Neuropathology Supplemental Guide Supplemental Guide: Neuropathology November 2020 1 Neuropathology Supplemental Guide TABLE OF CONTENTS INTRODUCTION ............................................................................................................................. 3 PATIENT CARE .............................................................................................................................. 4 AUTOPSY ....................................................................................................................................... 4 SURGICAL NEUROPATHOLOGY ........................................................................................................ 7 INTRA-OPERATIVE CONSULTATION (IOC), INCLUDING FROZEN SECTION............................................ 9 REPORTING .................................................................................................................................. 11 MEDICAL KNOWLEDGE .............................................................................................................. 13 DIAGNOSTIC KNOWLEDGE ............................................................................................................. 13 NEUROPATHOLOGY INSTRUCTION .................................................................................................. 15 CLINICAL REASONING ................................................................................................................ 16 SYSTEMS-BASED PRACTICE .................................................................................................... 18 PATIENT SAFETY AND QUALITY IMPROVEMENT (QI) ........................................................................ 18 SYSTEMS NAVIGATION FOR PATIENT-CENTERED CARE ................................................................... 20 PHYSICIAN ROLE IN HEALTH CARE SYSTEM ................................................................................... 23 ACCREDITATION, COMPLIANCE, AND QUALITY ................................................................................ 25 UTILIZATION ................................................................................................................................. 27 PRACTICE-BASED LEARNING AND IMPROVEMENT .............................................................. 28 EVIDENCE-BASED PRACTICE AND SCHOLARSHIP ............................................................................ 28 REFLECTIVE PRACTICE AND COMMITMENT TO PERSONAL GROWTH................................................. 30 PROFESSIONALISM .................................................................................................................... 32 PROFESSIONAL BEHAVIOR AND ETHICAL PRINCIPLES ..................................................................... 32 ACCOUNTABILITY AND CONSCIENTIOUSNESS .................................................................................. 35 SELF-AWARENESS AND HELP-SEEKING ......................................................................................... 37 INTERPERSONAL AND COMMUNICATION SKILLS ................................................................. 39 PATIENT- AND FAMILY-CENTERED COMMUNICATION ....................................................................... 39 INTERPROFESSIONAL AND TEAM COMMUNICATION ......................................................................... 41 COMMUNICATION WITHIN HEALTH CARE SYSTEMS .......................................................................... 43 MAPPING OF 1.0 TO 2.0 .............................................................................................................. 45 RESOURCES ................................................................................................................................ 47 2 Neuropathology Supplemental Guide Milestones Supplemental Guide This document provides additional guidance and examples for the Neuropathology 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. 3 Neuropathology Supplemental Guide Patient Care 1: Autopsy Overall Intent: To demonstrate competence in removal, sampling, and gross/histologic interpretation of autopsy neuropathology specimens Milestones Examples Level 1 Performs simple extractions, including ● Performs extraction of brain and spinal cord from patient who died of hypertrophic removal of the brain and spinal cord, with cardiomyopathy with no anticipated central nervous system findings, with supervision supervision Participates in brain cutting conference and ● Identifies basal ganglia, thalamus, and hippocampus at brain cutting conference identifies basic gross neuroanatomy Recognizes microscopic anatomy, as well as ● Recognizes basal ganglia, hippocampus, and visual cortex on a slide normal and abnormal histologic findings Level 2 Independently performs simple ● Independently performs extraction of brain and spinal cord from patient who died of extractions, including removal of the brain and hypertrophic cardiomyopathy with no anticipated central nervous system findings spinal cord Participates in the brain cutting conference and ● In a patient with right middle cerebral artery occlusion, identifies the distribution of the selects tissue samples in simple cases based on right middle cerebral artery and select sections to demonstrate anticipated pathology gross findings and relevant clinical and imaging data Interprets common histologic findings and ● Identifies acute and subacute hypoxic ischemic changes in the brain chooses relevant ancillary testing, with supervision Level 3 Performs complex extractions, including ● Performs extraction of brain from patient with prior history of brain surgery, with eye removal, if indicated, with supervision supervision ● Utilizes anterior approach for spinal cord extraction in a case of a patient with posterior spine hardware ● Safely removes, cuts, and triages brain specimen suspected of having prion disease Leads the brain cutting conference and selects ● Highlights key anatomic findings to learners at brain cutting conference, and selects tissue samples in complex cases, with appropriate tissue samples from a case of Pick’s disease, with supervision supervision 4 Neuropathology Supplemental Guide Interprets uncommon histologic findings and ● Interprets findings in a complex case of multiple sclerosis and can choose stains to chooses relevant ancillary testing, with identify demyelination supervision ● Identifies subtle amyloid plaques and neurofibrillary tangles in a case of Alzheimer’s disease, orders appropriate work-up, and additionally differentiates from primary age- related tauopathy ● Identifies spongiform encephalopathy and recommends appropriate work-up to rule out prion disease Level 4 Independently performs all aspects of ● Independently extracts the brain and spinal cord from a patient with prior history of gross evaluation including multiple brain surgeries and craniospinal radiation complex extractions Independently leads the brain cutting ● Leads brain cutting conference, including providing key teaching points on a conference and selects tissue samples in frontotemporal lobar degeneration case; can independently select appropriate sections complex cases ● Dissects out complex vessel anatomy in a patient with Moyamoya Independently interprets histologic findings and ● Identifies cortical Lewy bodies and orders alpha-synuclein immunostain chooses relevant ancillary testing ● Identifies features of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and orders NOTCH1 testing ● Identifies a case of suspected frontotemporal lobar degeneration (FTLD), orders TDP-43 and tau immunostains and subclassifies appropriately Level 5 Teaches and serves as a consultant for ● Serves as a consultant on a complex case of brain hemorrhage of unknown etiology complex extractions Performs complex dissections, modifying ● Modifies approach to brain cutting for a midline craniopharyngioma techniques according to the needs of the case Assessment Models or Tools ● Assessment of final report ● Direct observation ● Multisource feedback Curriculum Mapping ● Notes or Resources ● BrainSpan. BrainSpan Reference Atlases. http://www.brainspan.org/static/atlas. 2020. ● Consensus Guidelines for Neurodegenerative Diseases: ○ Mackenzie I, Neumann M, Bigio E, et al. Nomenclature and nosology for neuropathologic subtypes of frontotemporal lobar degeneration: An update. Acta Neuropathol. 2010;119(1):1–4. https://link.springer.com/article/10.1007%2Fs00401- 009-0612-2. 2020. 5 Neuropathology Supplemental Guide ○ Mackenzie IR, Neumann