet.

The role of the humanities (eg, philosophy, bioethics, literature, music, theater, religion, anthropology) in medical education has been argued long and hard for decades. It is argued that the study of subjects included in the humanities can enhance critical thinking skills, foster a deeper level of learning and understanding, and help to enhance one's level of compassion, empathy, and moral/ethical reasoning. It is the author's contention that writing and reading poetry (as an example of a personal pursuit in the humanities) can help achieve these goals not only in our contact with patients but also in our contact with other humans and cultures in the world at large.

Professionalism in Residency Training: A Compilation of Desirable Behaviors and a Case-Based Comparison Between Pathologists in Training and Practice.

Professionalism is one of the most important competencies for physicians but is also the most difficult to teach, assess, and manage. To better understand professionalism in pathology, we surveyed practicing pathologists and pathology residents and fellows in training. We identified 12 key desirable attributes of professionalism. In addition, 8 case scenarios highlighting unprofessional behavior were presented, and results between pathologists in practice and in training were compared. No significant differences between attending pathologists and residents were identified in how these cases should be managed. Our study demonstrated remarkable concordance between practicing pathologists and residents as to what constitutes professionalism and how to manage unprofessional behavior. Our case-based approach can be a useful technique to teach professionalism to both pathologists in practice and in training.

Ethical issues in transfusion medicine: the safety of blood and hematopoietic stem cell donation.

Blood and hematopoietic stem cell donors present special challenges to the transfusion medicine and hematology services. The autologous donor has a personal, vested interest in the donation, but the allogeneic donor is usually donating for altruistic reasons. Our ethical obligation and duty to donors requires that the donor be fully informed of any risks and benefits associated with the donation process. This duty is even more imperative as donors are increasingly exposed to a variety of medications to optimize the production and collection of hematopoietic cells. Transfusion medicine professionals must work to safeguard the health of the donor. The establishment of a national donor registry to collect and analyze short-term and long-term safety data is recommended.

Donor-specific antibody to trans-encoded donor HLA-DQ heterodimer.

The majority of de novo donor specific HLA antibodies (DSAs) in transplant patients are directed to HLA-DQ antigens, which consist of a heterodimer of alpha and beta chains. Although a heterodimer can theoretically be cis- or trans-encoded, the sensitizing forms generally appear to be forms. DSA to DQ trans-heterodimer has never been reported. We reviewed 360 post-kidney transplant recipients (transplant: 2002-2013; follow-up: 5.6±3.3years). DQ DSA was detected in 46 of 57 patients who developed DSA. DSA specificity was consistent with donor mismatched DQ trans-heterodimers in three patients: DQ2.5 (DQB1*02, DQA1*05), DQ2.3 (DQB1*02, DQA1*03), and DQ4.3 (DQB1*04, DQA1*03). Two of them eventually lost grafts (2 and 5years later) with allograft nephropathy. In conclusion, post-transplant patients may develop DSA to donor DQ trans-heterodimers. Further studies are warranted to determine the clinical significance of such DSAs.