i

National Postgraduate Medical College of Nigeria

Faculty of Pathology

Revised Training Handbook/Curriculum

for

Post Graduate Fellowship/Residency Programme

in Pathology

September 2013

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© Faculty of Pathology, 2013

All rights reserved. No part or whole of this book is allowed to be reproduced, stored in a retrieval system or transmitted in any form or by any means, without

prior permission of the Copyright owner

ISBN: 978- 125-

Published and Printed by:

Ahmadu Bello University Press Limited, Zaria, Kaduna State, Nigeria.

Tel.: 08065949711

E-mail: abupresslimited2005@yahoo.co.uk or abupress2013@gmail.com

Website : www.abupress.org

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Vision of the Faculty

The Faculty of Pathology of the National Postgraduate Medical College of Nigeria, being the only one in the College with four distinct subspecialties, hopes

to maintain that integration and unity in diversity that makes the Faculty unique. We seek to uphold standards and remain contemporary internationally by carrying out periodic accreditation of our training institutions. We hope to train Laboratory

Physicians who will be able to cope with rapid advances as well as have in-depth knowledge of mechanisms of disease and diagnostic Pathology. We also seek to

train specialists who will have the ability to initiate and carry out research in local and international medical problems. We will also ensure that our examinations measure up to high academic and professional standards so that we can maintain

the self –esteem of our graduates and provide our medical schools with well trained, confident and highly motivated teachers in Laboratory Medicine.

Mission Statement

Our mission statement is the same as that of the College:

As a Faculty in an apical Health Institution in the country, we are committed to the production of Pathologists of the highest calibre who will man our secondary, tertiary and all other health Institutions. We shall continue to provide lecturers for

our medical schools. The high quality of our products is to be sustained and nurtured through a vibrant continuing medical education programme for

Laboratory Physicians nationwide.

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Table of Contents

Vision of the Faculty... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... iii

Mission Statement... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ..iii College and Faculty Officers... ... ... ... ... ... ... ... ... ... ... ... ... ... v

Introduction... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1

Training Curriculum - Chemical Pathology

11.0 Chemical Pathology Residency Training... ... ... ... ... ... ... ... ... ... ..25

Training Curriculum – Haematology and Blood Tranfusion Medicine

12.0 Residency Training in Haematology (RTH) ... ... ... ... ... ... ... ... 51 Training Curriculum - Anatomic Pathology (Morbid Anatomy and

Histopathology)

13. Residency Training in Anatomic Pathology... ... ... ... ... ... ... ... 73

Training Curriculum - Medical Microbiology & Parasitology

14. Residency Training in Medical Microbiology & Parasitology... ... ...95

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College and Faculty Officers

College Presidents

1. Dr. T. O. Ogunlesi, FMCP, PNMC, DFMC Oct. 1979 – Dec. 1983

2. Dr. E. Ade Elebute, FMCS, PNMC, DFMC Jan. 1984 – Dec. 1985

3. Dr. Bayo Banjo, FMCR, PNMC, DFMC Jan. 1986 – Dec. 1987

4. Dr. A. Akinkugbe, FMCOG, PNMC, DFMC Jan. 1988 – Dec. 1989

5. Dr. M. O. Akindele , FMCPsych, PNMC, DFMC Jan. 1990 – Dec. 1991

6. Dr. A. O. Ajayi, FMCGP, PNMC, DFMC Jan. 1992 – Dec. 1993

7. Dr. P.O. Okeowo FMCORL, PNMC, DFMC Jan. 1994 – Dec.1995

8. Dr. S. Olu oduntan, FMCPH, PNMC, DFMC Jan. 1996 – Dec. 1997

9. Dr. C. E. Famewo, FMCA, PNMC, DFMC Jan. 1-7 1998

10. Dr. M. O. Obiaya, FMCA, PNMC, DFMC Jan. 1998 – Dec.1999

11. Dr. A. A. Majekodunmi, FMCOph, PNMC, DFMC Jan. 2000 – Dec. 2001

12. Dr. T. O. Odugbemi, FMCPath, PNMC, DFMC Jan. 2002 – Dec. 2002

13. Dr. J. C. Azubuike, FMCPaed, PNMC, DFMC Jan. 2004 – Dec. 2005

14. Dr. S. O. Jeboda, FMCDS, PNMC, DFMC Jan. 2006 – Dec. 2007

15. Dr. M.O. Taiwo, FMCGDP, PNMC, DFMC Jan. 2008 – Dec. 2009

16. Dr. L. I. D. Kufeji, FMCS, PNMC, DFMC Jan. 2010 – Dec. 2011

17. Dr. V.C. Wakwe, FMCPath, PNMC Jan. 2012 – Date

College Registrars

1. Dr. M. A. Bankole, FMCS Jul. 1985 – Nov. 1991 2. Dr. O. K. Alausa, FMCPath, FMCPH Aug. 1992 – Sep. 1998 3. Dr. B. J. Bojuwoye, FMCP Feb. 1999 – Jan. 2003 4. Dr. O. E. Antia-obong, FMCPaed Mar. 2005 – Mar. 2013

5. Dr. O.A. Atoyebi, FMCS Jun. 2013 – Date

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Faculty Chairmen

1. Dr. A. O. Williams, FMCPath (Histopathology) 2. Dr. E. O. Odunjo, FMCPath (Histopathology)

3. Dr. O. Dosunmu-Ogunbi, FMCPath (Microbiology) 4. Dr.Tolu Odugbemi, FMCPath (Microbiology) 5. Dr. B. Onile, FMCPath (Medical Microbiology)

6. Dr. V. C. Wakwe, FMCPath (Chemical Pathology) 7. Dr. A. H. Rafindadi, FMCPath (Histopathology)

8. Dr. M. A. Durosinmi, FMCPath (Haematology) Faculty Secretaries

1. Dr. G. J.F. Esan, FMCPath (Haematology)

2. Dr. T. A. Junaid, FMCPath (Histopathology) 3. Dr. V .O. Rotimi, FMCPath (Medical Microbiology) 4. Dr. O. A. Afonja, FMCPath (Chemical Pathology)

5. Dr BA Onile, FMCPath (Medical Microbiology) 6. Dr. O. S. Ojo, FMCPath (Histopathology)

7. Dr. Sade Ogunsola, FMCPath (Medical Microbiology) 8. Dr. T Wakama, FMCPath (Haematology) 9. Dr. S.M. Shehu FMCPath (Histopathology)

`

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Introduction

1.1 What is Pathology?

Pathology is that branch of Medicine concerned with disease processes, their causes and natural history, laboratory diagnosis, laboratory monitoring of therapy

and surveillance of communicable diseases. In the faculty of Pathology of the National Postgraduate Medical College of Nigeria, four main sub-specialties exist; these are:

1. Chemical Pathology 2. Haematology and Blood Transfusion

3. Medical Microbiology and Parasitology 4. Morbid Anatomy and Histopathology (Anatomic Pathology)

Otherimportant sub-specialties include Immunology, Cytogenetic and Forensic Pathology. The latter three disciplines are usually grouped along with any of the

four major sub-specialities (e.g. Chemical Pathology and Immunology; Haematology and Cytogenetic, Anatomic Pathology and Forensic Pathology, etc).

As part of its Fellowship program, the Faculty of Pathology of the National Postgraduate Medical College of Nigeria (NPMCN) conducts two sets of

pathology examinations each year in the months of March and April/May and September and October/November. These are the primary/staggered Part I, part I and part II examinations. Success in these, and the required pre-examination

training, qualifies the medical graduate to become a Fellow of the College on the approval of the College Senate.

Training is accredited and the faculty conducts examinations. The decision making body for the faculty is the Faculty Board comprising a Chairman,

Secretary, Third Senate Member and three representatives from each of the composition units- Chemical Pathology, Haematology & Blood Transfusion,

Morbid Anatomy (Anatomic Pathology), and Medical Microbiology & Parasitology. The examinations are conducted in conjunction with a court of examiners appointed by the Secretary. Admission to Fellowship certifies the

medical graduate as trained and qualified to work as a specialist in the practice of pathology.

To ensure adequate training, the Board offers advice, subject and sub-discipline outlines, mentoring and training accreditation to help graduates and their

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supervisors cover the large amount of work needed to prepare for examinations and acceptance as a Fellow.

This booklet provides medical graduates, and current pathology Trainees and their

Supervisors, with information on pathology training, examinations, qualification requirements and responsibilities of pathologists.

1.2 About the College

The NPMCN was established by Act 67 of 24th September 1979 for the training and production of specialist doctors and dentists in the country. The Principal Officers of the College are the President, Vice President, Treasurer and the

Registrar. The Registrar is the Chief Administrator of the College. The Senate is the highest policy making body of the College and consists of the Principal

Officers and all the Chairmen, Secretaries and Third Senate Members of each of the 15 Faculties in the College.

The College‟s primary focus is educational. It is involved in the examinations and certification of Pathologists and other specialists, as well as their ongoing

professional development. It also provides professional leadership, including the setting of professional practice standards, and it is heavily involved in government relations and negotiations concerned with maintaining the role of Pathology in

clinical practice.

1.2.1 The Faculty of Pathology Responsibilities

The Faculty of Pathology of the College is primarily charged with the following

objectives and responsibilities:

To promote the study of the science and practice of pathology in relation

to medicine.

To encourage research in pathology and ancillary sciences.

To bring together pathologists for their common benefit and for scientific discussion and demonstration.

To disseminate knowledge of the principles and practice of pathology in relation to medicine by such means as may be thought fit.

To consider and advise as to any course of study and technical training

To diffuse any information calculated to promote and ensure the fitness of

persons desirous of qualifying for Fellowship of the College in Pathology.

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To achieve these objectives, there are regular Pathology Update/Revision courses, All fellows meetings and local scientific meetings; and the publication of the

Faculty Journal, Annals of Tropical Pathology and the College Journal, Nigerian Postgraduate Medical Journal

1.3.1 Registration and Training Requirements

Prospective Pathology Trainees are strongly advised to consult the relevant Training Institutions to ascertain their accreditation status before applying to train.

Almost all the training centres are located in the University Teaching Hospitals and Specialist Medical centres across the country.

It shall be the responsibility of the Department employing the Trainee to follow the guidelines for training and curriculum provided by the faculty. Pathology

training is a full- time program. A minimum of four full- time equivalent years of certified training in accredited

institutions (training institutions would normally not allow more than 6 years). Time spent in research or project work is encouraged and up to one year in

relevant work is readily approved. More extensive research projects will be considered on an individual basis and Trainees should obtain permission for time to do so from their employer, and a copy of such permission should be submitted

to the Board through the Secretary. Check under each discipline‟s chapter in this Handbook for more detailed training requirements.

1.3.2 Entry Requirements for Residency Training in Pathology

Candidates applying for training in Pathology must fulfil the following conditions:

i. Medical graduate fully registered with the Medical and Dental Council of Nigeria (MDCN).

ii. Certificate of National Youth Service Corps (NYSC) or Exemption from

NYSC (Nigerian Candidates Only) iii. Pass in Primary Examination of the Faculty of Pathology of the National

Postgraduate Medical College of Nigeria (NPMCN), or its equivalent as approved by the College.

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1.3.3 Registration of Associate Fellows of the College

Residents admitted for training are associate fellows of the National Postgraduate Medical College of Nigeria and must apply to be so registered by the college. The

application forms for registration are obtainable from the College or the Chief Medical Director of each of the accredited institutions and must be returned to the College Registrar not later than 4 months from the date of admission into the

residency Programme. Candidates who are not registered as associate Fellows of the College will not be allowed to sit for the Part I or Part II Fellowship

Examinations of the College.

1.3.4 Training Limitation

Training limitation is enforced to ensure that Trainees are exposed to all aspects

of pathology practice. In Institutions where there are deficiencies, arrangements should be made for the trainee to rotate in institutions where facilities are available. The training institutions are responsible for making such arrangements.

1.3.5 Temporary Suspension of Training

If the trainee intends to take an extended leave or suspend training for any reason, the Faculty Secretary should be duly informed in writing, providing details of the

anticipated duration of leave or suspension. This excludes periods of standard annual leave.

The Trainee will be required to undertake additional training time up to the period of additional leave. Where this training suspension exceeds two years and activity

during this period is outside Pathology Department, the period of training already undertaken shall be deemed to have lapsed. The trainee therefore starts afresh

(junior or senior residency postings) provided that no examination already passed has lapsed (primaries – 5yrs, part 1 - 4yrs).

1.3.6 Training Portfolio

All Trainees are to maintain a Training Portfolio folder. Trainees are expected to maintain comprehensive records of their training and examinations, including copies of application forms, supervisors‟ reports, examination results, academic

and clinical activities in the department; and correspondence with the College.

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The Record of Training within this Portfolio must be submitted to the Faculty or College on request on its merits.

1.4 Trainers and Supervisors All training must be supervised. All the consultants in the department have the collective responsibility for providing training/mentoring. The trainee is however

at liberty to choose his/her supervisor for research purposes. The supervisor of laboratory training will normally be a Fellow of the College by examination.

Each department should have a residency programme coordinator who shall be directly responsible for the day-to-day training of the trainees.

The supervisor of a Part II dissertation must be a fellow of not less than 5 years

standing; where more than 1 supervisor is employed to supervise a part 2 dissertation, the primary supervisor must be a fellow of the faculty (not less than 5 years post Fellowship). Where the institution has no qualified supervisor, the

trainee may seek supervision from another institution while the internal supervisor shall be the secondary supervisor. Supervisors are expected to assist Trainees to

develop their individual training objectives and to provide structured feedback of performance on a regular basis. For this reason, the College recommends that any one supervisor be responsible for no more than three Trainees.

1.5 Education Programmes 1.5.1 Pathology Update and Revision Courses

The Pathology Update/revision courses are organised bi-annuallyunder the

auspices of the Faculty Board. Periodically, pathology sciences seminars and workshops are organised by the Faculty alone or in conjunction with other bodies

or by training institutions. These educational programmes are widely publicised. Sub-specialty professional bodies also organise scientific meetings.

Pathology Update/revision courses are held in any of the chosen training institutions each year in February/March and August. The Update/revision

courses are prerequisites for registration for the Part I and Part II examinations.

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1.6 College/Faculty Communications

The Trainee Handbook is to be used as a guide for training requirements, but any printed version may be out of date. When changes are made due to ongoing policy

development, the most recent version will be made available. Trainees will always be advised at least 12 months in advance of significant changes in the training programme.

The College or Faculty also communicates with Trainees through the Chief

Executives of their training institutions. The Faculty will also communicate with Trainees and Supervisors through the Faculty‟s Newsletter and Journal.

1.7 Examination Requirements

There are three parts to the examination process:

1.7.1 Primary Examination is composed of Basic Medical and Pathological Sciences. It is the main entry point into the Fellowship programme. The examination is open to medical doctors from the level of house officer. No trainee

shall be allowed to sit for the Part I Fellowship examination of the Faculty unless he/she passes the primary examination and has fulfilled other requirements.

1.7.2 Sub-specialty Part I: This is usually taken after the initial two years of training (i.e. Junior residency programme). Only candidates that complete the

initial 24 months of training (without interruption other than the normal annual leave periods) are eligible to write Part I Sub-Specialty Examination.

1.7.3 Sub-specialty Part II: This is usually taken at least 2 years post part 1 (senior residency programme).

Candidates should refer to the specific departmental requirements below.

1.7.4 Examination Exemptions

Admission to Fellowship is always by examination, although the Faculty Board may grant exemptions from some components of the examination. Candidates with foreign/local qualifications in disciplines within pathology may be eligible

for some exemptions from the 5-year training period.

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Application for exemption can be made on the Application for Examination form, which must be submitted to the Faculty Secretary not later than 120 days to the

next Faculty examinations in the year of intended examination. Trainees seeking an exemption need to submit full details with supporting evidence. Such

candidates must also pay the usual examination fee for any examination from which they are seeking exemption.

Because the form and content of examinations vary from time to time, exemption from a total examination (e.g. Part I) is valid for four years.

Exemption from a single component of examination is only granted for the following examination cycle. In subsequent years, the exemption must be

requested at the time of application for examination.

There are no absolute indications for exemption and any application will be treated on its merits, with relevant postgraduate qualifications, research, publications and experience taken into account.

1.8 Examination Applications

To sit for examinations, apart from Basic Pathology Sciences (Primary Examination), Trainees must be registered with the Faculty of Pathology training

programme and be employed in an accredited Pathology department. Examination application forms are available from the College and may be

collected by accredited training centres. The due date for each examination is advertised in Faculty’s Newsletter and some national daily newspapers. An application form must be completed for each year‟s examinations. The

appropriate fee and all relevant documentation must accompany the form. Applications for all examinations close 60 working days to each examination. The

closing date is observed strictly. 1.8. Late Applications

As determined by the College 1.9.1 Examination Time Tables

1.9.2 Examination Venues

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1.9.3 Withdrawal from Examination and Failure to Attend

A Trainee who wishes to withdraw from an examination must provide writte n notice to the Faculty Secretary. There are penalties for withdrawal as determined

by the College. 1.9.4 Refusal of Examination

The Faculty Board may refuse to accept examination applications, which do not

meet the stated requirements. The Board may also refuse to proceed with examination of a Trainee who infringes regulations or whose behaviour is considered to prejudice the proper management and conduct of the examination,

or for any other sufficient reason. Such Trainees may also be refused permiss ion to take future examinations.

1.9.5 Examination Results

Results of examination are considered and endorsed by the court of examiners at the end of each examination session. The results are usually published at the

College and its liaison offices as provisional. Only results ratified by the Senate of the College are considered authentic and normally sent to candidates and training institutions. All enquiries regarding unsuccessful examination results must be

directed to the College Registrar. Trainees may not directly contact the Faculty Secretary.

1.9.6 Repeat Examinations

Candidates who fail any of the examinations may wish to resit the examination six months later except as may be barred by the Court of Examiners based on a

policy ratified by the Faculty Board. 1.9.7 Communication between Candidates and Chief Examiners

In the interest of fairness and integrity of the examination process, Trainees are

not to contact the Chief Examiner directly during the examination period, in April/May and in October/November, and where special circumstances concerning a Trainee‟s performance, such as illness, are known to exist, they

should be communicated as soon as possible. This could be by a telephone call in cases of emergency, or a letter to the Faculty Chairman or College Registrar.

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Correspondence must not be sent directly to the Chief Examiner. Lobbying to influence results by Trainees, Supervisors or other persons, will disqualify the

Trainee.

1.9.8 Examiners’ Comments

Comments on the performance of Trainees who have failed will be to the Training

Coordinators of their institutions following completion of the examination cycle. Trainees are strongly advised to discuss these comments with their Trainers, with

a view to remedying any deficiencies, and to seek further advice where necessary from their Supervisors or Faculty.

1.9.9 Duration of Examinations Passed

A pass in the primary examination stands for 5 years while a pass in the Part I examination will be for four years. Candidates will be required to retake the part 1 fellowship examination after repeating their pre-part 1 postings if they fail to

attempt the examinations 4 years after passing.

2.0 Fellowship Requirements A pass at the Part Two examination automatically qualifies a candidate for the

award of the Fellowship of the National Postgraduate Medical College of Nigeria and entitles the Fellow to appendage the acronym (FMCPath) after his or her

name. Conferment of the Fellowship to foreign trained Pathologists will require the

fulfilment of all the following conditions

The candidate must be a graduate in medicine from an institution

approved by the Medical and Dental Council of Nigeria and should have obtained by examination a fellowship or equivalent in Pathology approved

by the Faculty Board of Pathology of the National Postgraduate Medical College of Nigeria.

The candidate must have been engaged in full-time medical practice

related to pathology for five years full- time or part-time for periods aggregating five years; or engaged in a form of medical practice related to

pathology for eight years or periods aggregating eight years

The candidate has passed such examinations or exempted from it as the

Faculty Board of Pathology has determined; and

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The College considers that the applicant is a fit and proper person to be

admitted as a Fellow of the College.

2.1 Admission To Fellowship And Ethics

Once Trainees are accepted and have paid their registration fees, they receive an

official Certificate of Fellowship. As College Fellows they are expected to observe the universally accepted code of ethics of medical practice.

2.1.1 The fundamental objective of the practice of Pathology is to promote the welfare of patients in terms of maintenance or restoration of health.

2.1.2 Fellows engaged in the practice of Pathology should be guided by the same ethical considerations, as are practitioners in other areas of medicine. For

these purposes the College follows the Medical and Dental Council of Nigeria (MDCN) Code of Ethics (as lately Revised).

3.0 Specialist Registration

All Fellows must register the Fellowship qualification with the MDCN before they can present it for appointment. Failure to do this will be a breach of the law.

This registration puts the Fellow in the specialists‟ register of the council.

4.0 Continuing Professional Development The Faculty of Pathology of the National Postgraduate Medical College of

Nigeria offers a Continuing Professional Development Programme (CPDP) to its Fellows, Affiliates and Trainees, through conferences, update/revision courses, seminars and workshops.

Participation in CPDP, or an equivalent programme, is mandatory for Fellows. Proof of participation is a requirement for the annual registration by the MDCN.

5.0 College Policies

Trainees are advised to familiarise themselves with the College‟s by-laws, policies, roles and responsibilities. Specific documents that should be reviewed

include:

Policies

Regulations governing the conduct of Fellowship Examinations

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Complaints in Relation to Examinations

Discrimination and Harassment

Complaints Handling

By-Laws

Regulations Governing Review of Council Decisions on Admission to

Fellowship and Termination of Membership of a Fellow.

Regulations Governing Review Process for Review of Decisions of

Committees of the College Council

Roles and Responsibilities

6.0 Recognition of Overseas Trained Specialists

Medical practitioners qualified as specialist pathologists in a country other than Nigeria or West Africa, and who are not Fellows of Medical College of

Pathologists of Nigeria (FMCPath) or Fellows of the West African College of Physicians-Lab Med, (FWACP-Lab Med) may apply for specialist pathologist recognition in Nigeria.

Applicants must apply initially to the MDCN. Information and application forms

are available from: The Medical and Dental Council of Nigeria MDCN HOUSE

Plot 1102, Cadastral Zone, Kaura District Abuja

900001 Email: medicalcouncilnigeria@yahoo.com

Applications are processed by the MDCN and then submitted to the Faculty of Pathology through the College Registrar for assessment. A panel of Fellows will

verify the certificates and interview the applicant in Nigeria, and the Faculty Board will take the final decision about comparability to Nigerian training and examinations.

The decision of the Faculty Board on this matter shall be final. Persons holding any pathology qualification obtained by election or honorary award shall not be

recognised as specialists in Pathology unless such a person holds a recognised pathology specialist qualification registerable in category by the MDCN prior to the election or honorary award.

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7.0 Prospective Training Programme

A Prospective Training Programme should be prepared by the Training Department and made available to Trainees on admission into the residency. This

programme shall be reviewed annually in order to update it in line with developments within the speciality and to accommodate any changes introduced by the College or Faculty. In order to gain a full understanding of the intended

outcomes of the training programme and a commitment to the process, it is vital that the Trainers and the Trainees spend some time together in developing the

programme. The Programme should be devised with reference to the Specialty checklists in

the Trainee Handbook. The prospective training programme should include the following elements:

i. A very brief overview of the laboratory and its networks. This provides the context for the Trainee, their stage of training and the resolution of any previous difficulties or deficiencies in training.

ii. Planned exposure to relevant experience. This should include the major aspects of the specialty, or test groups, that the Trainee is expected to

experience in the ensuing year. It should also specify any standard rotations that the Trainee will be undertaking to other accredited laboratories.

iv. Specific responsibilities of the Trainee; what specific responsibilities will the Trainee be given, relevant to their level of skill and experience? For

example: checking laboratory reports; liaising with clinicians; quality control of assays; rotation on the benches; call duties; trialling of new methods, clinical duties (in and out patient case management).

v. Additional external experience required; are there specific se rvices, which are not provided by the laboratory? If so, what arrangements are being

made for the Trainee to receive this experience elsewhere? Of course where the hospital is unable to sponsor such external training, the trainee must be prepared to seek sponsors to fund same.

vi. Intended participation in projects or research: To what extent will the Trainee be developing core skills or gaining additional skills through

participation in projects and research throughout the year? vii. Educational programme: List any regular activities in which the Trainee

will be participating, e.g. weekly journal club, departmental administrative

or patient care meetings, as well as planned attendance at conferences or seminars.

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viii. Teaching and presentation activities: What responsibilities will the Trainee have, e.g. tutorials to medical students. Are any conference papers

anticipated?

The Trainer should meet with the Trainee at least every month, to provide structured feedback on their performance and review progress of the training programme.

8.0 Application for Accreditation of Laboratory for Training of

Candidates in Pathology

This form is used by Pathology departments wishing to apply for accreditation for pathology training. Pathology departments will be notified six months prior to the expiration of their current accreditation. Forms are available from the College for

new applicants. The completed form is returned with the prescribed fee. The expected date is fixed by the College and communicated to the Institution. For

more details, refer to the Accreditation Booklet.

9.0 The Pathology Curriculum This framework includes the “generic” roles and core competencies, common to

every branch of pathology, set out in the “Generic Curriculum”. The specialty-specific competencies, embodied in the role of the “Medical Expert” are set out in this Handbook under the requirements for each specialty.

9.1 Rationale for the Curriculum

In developing the curriculum the Faculty ensures that the needs of Trainees and the profession are well-matched, and that there is consistency between learning

outcomes, their assessment, and the necessary learning activities.

10.0 Assessment of Fellowship Training and Examination

Assessments are both Formative and Summative

10.1 The Formative assessment is based on the use of Log Books and Training

portfolio, and is supervised essentially by the Training Institutions but verified by the College before any candidate is allowed to sit for Examinations. The

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Department‟s training coordinator shall have the responsibility of working with the Trainees to monitor the training programme, log book and training portfolio.

All trainings are conducted in accredited training Institutions. A list of such

institutions can be obtained on request from the Faculty Secretary.

10.2 The Summative assessment is based on Examinations and it is the primary

responsibility of the College through the Faculty.

The faculty of Pathology of the NPMCN controls all examination applications and examination processing. The College conducts examination in the following pathology disciplines:

Morbid Anatomy/Histopathology (Anatomic Pathology)

Chemical Pathology

Haematology and Blood Transfusion

Medical Microbiology and Parasitology

10.2.1 Primary Examination

A pass or exemption in the Primary examination is a prerequisite for entry into the

training programme. The purpose of the primary examination is to assess basic understanding of:

Scientific knowledge that can be found in undergraduate, up-to-date

textbooks of pathology

The principles of scientific methodology that under pin the daily

diagnostic work of pathologists, including technology, molecular biology and cytogenetics.

Factual knowledge of what was once describes as “general pathology”, comprising mechanisms of cellular injury, cellular growth and cell death,

inflammation and tissue repair, haemodynamic disorders, genetic disorders, immunity, environmental hazards, neoplasia and infectious diseases; and

To encourage a lifelong professional interest in keeping abreast of new advances.

Candidates should also be able to display some comprehension of the newer

scientific methods that have led to advances in understanding of the mechanisms of disease, such as molecular biology, cloning, adult and embryonic stem cells,

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molecular and cytogenetic methods in the diagnosis of disease and prediction of disease outcome, etc.

The examination will be a 3-hour multiple choice questions divided into two

sections as follows: Section A: contains 80 questions in Basic Medical Sciences (Anatomy,

Biochemistry, Physiology and Immunology)

Section B: contains 80 questions in Basic Clinical sciences (Chemical Pathology, Haematology and Blood Transfusion, Medical Microbiology and Histopathology).

The pass mark is 50% (please note that wrong answers will be penalised).

A candidate who has passed the primary examination and has not attempted the Part I after five (5) years will have to retake the primary examination to continue.

10.2.2 Syllabus for Primary Examination

The examination will concentrate on the following general subjects (please note that the list of examples is not exhaustive):

Basic Anatomy, Physiology and Biochemistry

Cellular Pathology (cell growth and ageing, cell injury and death)

Acute and chronic inflammation, healing and repair

Immunity (building blocks of the immune system, hypersensitivity

reactions, autoimmune diseases, AIDS, amyloidosis)

Haemodynamic disorders (oedema, thrombosis, embolism, infarction,

shock).

Genetic basis of disease (genetic mechanisms of disease; basic knowledge

of the more common genetic diseases as well as an understanding of commonly-used genetic tests

Microbiology (general principles of microbial pathogenesis, common viral, bacterial and parasitic infections).

Neoplasia (biology of benign and malignant tumours, epidemiology of cancer, molecular and cellular oncogenesis).

Occupational and environmental pathology (common toxins and their manifestations in the human body, such as asbestosis, smoking, industrial toxins etc.).

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Nutrition, metabolism (common nutritional deficiencies, obesity).

Acid-base balance and fluid/electrolyte disturbances (basic physiological and pathophysiological mechanisms).

In each of these subjects, emphasis will be placed on:

Nomenclature and definitions of disease

Classification of diseases

Disease processes/pathogenesis

Causation/aetiology

Scientific methodology and new diagnostic methods

Ethics, social and political aspects of Pathology and disease

Analysis of data (e.g. incidence, prevalence, accuracy, precisio n, predictive value, correlation).

10.2.3 Part IFMCPath Examination

The part 1 examination is staggered into two, an initial screening exam (Paper I) is taken a day after the primary exam in either March or September as the case ma

be. The details of the examination are:

10.2.4 Paper I:

Consists of a 3-hour 160 MCQs, 40 from each specialty. All questions are

compulsory. A candidate must score 50% to pass this paper. The penalty is half of the score for each question failed. A pass in this paper is required for the candidate to proceed to the main examination in April/May and

October/November respectively. 10.2.5 Paper II:

This consists of a 3-hour essay type questions for each specialty and the candidate

is required to answer 4 questions out of 5 questions. Each question shall carry 25 marks. The pass mark shall be 50%, irrespective of scores in the individual question.

Candidates only answer questions in their own discipline in this section of the

Part I FMCPath examinations.

17

10.2.6 Part I Practicals:

The practicals carry a total of 150 marks. A candidate must score 75 marks (50%) to pass this examination. Practical examinations are conducted only in the

candidate‟s subspecialty. Candidates in histopathology (anatomic pathology) must in addition get correctly 75% of the surgical pathology slides (at least 15 out of 20 slides) and a minimum of 50% in autopsy examination.

10.2.7 Oral Examination (Viva Voce): This is usually for a minimum of 20

minutes for each candidate, during which time candidates answer questions from a panel of examiners drawn from all the 4 disciplines. The total mark is 50.

10.2.8 Pass in Part I

To pass the Part I FMCPath Examinations, candidates must score 50% or above in paper 1; 75 marks or above in Practicals and have an overall average score of 200 or above. Candidates in histopathology (anatomic pathology) must in addition get

correctly 75% of the surgical pathology slides (at least 15 out of 20 slides) and a minimum of 50% in autopsy examination.

10.2.9 PART II FMCPath Examinations:

The Part II FMCPath Examination shall consist of the following components:

10.2.10 Part II, Paper I:

There shall be 5-essay type questions and the candidates shall be required to

answer 4 questions within the 3-hour period in their subspecialty. Pass mark shall be 50% irrespective of scores in the different questions.

10.2.11 Part II, Paper II

Four questions are answered out of five and each shall carry 25 marks. Pass mark shall be 50% irrespective of scores in the different questions

To pass the Part II FMCPath Examinations, candidates must score 50% or above in at least one of the two written papers above in addition to other requirements

outlined below.

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10.2.12 Practicals and Clinicals:

These are conducted over 3 days, after the written examinations in the candidate‟s specialty. The dissertation is also defended during this period. The Practicals and

Clinicals carry a total of 150 marks. A candidate must score a minimum of 75 marks (50%) in the practicals to pass this examination

For Histopathology, candidates must not miss more than 5 slides out of 20 in addition to scoring a minimum of 50% at Autopsy.

Haematology candidates must pass Morphology in addition to scoring 75 marks to earn a pass in practicals.

10.2.13 Clinical Examination in Haematology

Candidates must pass the Clinical Examination to earn a pass in addition to scoring an average of 200 marks or more out of the overall mark of 400.

10.2.14 Clinical Examination in Medical Microbiology

Candidates must in addition pass Clinical Examination to earn a pass.

10.2.15 Defence of Dissertation and Oral Examination (Viva Voice):

There shall be 2 aspects of Oral Examination namely: Specialty Oral Examination: Candidates shall answer questions from a Panel of

Examiners drawn from candidates‟ area of specialty.

Dissertation Oral Examination: Candidate shall answer questions from a panel made up of two assessors of his/her Dissertation.

The importance of the oral defence of dissertation is to give the candidate an opportunity to defend his/her position in respect of his/her research methodology, result analysis and conclusions, as well as to demonstrate further the depth of his

understanding of the subject matter as well as the general procedure for problem solving and, if possible, convince the examiners to modify the pre-viva rating of

the work. These orals should be structured to give the candidate such an opportunity. They are not meant to be scored independently.

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10.2.16 Examination and Processing Part II Dissertation:

Candidates for Part II Fellowship Examinations are each to submit 4 typed loosely bound copies of their dissertation/case book along with their

application for the examination.

At the close of application for the Examination, the Examina tion

Department of the National Postgraduate Medical College of Nigeria compiles in tabular form, for each Faculty, the list of candidates, their dissertation titles, and their training institutions.

Not later than a week after the deadline, the examination Department shall forward to each Faculty Secretary, the form bearing the list of candidates

and title, along with a request that the Faculty Secretary supplies on the same form, a corresponding list of assessors complete with assessors‟

addresses BY STATED DEADLINE of 2 weeks.

The Examination Department immediately on receipt of the Secretaries

responses dispatches two copies of the dissertation to two nominated assessors with appropriate instructions and copies of the relevant sections of Examination Regulations for the Faculty.

In assessing the Case Book or Dissertation, the assessing examiner is expected to determine the overall quality of the work in the context of the

objectives of the examination and to write a report incorporating the following:

d1 A list of Editorial or Typographical Errors that need to be corrected before

the acceptance of work which is otherwise acceptable, i.e. rated P.

d2 Important errors of data handling or interpretation that must be corrected in an otherwise acceptable work rated (P-) or Borderline pass.

d3 Serious errors of conceptualization of the problem, of procedure of

interpretations, or data which severally or together, render the work

unacceptable = (P-1) or Fail. The final rating as follows;

P+ If no important errors are noted

P If only group d1 errors are noted If groups 1 and d2 or only group d2 errors are noted

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P-1 or F If any group d3 errors are noted.

The Faculty Secretary shall ensure the collection of the dissertations and

their written assessment from the assessors during the examination in respect of all candidates.

In case of candidates with P-1 or Fail in dissertation, the Faculty Secretary returns all four copies of the dissertation to the candidates at the end of the

defence.

In case of (P-) Provisional Pass candidates, the Faculty Secretary returns

two copies to the candidates. The Faculty Secretary sends the remaining copies to the Examinations Officer plus a copy of the Examiners‟ Report containing the recommendations and corrections required and the name

and address of the examiner required to do the re-assessment.

The Examinations Officer writes to inform the candidate of his results and

the corrections he/she has to make with instructions that he must return one neat corrected copy within three months of the date of the Senate

Meeting that approved the initial result.

When the candidates returns the corrected copy, the Examinations Officer

dispatches it to the re-assessor together with the examiners‟ report containing the corrections expected to be made, as well as the previously marked dissertation not later than one month from the date of receipt.

The re-assessor must return the corrected dissertation to the College‟s Examination Officer with his report and recommendation within 1 month

of receiving the corrected dissertation.

The Examinations Officer must forward new report to the Faculty

Secretary for endorsement or comments to be returned to the Registrar within 2 weeks.

On receipt of the Faculty Secretary‟s endorsement, the Registrar

immediately shall seek the approval of the results by the President on behalf of Senate.

The Registrar then formally informs the candidate of his success.

The candidate is requested at this stage to submit four bound copies of his

approved dissertation to the College Registrar to be disposed as follows:

a. One copy for the Central Medical library b. One for the Faculty Library, and c. Two for the college Library

21

The cover should be in the Faculty colour i.e. maroon.

10.2.17 Proposals for Dissertation for Part II Examinations:

The essence of dissertation is for the candidate to demonstrate competence in conducting research, present data in a logical and succinct manner and make similarly logical deductions. The work must be original and must make useful

contribution to clinical subject of local interest.

Candidates for Part IIFMCPath Examinations must submit their proposals for dissertation project, including a certificate of Approval from their Institutions‟ Ethical Committee, and the name(s) of, and letters of consent from their

supervisor(s) not less than 14 months before the date of the Part II examination they intend to sit, specifically on or before 1st September of the previous year for

the November examinations and on or before 1 March of the previous year for May examinations.

Candidates whose application forms or proposals are not received by the closing dates will NOT be allowed to participate in the examinations. In special

circumstances candidates may be allowed to sit for the examination after due consideration by the College Registrar and Faculty Secretary.

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23

Training Curriculum - Chemical Pathology

24

25

11.0 Chemical Pathology Residency Training

11.1 To specialize in Chemical Pathology, Trainees must undertake at least four years of training.

The objectives of the Chemical Pathology training are to produce individuals capable of managing high quality laboratories and of contributing effectively to

the biochemical investigation and management of patients. Training is designed to attract Trainees and maintain their interest - particularly those with the potential

to contribute to the advancement of Chemical Pathology. The primary role of the Chemical Pathologist is the study and measurement of

biochemical abnormalities in human disease. The Chemical Pathologist is trained in the operation and management of hospital biochemistry laboratories, and acts

as a consultant in all aspects of their use. As an academic specialist, he (she) develops and integrates a basic research program with clinical practice in a field of biochemical interest, and maintains an active role as a teacher of Chemical

Pathology.

When training is completed, Trainees will be expected to have a comprehensive knowledge of and skills in:

Biochemistry, physiology, general and special pathology

The biochemical basis of disease

The application of results of laboratory tests to the investigation and management of patients, particularly those with biochemical problems

Analytical techniques

Efficient laboratory administration and management

The functioning of health care services in Nigeria

The investigation of clinical and laboratory problems

The chemical pathologist should be routinely involved in:

The interpretation of laboratory-derived information on the basis of

clinical findings

Other investigations for the purpose(s) of establishing diagnoses

Assisting prognoses, indicating management, monitoring treatment and/or detecting complications

Chemical Pathologists bring a different but complementary perspective to clinical problems compared to a clinician, and act as a link between clinicians and

26

laboratory staff. As a result, they must have a clinician‟s trust and confidence, and laboratory staff must recognise and respect their scientific knowledge,

technical competence and medical skills.

11.1.1 Chemical Pathology Examinations

The Chemical Pathology examination process involves three parts – Primary,

Part1 and Part II examinations.(see 10.0 – 10.2.16)

11.1.2 The Primary Examination (10.2) is made up of the basic sciences and is usually taken before the commencement of the residency programme. It is a pre-requisite for entering into the programme.

11.1.3 Part I Examination (10.2.3-10.2.8)

Trainees take the Part I examination in Chemical Pathology at the end of the second year of training. During the first two years of training, the trainee spends 3 months each rotating through the other pathology specialties (Medical

Microbiology and Parasitology, Anatomical Pathology and Haematology/Blood Transfusion)

Trainees for the Part I examination in Chemical Pathology are required to have a

thorough working knowledge of laboratory aspects of Chemical Pathology as well as general competence in the field as a whole.

Candidates need to have a sound knowledge of laboratory procedures, analytical methods and instrumentation and practical familiarity with:

The analytical procedures being performed in an approved laboratory;

The interpretation of laboratory results with respect to both the patient's disease and test reliability

The management and organisation of a laboratory.

This knowledge can only be gained through supervised laboratory work and

contact with clinical cases exhibiting abnormal biochemical parameters. Practical experience should be supplemented by reading appropriate textbooks

and journals, discussion groups, seminars, lectures and clinical meetings.

NB: Trainees should refer to the Checklist for Chemical Pathology for more details.

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11.1.4 Part II Examination (10.2.9-10.2.16)

The Part II examination is taken at least two years after passing or exemption from the Part I examination and after meeting any other requirements for the

examination. A relevant clinical and laboratory-based research project is a requirement for the Part II examination and so is a short course on hospital management and research methodology.

The candidate must demonstrate to examiners that he/she: Is capable of taking an active role at the clinical interface with the

laboratory; Has a sound technical knowledge of the subject; and Is competent to independently manage a laboratory efficiently.

The candidate‟s ability to communicate is crucial in all of these functions.

11.2.0 Specialty Training Requirements

An integrated training compassing the diagnosis, investigation and management

of disorders of chemistry, metabolism and the endocrine system, together with the techniques, management and administration of a Chemical Pathology Laboratory

is required. Annual revision course is organised to emphasize these aspects of the training.

11.3.0 Chemical Pathology Syllabus

This syllabus is intended as a guide to: A. Trainers who provide the leadership in organizing local resources for the

training of residents and to meet and sustain the standards and

requirements for accreditation by the National Postgraduate Medical College of Nigeria; and

B. Trainees (residents), to assist them in their training as they prepare for the Primary, parts I and II examinations of the College. The examinations are based on the syllabus, but may also contain questions on topics pertinent

to Chemical Pathology beyond the scope of the Syllabus.

11.3.0 Responsibilities of a Chemical Pathologist

11.3.1 General

Understanding (and teaching) the appropriateness of a laboratory test for a particular patient at a particular time - which includes the sensitivity,

28

specificity and predictive value of these tests, in relation to the prevalence of the disease in the population being studied. This goes beyond the

simple statement of reference ranges.

11.3.2 Analytical Selecting test procedures for routine, "stat", and special needs; directing

the laboratory to maintain high standards of practice; ensuring safety and

pollution controls; maintaining procedure manuals relevant to current needs.

Investigating and selecting new instruments and analysers appropriate for a particular service laboratory; monitoring the operation of this equipment in terms of precision, accuracy, cost-effectiveness, maintenance and

repair, and acceptability to the technical staff; approving the training provided by manufacturer's representatives.

Establishing effective procedures for test requests, and dependable standards of specimen procurement and handling; determining when, how, and by whom the analyses should be carried out.

Establishing satisfactory quality control; taking part in total quality management programs; monitoring the performance of referral

laboratories. Selecting the methods of reporting results, in an acceptable time frame;

highlighting noteworthy information; monitoring progress in computerized

data presentation and interpretation in a medical decision support system

11.3.3 Consultant

To demonstrate adequate knowledge, skills and appropriate attitude required to

head a metabolic unit. The new consultant must:

Must have the knowledge and skills to take responsibility for safe clinical decision.

Have self-awareness of the limit of their competency and when appropriate to call in colleague to assess the patient.

Have ability to take responsibility for clinical governance activities, risk

management and clinical audit in order to improve the quality of service provision.

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11.3.4 Clinical:

Relating analytical data to the patient's history; suggesting confirmatory

tests; providing clinical interpretation when appropriate.

Monitoring the clinical action taken on the basis of laboratory data

provided to the physician and the consequences for the patient.

Attending to all medical consults sent by fellow clinicians on patient

management

Carrying out dynamic tests on patients where applicable

Running of a metabolic clinic to assist in the management of metabolic cases in conjunction with other clinical colleagues

11.3.5 Education

Self improvement:

Monitoring advances in our knowledge of test procedures of a biochemical

nature that can be applied to the diagnosis, management and prognosis of disease in humans.

Participating in continuing education and maintenance of competence programs.

Keeping pace with developments in related disciplines, in order to understand and apply the new technologies they may provide.

11.3.6 Research

Conducting basic and applied research relevant to the discipline and the

profession of clinical biochemistry

Collaborating with members of the clinical staff when occasions present

themselves in clinical research programs.

11.3.7 Administration

Accepting fiscal responsibility for the laboratory; overseeing the budget

Ensuring cost-effectiveness in providing quality services

Maintaining job descriptions

Keeping track of workload statistics, laboratory expenditures and equipment contracts;

Maintaininglong-range planning.

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11.3.8 Other Functions

Assisting the clinical staff in practicing effective laboratory utilization;

Taking the initiative in introducing new laboratory tests and deleting those that have outlived their usefulness.

Participating in the education and training of residents, medical students, interns, scientists, technologists, and other health professionals.

11.3.9 Table 1: Weekly Routines in Chemical Pathology

Table 1: Weekly Chemical Pathology Resident Routines

Time

schedules

SUN MON TUE WED THU FRI SAT

8am-4pm Bench & Clinical Calls

Laboratory Work: general routine laboratory bench work exposures, special investigations, dynamic tests etc. Clinical Responsibilities: outpatient clinics, ward coverage, intensive care and emergency units. Weekly Educational Programmes : Seminars, Tutorials, Journal review, Pathology grand rounds (with sister pathology depts.), medical grand rounds (with internal medicine and paediatrics depts.)

Bench & Clinical Calls

4pm-8am Bench & Clinical Calls

Notes on Table 1: The schedules are compulsory for all residents. Each resident will rotate through the various laboratory and clinical sections.

Log Books will be filled and signed by supervising consultants at the end of each rotation. All activities are recorded and scored except during the Leave Periods (30

working days or 6 weeks annually).

Time available for Pre-Part I Resident Programmes (excluding 3 months of leave

periods) is 21 months, which translate to 6 Semesters of 15 weeks each. The programmes are weighted in hours and the weights are recorded in units: One Unit defines 1 hour of any of the following Seminar (S); Tutorials (T); Grand

Rounds and Journal Review or 2-4 hours of Practicals (P)/Clinicals (day care, out- patient and in-patient care) per week over a semester.

Therefore a course that has 1 hour of seminar, 1 hour of tutorial, 3 hours of bench work and 8 hours of clinical rounds every week earns 5 units per semester. *Mandatory Weekly Schedules for Every Resident in Hours are as follows:

Seminars, 1hr

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Tutorials, 1hr

Practicals, 12hrs

Clinical rounds, 20hrs

Pathology Grand Rounds, 1hr

Medical Grand Round 1hr

Journal Review, 1hr

Minimum Credit Units per semester for Junior Resident Training should be 14 and 84 for the 6 semesters for the mandatory 22-working months before Part II Examination (Table 2).

* Excluding the equally compulsory Emergency Clinical and Laboratory Calls, from 4pm-8 am every day; and 24 hours on weekends and public holidays

11.3.10 Table 2: Junior Residency Training

Programme Duration in

Months

Contact Academic

Hrs/Wk

(units)

Contact Bench

Work/Wk

(units)

Contact Clinical

Rounds/Wk

(units)

Minimum Credit

Units

earned

Basic chemical pathology: Specimen handling, Instrumentation, disorders of metabolism of water, electolytes, [H+ ] lipid, proteins, minerals and vitamins. Hormones disorders

4 5 (5) 12 (3) 20(5) 16 in 4 months

Tests of organ functions:kidneys, heart, liver, gastrointestinal, bone and endocrine organs, Disorders of musculoskeletal, metabolic and

4 5(5) 12 (3) 20(5) 16 per 4 months

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genetic diseases, purines, pyrimidines and haem metabolism

Prenatal diagnosis, paediatric clinical chemistry, toxicology and therapeutic drug monitoring. Tumour markers Hypertension, Pregnancy.

4 5 (5) 12 (3) 20(5) 16 per 4 months

Haematology 3 5 (5) 12 (3) 20(5) 12 in 3 months

Histopathology 3 5 (5) 12 (3) 20(5) 12 in 3 months

Medical Microbiology & Parasitology

3 5 (5) 12 (3) 20(5) 12 in 3 months

Leave Periods 3 - - - -

Total 24 30 (30) 72 (18) 120 (31) 84 units

in 24

months

Trainees in JRT programme will be Eligible to SIT for Part IFMCPath Examination only after he/she must have completed a minimum of 24 months

of postings as follows:

12 months (48 weeks) of Chemical Pathology postings 09 months (36 weeks) of outside postings in other pathology areas

03 months (12 weeks) of leave The trainee must have accumulated a total minimum credit points of 84 units for

both Chemical Pathology, postings to the 3 sister departments of Haematology, Histopathology and Medical Microbiology and Parasitology

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The postings and Credit points Must be Confirmed in the appropriately Signed Log Book in all cases before the candidate is Allowed to Sit for the Part

IFMCPath Examination.

11.3.11 General Laboratory Procedures

Methods of generating requests for laboratory tests; requisition forms,

computerized order entry, selective requests versus organ system profiles; screening procedures; 4 function tests; prearranged batteries of tests or algorithms to answer specific clinical problems.

Specimen collection, identification, transport, delivery, preparation and preservation. Patient preparation for tests. Collection on neonates.

Anticoagulants and preservatives. Regulations and precautions regarding transport of biological specimens.

Laboratory safety

Statistics: Concepts of probability and significance, standard deviation,

confidence limits, t-test, F-test, analysis of variance, Chi-square, linear and other regression, difference plots, non-parametric testing. Sensitivity, specificity, predictive value and ROC curves.

Precision, accuracy, errors of laboratory instruments; standardization units (S.I. and conventional); internal quality control, external quality control;

Statutory proficiency testing programs. Primary and secondary standards. Reference materials (International reference materials) and reference

methods. Evaluation and comparisons of methods and instruments.

11.3.12 Instrumentation

Instruments essential to the operation of a clinical chemistry laboratory. Trainees

should understand the principles of analysis, be able to set up and operate the instruments, know their inherent errors, general maintenance, defects and potential problems, and be able to "troubleshoot" or assist repair personnel.

They should conduct experiments under the direction of their consultants. Trainees should understand the criteria for instrument selection.

Spectrophotometers, reflectometers and nephelometers.

Flame photometers (emission and atomic absorption)

Ion specific electrodes: electrolytes and other applications.

Blood gas apparatus

Electrophoresis and densitometer equipment

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Automated and semi-automated analysers for general chemistry,

immunologic techniques, chemiluminescence, fluorescence polarization: discrete, centrifugal, random access and batchers; reagent cassette and thin film analysers.

Automatic sampling and pipetting devices.

General laboratory equipment such as centrifuges, water baths, balances,

microscopes, pH meters.

Water quality requirements; Water purification systems, stills, de- ionizers,

methods of checking the quality of water. Reverse osmosis.

High performance liquid chromatography.

Small instruments for satellite and point-of-care testing.

11.3.13 Techniques Used in Chemical Pathology

Trainees should have both a theoretical and practical knowledge of suitable

examples of each technique

General Techniques: Solvent extraction, selection of buffers; freeze-

drying; dialysis; concentration, ultrafiltration; preparation of derivatives, Calibration techniques.

Spectrophotometric Techniques: Molar absorptivity, reflectance, absorbance, transmittance;fluorometry, nephelometry, chemiluninescence

and turbidimetry.

Enzymatic Techniques: Enzyme and isoenzyme measurement methods

(fixed incubation and kinetic methods); standardization and optimization of methods; stability of enzymes.

11.3.14 Analytical Methods

Trainees should be familiar with the theoretical principles of the methods, the

factors which govern the choice of methods and their eva luation. The concepts of definitive and reference methods and standard reference materials should be

understood. They must be competent in the performance of the tests, and should have performed supplementary experiments under the guidance of the supervisor, to examine aspects of some tests in depth. The sensitivity, specificity and

predictive value of the tests should be assessed in relation to their interpretation, Potential effect of drugs on the interpretation of test results and clinical

application and cost benefits.

Bilirubin - total, conjugated (direct)

Blood gases and pH, O2 saturation

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Calculi (renal)

Renal functions: Urea, creatinine, uric acid, clearance studies

Electrolytes: sodium, potassium, chloride, CO2 (HCO3-), total and free

(ionized) calcium, phosphorus (inorg.), magnesium.

Enzymes: alkaline phosphatase (ALP), amylase, creatine kinase (CK),

gamma-glutamyltransferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LD), lipase, amylase.

Faecal analysis - fat, occult blood

Glucose

Glycated haemoglobin (HbA1c)

Hormone tests: Quantitative hCG, Thyroid function tests etc.

Diagnostic Procedures/dynamic tests: Dexamethasone suppression test

etc.

Iron - serum, iron binding capacity, iron saturation, transferrin, ferritin

Ketones - Blood and urine

Lipids: cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol,

apolipoproteins

Proteins: serum total, albumin, electrophoresis (serum, urine and CSF),

complements, urinary microalbumin, C-reactive protein.

Spinal fluid - glucose, protein

Specific Proteins/Tumour markers: prostate specific antigen (PSA)

carcinoembryonic antigen (CEA); alpha-fetoprotein (AFP); chorionic gonadotropin (CG).

Urinalysis (including microscopy)

11.4.0 Senior Residency Programme Chemical Pathology

The senior residency training (SRT) programme starts in the third year of enrolment, but, only after the trainee must have passed the Part I FMCPath examination. It includes both laboratory and clinical programmes. Residents

undergoing this phase of training will take part in all departmental activities at advanced level.

He/She would also spend Three Months, in the Departments of Internal Medicine or Paediatrics for further clinical exposure.

36

He would undertake a Clinical and Laboratory-based Research that will be presented as a Dissertation for Part II Final FMCPath Examination.

A Senior Resident is deemed to have completed his/her training if

He/she has completed 24 months of rotations (18 months (72 weeks) in Chem Path; 3 months for Internal Medicine or Paediatrics and cumulative 2 months of annual leaves)

He/she has completed the dissertation

If a senior resident doctor follows a mandatory weekly schedule, he/she has a cumulative Credit Units of 84 (including 12 units for Thesis)

11.4.1 Table 3: Senior Residency Training Table 3: Senior Resident Training Rotations (Months)

3mts 3mts 3 3 1mt

3rd

Year

Chemical

pathology

Chemical pathology Proposal

writing

Chem path Leave

4th

Year

Paediatrics or

internal

medicine

Chemical

pathology/dissertation

Chem path

/dissertation

Chem path

/dissertation

Leave

Candidates undergoing senior resident postings are expected to have a sound

theoretical and practical knowledge of use of clinical chemistry in practice. They however may lack a great deal of experience in applying that knowledge. The second phase of training is thus devoted to acquiring this self sufficiency in the

specialty. There will also be exposure to management issues and the trainee should be involved in the teaching of medical and paramedical students, as well as

supervision of junior residents. In addition part of this time (12 – 24 months) should be used for a relevant

clinical and laboratory-based research project approved by the NPMC that will be presented in part fulfilment of the FMCPath Part II examination.

In addition to the requirements in the syllabus for junior residency training, the following are required:

11.4.2 General Laboratory Procedures

1. Laboratory reporting systems: Ensuring that the information reaches the attending physician within a time-frame for appropriate action. Critical

37

values. Directing attention to abnormal results when necessary; providing clinical interpretation when appropriate.

2. Keeping laboratory records, retention policies; workload measurement systems. Preparation and maintenance of proper laboratory manuals.

Accreditation requirements. 3. Assessing the quality, stability and costs of reagents, commercial "kits",

near-patient and laboratory instruments and analysers; strategies to select

instruments. 4. Biological variations: Understanding the concept of pre-analytical

variables

11.4.3 Instrumentation

Trainees should understand the principles of analysis, be able to set up and operate the instruments, know their inherent errors, general maintenance, defects

and potential problems, and be able to "troubleshoot" or assist repair personnel. They should conduct experiments under the direction of their consultants.

Trainees should understand the criteria for instrument selection. i. Polymerase chain reaction cyclers and other amplification techniques.

ii. Osmometers.

iii. Fluorometers. iv. Gas chromatographs.

v. Liquid scintillation counters. vi. Infra-red/ultraviolet spectrophotometer.

vii. Refractometers.

viii. Isoelectric focusing. ix. Ultracentrifuge.

x. Mass spectrometers. xi. Flow cytometers.

xii. Amino-acid analyzer.

11.4.4 Techniques Used in Chemical Pathology

Immunologic and Competitive Binding Techniques: Immunodiffusion, immunoelectrophoresisimmunoblotting and immunofixation;

Immunoassays: isotopic and non- isotopic, competitive, non-competitive or immunometric, liquid or solid-phase etc

Chromatographic Techniques: HPLC/GC/TLC

Electrophoretic Techniques

Isotope Techniques: Counting techniques etc

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Molecular Biology Techniques Principles and methods of DNA and RNA

isolation, purification, polymerase chain reaction (PCR).

11.4.5 Analytical Methods

Trainees should be familiar with the theoretical principles of the methods, the

factors which govern the choice of methods and their evaluation. The concepts of definitive and reference methods and standard reference materials should be understood. They must be competent in the performance of the tests, and should

have performed supplementary experiments under the guidance of the supervisor, to examine aspects of some tests in depth. The sensitivity, specificity and

predictive value of the tests should be assessed in relation to their interpretation, Potential effect of drugs on the interpretation of test results and clinical application and cost benefits.

Cardiac Markers: CK-2 (CKMB), troponins, myoglobin

Drug analysis: acetaminophen, aminoglycosides, phenobarbital,

phenytoin, etc

Enzymes: alkaline phosphatase (ALP), amylase, creatine kinase (CK),

gamma-glutamyltransferase (GGT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactate dehydrogenase (LD), lipase,

amylase.

Glycated serum proteins (fructosamines)

Iron - serum, iron binding capacity, iron saturation, transferrin, ferritin

Ketones - Blood and urine

Metanephrines, catecholamines, VMA

Osmolality

Porphyrins - (qualitative/quantitative)

Specific Proteins/Tumour markers: prostate specific antigen (PSA)

carcinoembryonic antigen (CEA); alpha-fetoprotein (AFP); chorionic gonadotropin (CG).

Vitamins: vitamin B12, folate, Schillings test.

Trainees should understand the theoretical basis of the tests, and the

clinical interpretation. If the tests are available in another training centre other than their own, the trainees should gain practical experience with as many of them as possible.

Amino acids screen:

chromatography;

Ammonia analysis

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Amniotic fluid analysis: bilirubin, alpha-fetoprotein, fetal lung maturity

testing

Vitamin analysis (A, B, C, E,)

Drugs of abuse screen or quantitative

Enzymes electrophoresis: CK, LD, ALP

Other Hormone Tests: 17-hydroxyprogesterone, 11-deoxycortisol, corticotropin (ACTH) etc

Metals - copper, lead, mercury, zinc, aluminium.

Proteins: alpha-1-antitrypsin, fibrinogen, cryoglobulin, haptoglobin,

immunoglobulin IgE

Hemoglobins: HBA1c, HBA2

Pyruvate/Lactate

Sugars - galactose, lactose, urine chromatography.

Tumor markers: 5-HIAA, PTHrP, CA 125, CA 19-9.

Bone markers; pyridinoline cross- links, hydroxyprolline

Tests not commonly requested in Biochemistry; clinical knowledge is required, but only general, regarding the type of analytical approach.

Amino acids: hydroxyproline; branched chain aminoacidemia, etc.

Antibodies: e.g. anti-ds-DNA; anti-nuclear antibodies, anti-thyroglobulin

Bile acids

Breath tests: hydrogen (jejunaldisaccharidases); 14CO2 (bile acids)

Lipoprotein electrophoresis

Metals - arsenic; chromium.

11.4.6 General and Interpretive Clinical Biochemistry

(Junior and Senior Residency Programme)

The prime objective in the education of chemical pathologists is to impart an understanding of the appropriateness of a laboratory test for a particular

patient at a particular time.

They must be familiar with the meaning of sensitivity and specificity of

tests and the importance of prevalence in determining the predictive value of a test result.

Trainees should know the details of the various tests of organ function, as

well as the laboratory determinations involved, the relative merits of multiphasic screening, organ profiling versus cost effective testing

protocols.

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They should know the biochemical and pathological mechanisms of tissue

injury, as well as the factors underlying the tests and the principles of management of the common clinical disorders.

Trainees must be able to advice on the choice of tests when necessary and

on the interpretation of laboratory results when appropriate.

11.4.7 Organ System Diseases

Fluid and electrolyte disorders

Acid-base and respiratory function

Disorders of the kidney and urinary tract

Cardiovascular disorders and hypertension

Hematologic disorders; porphyrins, haem and bile pigments

hepatobiliary disorders

Gastrointestinal and pancreatic disorders

Immune system

Musculoskeletal, arthritic and rheumatic disorders

Endocrine disorders

Metabolic and genetic diseases

Diabetes mellitus and other carbohydrate diseases

Calcium, magnesium, the parathyroids and bone diseases.

Proteins, disorders of protein metabolism and nutrition

Disorders of purine and pyrimidine metabolism

Lipids and lipoprotein disorders

Molecular diagnosis of genetic defects

Cell regulation and disorders of signal transduction

Prenatal diagnosis, assessment and monitoring of high risk pregnancy

Paediatric clinical biochemistry

Vitamins, trace elements and environmental toxins

Pharmacology / toxicology / therapeutic drug monitoring

Biochemical aspects of oncology

Geriatric clinical biochemistry

11.4.8 Management (For Part II candidates)

Laboratory Data Processing and Computing

Use of computers in quality control and management; use of computers for calculating analytical results (e.g. non- linear functions).

41

General aspects of system design; central vs. stand-alone systems, host computers and equipment interfaces.

Laboratory information systems (LIS), Hospital information systems (HIS)

Personal computer use; word processing, spreadsheets, database, graphics, statistics, presentations, email, internet.

Security of data storage and transmission. Appropriate access control to patient information.

11.4.9 Laboratory Management

Preparation of operating budgets: o General aspects of financial management of laboratories. o Cost-analysis (tests and instruments); o Justification of providing new services or rejecting existing ones; o Lease and purchase decision analysis; o Delegation of budget responsibilities, workload statistics.

Laboratory design: o Designing laboratories for different types and sizes of institutions: o Selection of equipment and systems for the laboratory, o Concepts of workstation consolidation, o Work flow analysis, o Concepts in laboratory automation (sample transportation systems, modular

systems, robotics).

Laboratory safety: o Fire, chemical, radiation and infection control (body substance precautions), o Hazardous waste and transport of hazardous materials.

Training of technical staff: o Familiarity is needed with the syllabi of various training programs; o Knowledge of the teaching requirements and level of knowledge of each staff

cadre o Understanding of qualifications of technologists and scientists trained in

other countries.

Record keeping: o Standard operating procedures o Quality control programs o Patient data retrieval.

Personnel management: o Personnel policy manual; o Job descriptions; o Labour relations; o Delegation to a laboratory manager. o Legal requirements for laboratory operation: o Knowledge of relevant government guidelines

42

o Personal liability.

Hospital organization: o Interactions between the laboratory service and the rest of the hospital. o Professional ethics.

Quality assurance: o Total quality management; o Development and monitoring of performance indicators.

Public relations: o Hospital and community.

Emergency and clinical call duty services.

11.4.10 Part I (Check the syllabus for details)

Trainees should:

i. Have a satisfactory knowledge of laboratory organisation including work flow, reporting systems, handling urgent samples;

ii. Understand the principles and practice of quality control procedures; iii. Have a working knowledge of basic statistics, including calculations of

mean, standard deviation, confidence limits, coefficients of variation etc.; iv. Know methods of collection, identification and preservation of specimens;

principles of screening and discretionary testing; v. Be proficient in data manipulation and interpretation; vi. Learn the theory and practice of reference values, quantities and units;

vii. Be knowledgeable in laboratory safety including control of chemical, physical, microbiological and radiation hazards;

viii. Take laboratory and clinical duty calls; ix. Have hands on experience on all laboratory benches x. Participate actively in departmental academic/clinical programs; xi. Have an in depth knowledge of pathophysiology of disease processes and

management of biochemical derangements; xii. Be able to describe the analytical methods used in their laboratory in

detail, together with an outline of alternative methods; xiii. Understand the purpose of all reagents used in particular procedures and

their preparation, be able to describe the chemical reactions involved, list sources of known interference, and be able to discuss critically the advantages and disadvantages of the method used compared with alternative techniques;

xiv. Be familiar with the use, method of analysis, analytical procedure and interpretation of all tests commonly performed in a clinical chemistry laboratory; and

43

xv. Be aware of the commonly performed tests and developments in clinical chemistry testing, relating to alternative methods of analysis, new instrumentation and new tests.

11.4.11 Part II (Consult the syllabus above) In addition to meeting the requirements stated above for Part I, the Part II candidate should fulfil the following:

Detailed knowledge of instrumentation (as in the syllabus); Participation in metabolic clinic; A three-month rotation in internal medicine (1 month each in nephrology,

endocrinology and cardiology); Research methodology course; Health management course; Laboratory based research project; Perform bench work such as hormonal analysis, osmolality measurements; Perform and interpret dynamic function tests e.g. OGTT; Interpretation and signing off of laboratory results; Participate in molecular diagnostic techniques such as DNA/RNA

isolation; Participate actively in patient management; Take emergency and clinical duty calls; Participate in the departmental Journal Club; and Supervision of junior residents.

Tasks, Learning Outcomes and Activities in Chemical Pathology

Functions of the Chemical Pathologist as a Medical Specialist in the

Laboratory TASK LEARNING OUTCOMES LEARNING ACTIVITIES

The Patient - Advise clinicians and patients on preparation for specific tests .

- Advise clinicians on the effect of

coexistent illness. - Maintain patient confidentiality

and privacy. - Maintain patient safety and

comfort whilst performing tests and procedures

- Participate in ward rounds and discussion with clinicians.

- Participate in bench work, dealing

with general inquiries and actively learn to maintain confidentiality.

- Multidisciplinary approach to interpretation of results.

- Involvement in performing various tests and procedures especially

dynamic tests . Management

And Processing of Specimens

- Apply laboratory procedures for

routine emergency work. - Analysework flow and determine

whether procedures are optimal. - Using expert knowledge of value

of tests in different disease states,

- Participate in daily laboratory

activities, review the workflow on a particular day to assess workflow in

your laboratory and identify any problems.

- Partake in daily biochemistry duties

44

advise clinician as to appropriateness of test

such as manning phone inquiries. Deliver lectures or seminars to lab and

clinical staffs on an existing test or the preparation for the introduction of a

new analyte Ensure the appropriate collection

is made with regard to variables such as choice of anticoagulant,

time of day etc., e.g. explain to requesting clinicians why OGTT

should only be performed in the

morning and consequences of inadequate patient preparation.

Participate in daily biochemistry

duties. Review of standard operating procedures for various tests such as

OGTT or dexamethasone suppression test.

Ensure accurate patient

identification is made and sample labelling is sufficient.

Document examples of problems

resulting from inadequate patient identification. Educational seminar to

staff about the importance of correct

patient identification and subsequent data entry.

Ensure specimen transport is

appropriate to guarantee integrity

and timeliness.

Self performing „experiment‟ at bench

level to assess for the problem with

glucose or homocystine and delayed separation.

- Using knowledge of laboratory

information system, ensure that procedures for data entry include

the recording of adequate

information on both patient and sample.

- Ensure accurate sample labelling and appropriate sample

preparation for analysis. - Monitor workflow within the lab

to ensure that processed samples

are presented to appropriate instrumentation for analysis .

- Observe system problems when

inadequate information is available. - Observe system handling of

inadequately identified samples.

Identify any samples labelling that may affect sample analysis or the

production of report such as dynamic tests where the times recorded (both

absolute and relative) are critical for interpretation and reporting.

- Map the workflow and optimise it.

Instruments Ensure that appropriate

instrumentation is used for analysis of sample based on menu,

throughput, design of assays,

quality performance, financing and laboratory physical

constraints.

Participate in drawing up a tender for

a new analyser in the department or in smaller point of care devices .

Analysis Apply laboratory criteria for

potential sample rejection

Bench work assessment of „abnormal‟

samples, which include haemolysis, severe lipaemia and exposure of

bilirubin sample to UV light.

Follow laboratory procedure for reagent handling.

Bench work activity

45

- Monitor results to identify and prevent errors due to out of range

samples. - Explain to clinicians importance

of limit of detection such as Troponins and beta-HCG levels.

- Perform calibration procedures on

as many platforms and analytes as possible.

Bench work

Apply findings of Internal and

External quality control to

laboratory procedures.

Review of laboratory internal QC

procedures and update if required.

Review of EQA reports and any remedial/corrective actions.

Ensure appropriate determination

of reference intervals including the practicality of applying such

interval to a new test.

- Review various RI‟s and compare

with other laboratories. Read manufacturers‟ inserts to assess their

way of establishing RI.

- Establish reference interval to a new analyte.

Implement trouble-shooting

procedures as required.

Bench work

Ensure waste disposal occurs in

accordance with laboratory procedures and government

regulations.

Identify the ways in which the

laboratory disposes of various wastes including radioactive materials,

infectious wastes etc.

- Ensure water supply and

purification measures meet quality control standards.

- Ensure regular and preventative maintenance of existing platforms.

- Identify the source of water supply in

your laboratory. Review the grading of water purification in your

laboratory and its quality control. - Bench work. Review and benchmark

the performance of a platform in

terms of breakdowns, reparation frequency as distinct from planned

preventative maintenance. Laboratory Management

Participate in budget planning and ongoing monitoring.

Take part in drawing up an annual department budget and identifying the

fixed, variable and discretionary costs .

Participate in organising staff

recruitment, training, continuing education etc.

Bench work, identifying any scientific

or personnel deficiency and put in a business case for extra staff.

Monitor the organisation of the laboratory so that required work is

handled most effectively and efficiently

Perform time and motion studies in your own lab and visit other labs of

similar size and view their procedures

Validation and Reporting of

Laboratory Data

Implement staff training to detect potential causes of error.

Perform literature review on test sensitivity and specificity, disease

prevalence and predictive value.

- Record and verify result in accord with laboratory procedures

- Review IQC in one area of lab. - Explain consequences of

46

relating to QC etc. - Use laboratory information system

to design algorithms for reporting.

inappropriate QC limits in terms of assay out-of-control.

Develop policies relating to

printing of results, considering especially incomplete requests and

site of printing.

Monitoring Patient

Progress

Where laboratory results suggest

developing disease, appropriately monitor patient progress using

direct visit or surveillance via laboratory information system, so

as to advise clinicians.

- Clinical call duty

Storage and Retrieval

of Laboratory Data and Specimens

Develop standard procedures on

specimen storage

Laboratory work. Appropriate

labeling and retrieval system

Performing Specific

Laboratory Procedures

- Automated general chemistry

analyser.

- High performance liquid chromatography.

- Serum protein electrophoresis. - Atomic absorption spectroscopy.

- Polymerase chain reaction. - Blood gas analysis.

- Immunoassay. - Others

Bench work

Dynamic Tests Be able to perform, or advise clinical staff on protocols for

performance of dynamic tests such as: Overnight dexamethasone

suppression test, Oral glucose

tolerance test, water deprivation test

Perform the test, Review the guidelines together with other clinical

disciplines (endocrinology)

Interpret results of such tests Discuss interpretation with relevant

disciplines and colleagues

Assessing and Using

New Information

Use the library and internet

sources like medscape, pubmed and HINARI

Discuss new tests with clinicians

Research - Ability to formulate and test

hypothesis.

- Demonstrate deep knowledge of value of tests in investigation of

specific clinical problems.

- Carry out research projects.

- Acquire knowledge of testing

methodology, laboratory results, typical results in patients with the

relevant condition and integrate these experiences

Developing and Communicating an

Opinion

- Combine knowledge of test value with relevant clinical information

to form and record a professional opinion as to nature, cause,

severity and likely outcome of

- Patient review and opinion. - Outpatient clinic attendance.

- Participation in ICU or other ward rounds.

- Participate in signing out

47

clinical condition in question. - Demonstrate when it is

appropriate to add comments about a set of results on a written

report. - Demonstrate when it is

appropriate to communicate

directly with a doctor about a set of results.

- Contribute appropriately to Grand Rounds, clinico-pathological

conferences, morbidity and mortality reviews, quality and

audit committees and other similar

meetings.

- Talk at grand rounds. - Participate in QA meetings.

- Ringing out critical results to doctors

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49

Training Curriculum – Haematology and

Blood Tranfusion Medicine

50

51

12.0 Residency Training in Haematology (RTH)

12.1 Introduction

RTH will occupy not less than four years subdivided into:

12.1.1 Junior Residency Training (JRT) for the first minimum of two years and it will be directed towards acquiring a broad general experience in

Pathology with emphasis on Haematology under supervision with both formal and informal teaching. Part I fellowship examination will be written at the end of JRT.

12.1.2 Senior Residency Training (SRT), the trainee will acquire a greater independence in clinical and laboratory practice of haematology speciality.

Residents must also spend Six months rotating through Internal Medicine/Paediatrics as a compulsory component of SRT programme.

12.1.3 General Requirements

All residents must obtain certificate of attendance of both the Update Course and Revision Course before writing Part I Fellowship Examination, and Research

Methodology Course before the Final Part II FMCPath Examination organised by the College.

Senior resident trainees are strongly encouraged to have a short course in Hospital Management before the final Part II FMCPath examination.

12.2 Sub-specialisation within Haematology:

The trainee will be required to engage in research in an area of interest, present and defend the same as a dissertation during a viva at the Part II examinatio n.

Some trainees may wish to spend one year as an attachment in an area of research interest in a more developed centre, usually abroad. This is usually allowed after passing the Part I Examinations.

12.2.1 Curriculum

The following knowledge and experience requirements are to be read in conjunction with the tables 1-10 below:

52

The trainee will be required to be instructed in the major aspects of laboratory and clinical haematology all through the period of training.

All residents in haematology will rotate through all sections of haematology including laboratories (general haematology and haemoglobinopathy, blood transfusion medicine, haemostasis and coagulation, special investigation laboratory and cytogenetic); in-and out-patient management; emergency bench calls from 4 pm to 8 am, and all-day during the week ends and public holidays. Clinical calls are also compulsory for all residents during the call periods as for emergency bench calls, except that bench and clinical calls are not run concurrently by the same individual. In addition to the weekly outpatient haematology clinics that is compulsory to all residents, daily Day-Care Clinicals are run in rotation for day case management of haematology patients in crises including haemoglobinopathy patients, haemophilia, patients on chemotherapy and any other registered patient in any form of crises.

12.2.2 Weekly routines in haematology are graphically represented in Table 1:

Table 1: Weekly Haematology Resident Routines Time schedules

SUN MON TUE WED THU FRI SAT

8am-4pm BENCH & CLINICAL CALLS

Laboratory Work: general laboratory, transfusion medicine, haemostasis & coagulation, special investigations, etc Clinical Responsibilities: outpatient clinics, ward coverage, day-care coverage Weekly Educational Programmes : Seminars, Tutorials, Journal review, Pathology grand rounds (with sister pathology depts.), medical grand rounds (with internal medicine dept.)

BENCH & CLINICAL CALLS

4pm-8am BENCH & CLINICAL CALLS

Notes on Table 1: The schedules are compulsory for all residents. Each resident

will rotate through the various laboratory and clinical sections. Log Books will be filled and signed by supervising consultants at the end of each

rotation. All activities are recorded and scored except during the Leave Periods (30

working days or 6 weeks annually).

Time available for Pre-Part I Resident Programmes (excluding 3 months of leave

periods) is 21 months, which translate to 7 Semesters of 13 weeks each. The programmes are weighted in hours and the weights are recorded in units: One Unit defines 1 hour of any of the following Seminar (S); Tutorials (T); Grand

53

Rounds and Journal Review or 2-4 hours of Practicals (P)/Clinicals (day care, out- patient and in-patient care) per week over a semester.

Therefore a course that has 1 hour of seminar, 1 hour of tutorial, 3 hours of

bench work and 8 hours of clinical rounds every week earns 5 units per semester. *Mandatory Weekly Schedules for Every Resident in Hours are as follows:

Lecture/Seminars, 1hr

Tutorials, 1hr

Practicals, 12hrs

Clinical rounds, 16hrs

Journal Review, 1hr

Minimum Credit Units per semester for Junior Resident Training should be 12 and 48 for the 4 semesters for the mandatory 12-working months of Haematology before Part I Examination (excluding the 9 months of outside postings and the 3

months of leave) (Table 2).

Senior Residents have an extra Six (06) credit units for the Thesis, making a cumulative of 70 before sitting for the Part II Examination. * Excluding the equally compulsory Emergency Clinical and Laboratory Calls,

from 4pm-8am every day; and 24 hours on weekends and public holidays

Tables 3-8 list the Mandatory Weekly Academic and Practical Activities for all

residents, junior and senior.

12.3 Junior Residency Training (Table 2)

12.3.1 A formal introduction to laboratory haematology is required during the

first three months of RTH, this will be followed by rotation through the major laboratories, in-and out-patient managements of patients, emergency bench calls from 4 pm to 8 am; and all-day during the week ends and public holidays. Clinical

calls are also compulsory for all residents during the call periods as for emergency bench calls, except that they are not run concurrently by the same individual.

Laboratory haematology will include instruction and hands-on experience in routine haematology/haemato-oncology, blood transfusion medicine, haemostasis and coagulation, and special tests, laboratories.

The trainee in haematology will spend the first 3 months as introduction to

laboratory and clinical haematology. He/She will spend a minimum of two weeks in blood transfusion, four weeks in general haematology (for stains preparation,

54

diagnostic blood counting, peripheral blood film and bone marrow slides reporting) and one week in coagulation. The remaining five weeks will be for

clinical exposure.

The trainee will be instructed in methods for obtaining bone marrow by aspiration and trephine, making slides from the aspirate and touch or roll preparations from the trephine. Resident must be conversant with preparation of basic stains.

Trainee will also be exposed to Fine Needle Aspiration Biopsy techniques.

Clinical training during this induction period will include supervised participation in in-patient and out-patient management of haematological disorders including clinical on-call as appropriate.

There will be an assessment at the end of the 3-month rotation.

12.3.2 Following the introductory period the trainee will receive instruction and practical experience in further aspects of haematology and rotate through other

specialities in pathology, for the rest of the 1st Year of training and through the 2nd. Part I FMCPath Examination will be written after the 1st Two Years of

Posting (Table 2). Junior residents will also start formal academic and clinical components of the

training, as indicated in the tables.

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Table 2: Schedules for Junior Resident Postings First 24 months Module Programme Duration

in

Months

Contact

Academic

Hrs/Wk

Contact

Bench

Work

Hrs/Wk

Contact

Clinical

Rounds

Hrs/Wk

Total Credit

Units/Module

earned

1 Haematopoiesis, Blood Cells and Functions. Introduction to Clin. Haematol

1 4 12 16 4

2 Non-haemolytic Anaemias( Nutritional Deficiencies, marrow failure, others)

2 4 12 16 8

3 Transfusion Medicine and) Haemolytic Disease of the Newborn

2 4 12 16 8

4 Haemolytic Anaemias (acquired & inherited 2 4 12 16 8

5 Haemostasis and Bleeding Disorders. AIDS 2 4 12 16 8 6 Haematologic Malignancies:

Lymphoproliferative&Myeloproliferative Disorders, Plasma Cell Neoplasia

3 4 12 16 12

Chemical Pathology 3 OUTSIDE POSTINGS Histopathology 3

Medical Microbiology & Parasitology 3

Leave Periods 3 - - - -

Total for the 4 semesters of 3 months each 24 192 576 960 48

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Note: Academic Work includes Lectures, Seminars and Journal Clubs

Lab./Bench Work includes Analytical procedures, Bone Marrow Aspiration, and PB and BM Slide reviews.

Contact Clinical Work includes Ward Rounds, Clinics, and Teaching Rounds Lab./Bench Work and Clinical Work should not necessarily follow the Academic Schedule.

1 hour of Contact Academic Work/week for 3 month = 1 Unit

2-4 hours of Contact Bench/Lab Work per week for 3 months = 1 Unit 2-4 hours of Contact Clinical Rounds per week for 3 months = 1 Unit.

Trainees in JRT programme will be Eligible to SIT for Part I FMCPath Examination only after he/she must have completed a minimum of 24 months

of postings as follows:

12 months (48 weeks) of haematology postings 09 months (36 weeks) of outside postings

03 months (12 weeks) of leave

Credit Units Earned during outside Postings are Determined by Individuals

Departments

To be eligible to sit for Part I Examination, the trainee must have accumulated a total minimum credit points of 48 Units for Haematology postings, and he/she should have completed rotations in the 3 sister departments of chemical

pathology, histopathology and medical microbiology and parasitology

All contacts must be entered in the appropriate section of the Log Book and

signed by the supervising consultant or appropriate person in all cases before the candidate is allowed to sit for the Part I FMCPath Examination.

12.3.3 Further Details on the Programmes (Tables 3-8)

Table 3: Module 1 - Basic Haematology: Haematopoiesis, Blood Cells and

Functions, and Introductory Clinical Haematology

S/N Topic 1 Haematopoiesis, Stem Cell and Blood Cells & Growth factors

2 Erythropoiesis, red cell metabolism and benign disorders of erythropoiesis 3 Haemoglobin structure, function and metabolism

4 Bone marrow structure and functions 5 Lymphatic structure and functions

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6 Innate and adaptive immunity 7 Leucocytes structure & function; benign disorders of leucocytes

8 The platelet Structure & function 9 History taking, physical examination of common haematological disorders

Table 4

Module 2: Non-haemolytic anaemias S/N Topic 1 Iron deficiency anaemia: iron metabolism; aetiopathogenesis; clinical features;

laboratory features, differential diagnosis; management and prevention

2 Megaloblastic anaemia: Vitamin B12 metabolism, Folate metabolism; causes and pathogenesis of megaloblastic; clinical features; laboratory features, differential diagnosis; management and prevention

3 Iron overload: aetiology; pathogenesis; laboratory diagnosis, clinical features and management. Chelating agents in iron overload

4 Bone marrow failure: Aplastic anaemia, causes, laboratory and clinical features, management

5 Bone marrow failure: Fanconi anaemia, pure red cell aplasia

Table 5:

Module 3: Transfusion Medicine and Haemolytic Disease of the Newborn

S/N Topic

1 The Blood bank: organisation, infrastructure & basic equipment, counselling room, bleeding room, donor resting room

2 Blood donor organisation: donor organisers, phlebotomists, types of

blood donors, donor care

3 Donor blood screening for transmissible infections: HBV, HCV, HIV, Syphilis, etc.

4 Medical screening of blood donors; Bleeding room procedures

5 Grouping antisera: sources; avidity; antigen/antibody reaction enhancing

agents

6 Laboratory procedures: ABO and Rhesus blood grouping (Tile and Tube techniques); antibody screening, direct and indirect anti-human globulin

tests, Cross matching;

7 Laboratory procedures: Component preparation, red cell concentrates, fresh frozen plasma (FFP), frozen plasma (FP), platelet concentrates, cryoprecipitate, etc.; indications for component use

8 Clinical transfusion practice: checking of donor/recipient data at bed

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side; hazards of blood transfusion, investigation and management of transfusion reactions

9 Red cell substitutes

10 Parentage dispute and blood group serology

11 Haemolytic disease of the newborn (ABO, Rhesus, others): diagnosis and

management

12 Laboratory safety and quality assurance in transfusion practice

Table 6

Module 4: Haemolytic Anaemias (acquired and inherited) S/N Topic 1 Haemolyticanaemias: Classification, laboratory and clinical features

2 Haemoglobinopathies: Sickle cell disorders, aetiopathogenesis, incidence, diagnosis, management

3 Haemoglobinopathies: Thalassaemic syndromes, aetiopathogenesis, incidence, diagnosis, management

4 Inherited haemolyticanaemias: G6PD deficiencies, hereditary spherocytosis, hereditary elliptocytosis. Diagnosis and management

5 Acquired haemolyticanaemia: malaria, septicaemia and other infections 6 Acquired haemolyticanaemia: Paroxysmal nocturnal haemoglobinuria (PNH)

7 Immune haemolyticanaemia: Autoimmune haemolyticanaemia 8 Laboratory methods other than haemoglobin electrophoresis: Direct and indirect

antihuman globulin tests; osmotic fragility test; acidified-serum lysis test (Ham‟s test), Schumm‟s test

Table 7:

Module 5: Haemostasis and Bleeding Disorders, Acquired immune deficiency

syndrome

S/N Topic

1 Physiology of haemostasis, coagulation and fibrinolysis 2 Platelets structure and functions

3 Aetiopathogenesis of bleeding and thrombotic disorders 4 Thrombophilia: Congenital and Acquired. Causes, investigations and treatment

5 Inherited bleeding disorders 6 Acquired bleeding disorders

Anticoagulant therapy, other methods of management of bleeding & thrombotic disorders

7 Laboratory techniques: PT and INR; APTT; TT; fibrinogen assay.

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8 Laboratory techniques: Platelet function studies (bleeding time, aggregation tests, etc.)

9 Laboratory techniques: specific factor assays (VIII & IX); identification of inhibitors; assays of proteins C & S, antithrombin III and lupus anticoagulant. Heparin assay

10 Acquired immunodeficiency syndrome

11 Laboratory procedures: HIV screening techniques, CD4 counting techniques, PCR techniques and Viral load in infants and adults living with AIDS

Table 8: Module 5: Haematologic Malignancies: Lymphoproliferative, Myeloproliferative

& Plasma Cell Disorders 1 Aetiopathogenesis

2 Classification, staging, prognosis

3 Clinical presentation, investigation, complication 4 Laboratory diagnostic methods: Fine needle aspiration (FNA) and histologic biopsy

of tissues; cytochemistry and immunophenotyping of tumour cells; cytogenetic characterisation of tumour cells;

5 General investigations of haematologic cancers: FBC, ESR, Serum biochemistry including LFTs, Viral screening (HBV, HCV & HIV), Radiology (chest X-ray, ultrasonography, computed tomography, magnetic resonance imaging (MRI), etc.

6 Cancer chemotherapy and cancer immunotherapy 7 Targeted therapy in haematologic cancers

8 Treatment of haematologic cancers 9 Common childhood tumours

12.3.4 Methods of training

All trainees will participate actively in all academic, practical and clinical programmes including, seminars, tutorials, patient management and out of hour

clinical and laboratory services. The trainee will require dedicated periods of training with a trainer consultant.

This will be especially important where skills are developed from pattern recognition, especially morphology but also clinical examination. The trainee will

also develop skills in directed but self-motivated training (text books, journals, videos etc.). Adequate time must be provided for such learning (minimum half day per week). Library facilities, journal clubs, scientific and clinical seminars

should be provided.

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Throughout the training period year there will be an increasing use of in-service experience for training purposes. At no time should this service load become such

that the trainee fails to benefit from clinical or laboratory service work.

12.3.5 Second year of training

During the second year of RTH, the trainee will externally rotate through other

specialties in Pathology; namely, Chemical Pathology, Medical Microbiology and Parasitology, and Morbid Anatomy and Histopathology. The trainee is expected

to spend at least three months in each posting and is required to participate in all the activities of each department. The trainee must be proficient in all the routine laboratory procedures of each department, give seminars that will be graded and

provide clinical service where appropriate (e.g. STI, Infectious Disease, Endocrine and Metabolic Clinics). In Morbid Anatomy, the trainee must conduct

post-mortems during the posting under supervision and later independently and attend Clinico-Pathological Conferences and grand rounds.

The trainee will be assessed at the end of each posting and a report of performance is forwarded to the trainer in Haematology.

12.3.6 Assessment of Junior Residency Training

At the end of the first two years the trainee will be qualified to sit for the Part I FMCPath examination majoring in Haematology.

12.4.0 Senior Residency Training (SRT)

The senior residency training (SRT) programme starts in the third year of enrolment, but, only after the trainee must have passed the Part I FMCPath

examination. It includes both laboratory and clinical programmes. Residents undergoing this phase of training will take part in all departmental activities as set out in tables 3-8, but at a more advanced level and acquire additional

competencies in the following:

Investigation and management of haematological conditions without supervision Involvement in on-going clinical and laboratory research in the department. Laboratory proficiency in the following:

1. Kleihauer technique for foetal haemoglobin (HbF); 2. Detection of anti-D antibodies

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3. Cytogenetic procedures. 4. Coagulation Factor Assays

5. Resolution of Parental disputes 6. Details of techniques of Bone Marrow/Stem Cell Transplantation

He/She would also spend Three Months each, in the Departments of Internal Medicine and Paediatrics for further clinical exposure.

He would undertake a Clinical and Laboratory-based Research that will be

presented as a Dissertation for Part II Final FMCPath Examination (Table 9). A Senior Resident is deemed to have completed his/her training if

He/she has completed 24 months of rotations (16 months (64 weeks) in haematology; 6 months for Internal Medicine and Paediatrics and cumulative 3

months of annual leaves) He/she has undertaken the Six months of Medical and Paediatric Postings

He/she has completed the dissertation He/she has a cumulative Credit Units of 70 (including 6 units for Thesis)

Table 9: Senior Resident Training Rotations (Months)

3mts 3mts 3mts 2mt 1mt

3rd

Year

Haemat Haemat Internal Medicine Haemat/Dissertation Leave

4th

Year

Paediatrics Haemat/Dissertation Haemat/Dissertation Haemat/Dissertation Leave

5th

Year

Haemat - - - -

Using 12 Units/3 months, excluding the 6 months of outside postings (Internal Medicine and Paediatrics) and 3 months of leave periods leaving half time in

fourth year for Dissertation, the maximum units for 3rd and 4th years should be 64. Dissertation carries 6 units, the total units for Part II candidates should be 70.

12.4.1 Curriculum for Senior Residency Training

Candidates undergoing senior resident postings are expected to have a sound theoretical and practical knowledge of haematological practice but will not have

had a great deal of unsupervised experience in applying that knowledge. The second phase of training is thus devoted to acquiring this self sufficiency in the

62

specialty. There will also be exposure to management issues and the trainee should be involved in the teaching of medical and paramedical students, as well as

supervision of junior residents.

This phase will also be used by the trainee to expand interests in particular aspects of haematology and to develop a wider expertise in these aspects eg, haemato-oncology, haemostasis and transfusion medicine.

If possible, and if desired by the trainee, more extended time can be spent in sub-

speciality training. In addition part of this time (12 – 24 months) should be used for a relevant clinical and laboratory-based research project approved by the NPMC that will be presented in part fulfilment of the FMCPath Part II

examination.

12.4.2 Required Facilities for Senior Resident Training

Specified out-patient duties with the opportunity to see new patients,

determine the diagnostic approach and therapy appropriate to their condition. There will be close collaboration with consultant colleagues and referring medical colleagues. Such experience is essential.

Increasing opportunity to oversee the care of in-patients. There must be regular, structured strategic discussion over management policy between

consultants, trainee, nursing and paramedical staff so that the trainee acquires the skills needed for effective team work.

The opportunity to be actively involved in the daily management of the

Haematology laboratory with full participation in management discussions. Trainees should be encouraged to attend appropriate

management courses. Such management instruction should include laboratory computer systems, quality control, audit, potential of

automation and near patient testing.

Familiarity with radiation techniques and the use of radioisotopes where

possible.

Regular update discussions of academic and practical aspects of haematology including the availability of appropriate journals.

Rotations at this level of training shall include blood transfusion, paediatric haematology and haemostasis for which secondment to other

centres may be necessary. The actual details and duration of exposure to each specialty should be a minimum of three months.

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12.4.3 Addition Formal/Informal training

Blood transfusion practice including the identification of antibodies;

methods for preparing leukocyte depleted blood products and their use; identification and management of auto-antibody diseases, both warm and

cold; methods of HLA typing. There should be instruction in methods for preparing blood components and in available techniques for rendering

blood products safer from virus contamination and transmission. A formal blood transfusion course of four weeks would be appropriate.

Formal and informal instruction in indication, techniques and problems of

allogeneic and autologous haemopoietic progenitor cell transfusions. Trainees should have experience in a transplant unit during this year.

More detailed instruction in clinical and laboratory aspects of coagulation including specific factor assays, identification of inhibitors, techniques for

measuring protein C, S, antithrombin III, lupus anticoagulant and such additional factors as from time to time become important. This practical experience should be linked to instruction in the theory of coagulation and

fibrinolysis.

Clinical and laboratory aspects of platelet disorders including numerical

and functional abnormalities and the use and limitation of platelet function studies. Such practical experience needs to be linked to an understanding

of platelet function and interaction with vessel wall. Mechanisms and use of antiplatelet drugs.

Clinical and theoretical instruction in radioisotope methods in

haematology. Clinical experience means knowledge of the usefulness of isotopes in clinical practice and interpretation of results. It is not necessary

at this stage to have 'hands-on' experience.

Basic theoretical and interpretative knowledge of radioisotope tests is desirable during the training and trainees who wish to obtain more experience are encouraged to do so.

Before signing trainees for examinations, trainers may use reasonable procedure to determine the readiness of otherwise of the candidate for the said examination.

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12.5.0 Assessment of Candidates

The Part I Examination (10.2.3-10.2.8)

A trainee is eligible to attempt the Part I Examination after at least two years of training in an accredited institution. The format of the examination is as previously prescribed:

Table 10: Functions of the Haematologist as a Medical Specialist in the

Laboratory Task Learning Outcomes Learning Activities

Accession, Management and Processing of Specimens

Advise clinicians on the appropriate choice and selection of tests and samples, their relative diagnostic strengths and the limitations of any proposed investigation • With reference to the relevant laboratory procedure manual, apply the principles of: - appropriate receipt, integrity and validation of specimens in the laboratory - specimen identification and laboratory accession - appropriate specimen transport, handling, storage, retention and subsequent disposal

• Providing advice to requesting clinicians (eg incoming phone calls) for test selection in conjunction with haematologists. • Work in reception area • Evaluate turn-around times in time critical tests eg. APTT identifying any source of non-compliance. • Review documentation and practice. • Evaluating different testing selection and technologies

Instrumentation & automation systems

• Apply laboratory-specified work flow procedures to routine, emergency and on-call services and determine whether they are optimal. • Select appropriate samples for integrity and intended assay. • Using expert knowledge of value of tests in different disease states, advise clinician as to appropriateness of test. Apply the principles of automated test method selection with reference to the requirements for: - specimen analysis – performance - quality control - calibration set up, including the

Work in automated area. Review QA/QC with senior scientists and pathologists

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development of normal and therapeutic reference ranges - trouble shooting – training

Production and Analysis of Laboratory Data

• Record, verify, interpret and report laboratory test results. • Identify potential causes of variation in results - clinical - non-clinical. • Explain the use of the laboratory information system to develop algorithms for production of results, interpretative comments and recommendations for further tests. Apply the principles of action limits with regard to: - their development - application in the laboratory - notification of abnormal results to pathologists and/or requesting clinicians.

• Participation in „normal‟ laboratory duties. • Review test procedures and prepare a report with recommendations for future local usage based on literature review and analysis of all methods and data including specificity, sensitivity and predictive values. • Review causes of variation. • Review action limits, documentation and compliance

Validation and Reporting of Laboratory Data

• Implement staff training to ensure that potential causes of laboratory error are identified – identify and record examples where training deficiencies lead to lab problems. • Implement staff training to ensure that clinically significant results are identified and communicated in accordance with laboratory procedures. • Demonstrate a detailed appreciation of test limitations when reporting results. • Record and verify result in accord with laboratory procedures relating to QC etc • Use laboratory information system to design algorithms for reporting – prepare algorithms for investigation of different clinical scenarios • Use these algorithms, action limits etc, to identify results which need non-routine action • Use departmental procedures to ensure that important results are conveyed to

• Review training manuals. • Review and develop with Supervisors laboratory procedures to identify and communicate clinically significant results. • Perform literature review on reported test sensitivity and specificity data and disease prevalence, estimate positive predictive value. • Review departmental list of tests and define appropriate QC/reporting. • Give seminars to scientific staff explaining significance and consequences of clinical

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appropriate clinician and extra testing is performed if indicated

reporting. • Review and preparation of action limit documentation. • Involvement in subsequent actions. E.g. Telephoning requesting clinician with recommendation for further investigation.

Monitoring patient progress

• Where laboratory results suggest developing disease, appropriately monitor patient progress using direct visit or surveillance via laboratory information system, so as to advise clinician when further specific testing may be warranted, or when a specific diagnosis becomes apparent. • Where appropriate, follow up patient outcomes by consultation with clinicians, in both hospital and general practice.

• Follow up of patients • Ringing out of abnormal/critical results • Participate in Supervised after hours roster. • Performance of daily laboratory and supervised on-call duties.

Storage And Retrieval Of Laboratory Data And Specimens

• Comply with the guidelines for specimens storage as set out in ISO or other relevant requirements. • Index specimens according to specific systems in use. • Retrieve specimens showing examples of specific diseases or processes for examination and review. • Retrieve laboratory data from information systems (LIS).

• Read guidelines and study local practice for monitoring documentation for ISO assessment • Retrieve specimens for review as part of daily work practice. • Using LIS retrieve reports with particular abnormalities for clinical review.

Laboratory Environment

• Comply with the regulatory requirements of running a laboratory with regard to national and International guidelines.

• Review or assess the laboratory as if a quality audit organization inspector and identify any problem areas as part of a quality audit. Critically review the last audit assessment reports of your laboratory and

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identify any contentious issues

Perform Administrative Duties

• Participate in budget planning and ongoing monitoring • Participate in organising staff, continuing education etc.

• Take part in drawing up an annual department budget and identifying the fixed, variable and discretionary costs • Participate in continuing education programs for pathologists, scientists and other staff and provide list of learning objectives associated with each presentation. • Attend unit management meetings

• Perform sterile procedures including bone marrow aspiration, trephine biopsies, cannulation and phlebotomy (including therapeutic venesection) with due consideration of:

- The individual patient‟s condition and clinical history.

- Benefits and potential risks. - Clinical indications. - Informed consent. - Resuscitation procedures.

• Satisfactory performance at a CPR teaching session

Performance and Interpretation of Specific Haematology Tests

Interpret and perform, where appropriate, the following laboratory tests as listed in detail in the Haematology check list: • Full Blood Count • Phenotype studies:

1. Morphology 2. Immunophenotype or flow cytometry

• Genotype studies: - Cytogenetics - Molecular genetics

• Erythrocyte studies • Haemolysis studies • Coagulation studies • Blood transfusion studies

• Perform tests as part of daily laboratory and training activities. May require attendance and performance at other laboratories.

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• Paediatric studies • Other studies.

Storage and Retrieval of Laboratory Data and Specimens

• Ensure that specimens are selected and stored appropriately in compliance with ISO or other relevant requirements. • Index specimens according to specific systems in use. • Retrieve specimens showing examples of specific diseases or processes for examination and review. • Retrieve records relating to specific cases or specimens. • Retrieve laboratory data from information systems.

• Critically review the last reports for any compliance irregularities. • Prepare a report on storage systems

Microscopy and related skills

• Prepare blood and bone marrow films according to laboratory guidelines. • Select, perform and interpret routine and special stains, and detect and correct errors in these processes. • Set up and maintain laboratory microscopes. • Use light and other microscopy appropriately. • Examine, describe and interpret blood and marrow films prepared by any of the techniques described in the Haematology checklist. • Record images for retention/teaching/manuscripts, etc e.g. Digital photography.

• Performance daily laboratory duties. Select and present slides to clinicians. Undergraduate and scientist teaching. • Preparation of teaching materials

Transfusion Related Skills

• Identification of donor and recipient and pre transfusion testing. -Donation/storage/transport/ issues -Indications for blood products (including modification). -Specification of blood products. • Complications of transfusion • Laboratory testing, reporting and documentation. • Monitoring efficacy of transfusion. • Provide clinical advice on the appropriate selection of blood and blood products and their administration.

• Daily laboratory duties. • Answering transfusion related queries from clinician and scientists. • Instigating and investigating transfusion reactions and preparing reports. • Perform all tests; include training exercises at Red Cross Blood Service or other relevant labs.

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• Perform blood transfusion studies as listed in the Haematology checklist. • Interpret blood bank results. • Recognize, investigate and manage transfusion reactions and other transfusion related adverse events. • Provision of urgent blood support

• Attend and contribute to Transfusion Committee meetings • Transfusion exercises set within the laboratory.

Assessing Sources of Information

• Access appropriate information to assist in the interpretation of specimens.

• Use textbooks, journals, internet, etc.

Developing an opinion

• On the basis of all the information available in relation to a specific case, develop and record a professional opinion as to the nature, causation, severity, likely sequelaeetc of the pathological process(es). • Seek further expert opinion as appropriate.

• Daily laboratory duties • Preparation under supervision of consultative reports.

Communicating an opinion

• Construct and sign off a written report which contains all appropriate diagnostic information and recommendations to the requesting clinician in a timely fashion. • Provide appropriate information and inferences about a case to referring clinicians by oral (face-to-face or telephone) communication. • Contribute appropriately to Grand Rounds, clinicopathological conferences,

• Preparation under supervision of consultative reports • Performance of daily laboratory and supervised on-call duties

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Training Curriculum - Anatomic Pathology

(Morbid Anatomy and Histopathology)

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13. Residency Training in Anatomic Pathology

13.0 Introduction

The discipline of Anatomic Pathology (Morbid Anatomy and Histopathology) is a specialization of Pathology that uses the knowledge of the mechanisms of disease

to diagnose disorders based on the interpretation of gross and microscopic techniques in both the living and the dead. The Anatomic Pathology Department provides services for virtually all other specialists in a teaching hospital setting.

Thus with the fundamental knowledge of medicine, they are able to interact and participate in patients‟ management through clinicopathology and surgical

pathology meetings. Anatomic Pathologists work in close concert with clinical colleagues, providing

consultancy service to surgeons, physicians, paediatricians, general practitioners, obstetricians and gynaecologists. Effective provision of histopathological services

is predicated upon clear mutual two-way communication between the pathologist and his or her clinical colleagues, which engenders the provision of timely, accurate and high quality service by the pathologist

Specialists in the field are addressed as Histopathologists, Anatomic Pathologists

or Cellular Pathologists but those with sub-specialty training and qualifications can in addition be addressed as appropriate, such as Cytopathologist, Neuropathologist, Renal Pathologist, Forensic Pathologist, etc.Histopathologists

work in tertiary and secondary health care centres, as well as in private and research laboratories.

13.1 The Scope of Anatomical Pathology

The scope of Pathology practice includes the following:

Surgical Pathology

Cytopathology

Autopsy Pathology

The Rudiments of Forensic Pathology including Clinical Forensic Medicine.

13.1.1 Surgical Pathology involves the macroscopic and microscopic

examination of biopsy specimens obtained from patients for the purpose of

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diagnosis, staging, treatment, monitoring and prognostication of clinical diseases. Tissue samples handled routinely by the Histopathologist include surgica l biopsy

specimens, needle biopsies and frozen sections.

13.1.2 Cytopathology involves the microscopic examination of individual cells in different preparations. Cytology samples include exfoliative cytology specimens (body fluids), scrapings, imprint smears and fine needle

aspirates.

13.1.3 Autopsy Pathology involves the employment of post-mortem techniques for the purpose of determination of the cause of death. All Anatomic Pathologists should acquire competence in the handling of adult and paediatric

post-mortem examinations, as well as basic skills in handling medicolegal autopsies.

13.1.4 Forensic Pathology (including Clinical Forensic Medicine)

involves the application of specialised medical/pathology skills in

addressing/solving legal questions. It does touches not just on the cause of death but also the mechanism and manner of death. Others are evaluation of time (since

death or the age of wounds), dtermination of weapon types based on wounds produced (in the dead and living), applications of the science of anthropology, entomology, odontology, radiology, palynology, toxicology etc. This specialty

deals with the investigation of special deaths in conjunction with other specialists like crime scene officers, trace evidence specialists, etc. Other aspects of clinical

forensic medicine include aspects of alcohol and drugs, euthanasia, medical ethics, courtroom practices, non-fatal wounds and their analyses, police surgeon duties, etc.

13.2.0 Residency Training in Anatomic Pathology The span of the training period is not less than four years after passing the primary examination. This period is divided into two equal parts namely, the Junior Residency Training (JRT) and the Senior Residency Training (SRT)

Table 1: Basic programme of an Anatomic Pathology Department from

8.00am to 4.00pm Slide review with consultants: All week days and call duty hours Cut up/Grossing sessions: All week days FNAC/Cytology clinics: all week days

Monday 8.30am Grand slide sessions

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Tuesday 2.00pm Journal review

Wednesday 9.00am Integrated Pathology grand round involving all departments of pathology

Thursday 8.30am Autopsy demonstration 2.00pm Postgraduate seminars

Friday 9.00am Neuropathology meetings/Brain cut up

Residents are to attend clinicopathology meetings with clinicians and attend

hospital grand rounds

The Anatomic Pathology Department should host Surgical Pathology meetings at least once a month

Each department of anatomical pathology may adjust the programme to suit the peculiarity of their centre of training.

13.2.1 Competence goals for the Junior Resident for the Part I

Examination:

Ability to dissect bodies according to disease specifications and preserve anatomical relationships. It is presumed the the candidates already have a

sound knowledge of normal anatomy and histology. Understand the principles of microscopy and appropriate use of the the

light microscope

Ability to interpret autopsy findings with sound clinical and morphological correlations

Ability to write autopsy reports in acceptable patterns Ability to fluently present and convincingly demonstrate organs at autopsy

demonstrations.

Ability to report histopathology slides Ability to advise clinicians on nature of specimens for optimal assessment

crucial to the management of patients. Ability to perform basic staining procedures Ability to understand the principles of histochemistry and

immunohistochemistry and their role in tissue diagnosis. Ability to design and implement simple of Quality Assurance procedures.

Ability to give academic seminars and clinicopathological presentations using ICT tools and skills.

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During the Senior Residency Training (SRT), the trainee will acquire a greater independence in anatomical pathology practice. There should be some scope for

pursuing sub-specialisation at the end of this training period and towards this end the trainee will be exposed to interpreting slides of cytology specimens, to

perform and interpret Fine Needle Aspiration Cytology Biopsies (FNACB); some under ultrasound guidance, interpret frozen sections and medicolegal autopsies. The trainee will also be required to engage in research in an area of interest,

present and defend the same as a dissertation during a viva at the Part II examination. Some trainees may wish to spend one year as an attachment in an

area of research interest in a more developed centre, usually abroad. This is usually allowed after passing the Part I Examinations. Candidates who are motivated should be encouraged and duly supported to later sub-specialise at

centres of excellence abroad or locally.

SRT is expected to culminate in the final Part II Fellowship examination in Anatomic Pathology with the award of the FMCPath.

13.3.0 Assessment (10.0-10.2.16)

13.2.1 The Part I Examination (10.2.3-10.2.8)

A trainee is eligible to attempt the Part I Examination after at least two years of

training in an accredited institution. The current format of the examination is as follows:

Paper One is a 3-hour multiple choice questions (MCQ) paper.

Paper Two is a 3-hour written paper (full length essay and short notes)

Practical examinations (6 hours): A morning 3-hour session of autopsy/post-mortem dissection of

clinical cases managed in the hospital wards. An afternoon 3-hour paper in diagnostic Surgical Pathology during

which the candidate is made to assess 20 slides selected from routine

bench work collections.

Viva/Oral Examination which should take 20-minutes with four examiners

(one from each specialty of Pathology) asking questions on mechanisms of diseases, aetio-pathogenesis, morphology, clinical practice (c, laboratory

procedures and test interpretation.

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13.2.2 The Part II Examination (10.2.9-10.2.16)

After a successful completion of the JRT, the trainee is expected to remain under supervision and training for a minimum period of 24 months before applying to

sit for the Part II Examinations. The Part II examination is taken at least two years after passing Part I Examination, or following exemption from Part I Examination.

The final assessment consists of:

A 6-hour written essay/short notes paper on core Histopathology for three hours; examination divided into Paper I and Paper II.

Paper I shall comprise theoretical questions on various aspects of general and systemic pathology,

Paper II shall include management questions (Human and material

resources, planning and management, Budget p lanning and control, General Administration, Laboratory Management, Quality Assurance) and

questions on the role of specialised techniques in Histopathology.

Practical Examinations (over 2-3 days):

A morning 3-hour paper which assesses the ability of candidates to

perform autopsy/postmortem dissection on clinical cases managed in the wards and properly interpret them.

An afternoon 3-hour paper which assesses the ability of candidates to

provide diagnosis to challenging slides/cases that may task his expertise as a specialist in histopathology;

A further slide session on cytology interpretation (sputum smears, pleural fluids, and artefacts.

A 1-hr viva examination on the defense of a dissertation – testing the Trainee‟s ability to formulate a research question, search the medical

literature, carry out a scientific investigation in Histopathology, present and discuss the results and draw conclusions.

A1-hr oral examination – candidates are asked questions on all aspects of

Histopathology including but not limited to administration and laboratory management issues. Further questions aimed at eliciting the level of

maturity and capability of the independence of the candidate in issues relating to histopathology practice vis a vis disease mechanisms,

aetiopathogenesis, routine diagnosis, prognostic indices, specific systems-organ reporting, laboratory organisation/management and interpretation of crucial slides in Anatomic Pathology.

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By the time of completion of the examination; the Successful candidates at the Part II examination in Anatomic Pathology should be certified and confident of

the following attributes/characteristics:

Have a sophisticated understanding and perspective of all branches of

laboratory medicine and the role of Histopathology in diagnosis and patient management.

Be able to independently report routine surgical pathology and cytology slides and autopsies and realise their own limitations and when to refer cases for further opinion.

Offer expert opinion to clinicians as to the choice of clinical or biopsy material most likely to yield relevant information for the suspected disease

process being investigated.

Be able to liaise with clinicians, explain the limitations of laboratory tests

in the interpretation of results and formulate clinicopathological correlations

Have sufficient knowledge and personal communication skills to regularly participate in clinicopathological review meetings

Have sufficient knowledge of laboratory procedures to be able to “trouble-shoot” problems, including accessioning problems, artefacts and staining problems to ensure accurate and high quality material is available for the

formulation of diagnostic opinions and be able to talk to scientific staff about the laboratory and its problems

Have a working knowledge of laboratory management procedures and be able to deal with staff problems

Be aware of how a laboratory budget is formulated and how their own practice, including selective requests for special procedures might impact

on a laboratory budget, and the possible “adverse” budgetary effects of indiscriminate ordering of tests (both internal and external to the laboratory).

Understand the need for, and principles of, continuing education and participation in Continuing Professional Development Programmes

Be prepared and able to offer guidance and teaching to trainees in Histopathology

At the final assessment (Part II) in Anatomic Pathology, the candidates should be aware that they are required to convince the Court of Examiners, through the

panel of examiners that they have sufficient knowledge and experience for the safe and unsupervised practise of Pathology and that they are ready for their

position as consultants in the medical multidisciplinary team.

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13.3.0 Curriculum for Histopathology Training

13.3.1 Rationale for the Curriculum

The purpose of the curriculum for specialty training in histopathology and its related subspecialty is toensure that trainees are fully prepared to provide a high quality service at consultant level.

The educational programme provides:

Experience of the diagnostic techniques required to become technically competent in practical work, and to master the underlying analytical

andclinical principles

The opportunity to gain knowledge of specialist areas such as

cytopathology, forensic pathology, neuropathology and paediatric pathology, in order to be able to make appropriate referrals for specialist advice.

Training in the communication and teaching skills necessary for effective practice

The opportunities to develop to the required standard the ability to provide specialist opinion in histopathology

Opportunities to acquire the management skills to lead a department providing an effective service

Experience of research and development projects and critical assessment of published work so as to contribute in a team and individually to the

development of the service

The framework for continued professional development (CPD) including life- long habits of reading, literature searches, consultation with

colleagues, attendance at scientific meetings and the presentation of scientific work

Practical experience of clinical governance and audit (specialist and multidisciplinary) through evaluation of practice against the standards of

evidence-based medicine. Clinical governance is defined as „a framework through which health care givers

are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which

excellence in clinical care will flourish‟. In histopathology, trainees must become familiar with the lines of accountability, quality improvement programmes, clinical audit, evidence-based practice, clinical standards and guidelines,

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managing risk and quality assurance programmes. Training in these areas will continue throughout all stages of the curriculum.

The course outlines for JRT are summarised in tables 2-4. Table 5 summarises

outline for SRT. Days should be allotted to lectures and presentations. No resident doctor should be certified for exams except the presentations or lectures have been taken. The old curriculum that is being redesigned and overhauled is in

italics.

13.3.2 Summary of Curriculum

The following knowledge and experience requirements are to be read in

conjunction with the Table of Tasks, Learning Outcomes and Activities in Anatomic Pathology, below:

Part I: Examination

Stained Tissue Sections

Principles of tissue fixation

Principles of manual and automated tissue processing; detection of defects in H

& E sections; correction technical errors responsible

Approximately 2,500 accessions, including biopsies from medical and

gynaecological cases as well as surgical specimens

Autopsies

Sufficient experience in performing general and, where appropriate, special

autopsies including Coroner‟s autopsies

Detailed knowledge of autopsy pathology

Immunology and Immunohistochemical Techniques

Basic immunopathological changes in biopsies from kidney, bone marrow, skin,

blood vessels and the lymphoid system.

Principles of, and techniques used for the localisation of antigens in tissue

sections e.g. immunoperoxidase, immunofluorescence, in-situ hybridisation and

FISH

Electron Microscopy, Cytogenetics, Flow Cytometry and Histochemical

Techniques

Possible applications and proper method of tissue preservation for these special

morphological and cytological techniques

Record Keeping and Disease Indexing

Record keeping and disease indexing systems

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Safety Precautions

- Procedures for staff protection against: infections, e.g. HIV, viral

hepatitis and tuberculosis. - Exposure to radiation from bodies or surgical specimens etc.

- Toxicity of chemicals; and - Precautions against fire and other laboratory hazards

Part II: Examination

Preparation for Part II is as for Part I with the following additions:

1. Stained Tissue Sections - Stains for acid-fast bacilli, fungi and iron pigment; interpretation of

stains such as those for mucin, fat, RNA, muscle fibres, reticulin,

elastin and collagen; 2. Frozen Sections

- Uses, limitations and artefacts of frozen sections 3. Cytology - Principles of exfoliative and aspiration cytology

- Techniques of collection and methods of preparation. - Experience in screening gynaecological smears and assessment of no

fewer than 250 abnormal gynaecological smears and 250 non-gynaecological preparations.

- Experience in the performance, preparation and reporting of 30 fine

needle aspirations. 4. Electron Microscopy, Cytogenetics, Flow Cytometry and Histochemical

Techniques - Possible applications and proper methods of tissue preservation for

these special morphological and cytological techniques.

5. Preparation, Interpretation and Reporting of Biopsy Cases. - A total of 7,500 accessions

6. Autopsies - Substantial experience additional to that required for Part I, including

hospital based and Coroner‟s (including perinatal/paediatric)

autopsies, together with examination of the relevant histological slides and generation of written reports on each case.

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13.3.3 Summary of Approved Syllabus in Anatomic Pathology at the Post

Primary Level

General Pathology

- Cellular Pathology (including normal cell structure and function, homeostasis, adaptation, reversible and irreversible cell injury and intracellular and extracellular accumulations).

- Inflammation and tissue repair (including acute and chronic inflammation, wound healing, cell cycle regulation and disorders of cell growth).

- Fluid and Haemodynamic disorders (including pathophysiology of oedema, shock, thrombosis, embolism and infarction).

- Neoplasia (including definitions, characteristics, oncogenesis, cancer cell

kinetics, epidemiology, dissemination of cancers, paraneoplastic syndromes and tumour markers).

- Genetic abnormalities (including chromosomal, single gene and multifactorials, congenital abnormalities and tumour genetics).

- Immunopathology (cellular basis of immune response, hypersensitivity,

autoimmune disorders and congenital/acquired immune deficiency)

Systemic Pathology

This Includes detailed Respiratory, Cardiovascular, Renal, Hepatobiliary,

Lymphoreticular, Male and Female Reproductive, Paediatric, Tropical and Neuropathology.

Forensic Pathology

This includes basic training in forensic autopsies, court procedures, coroner‟s system, the relevant Nigerian/international laws (civil and criminal), forensic

aspects of haematology and blood group serology, forensic paediatrics, forensic psychiatry, firearms, industrial injuries, sexual offences, homicides and suicides.

The trainee will be required to be instructed in the major aspects of Anatomic Pathology (Morbid Anatomy and Histopathology) as follows: -

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13.3.4 Junior Residency Training

a) A formal introduction to the histology laboratory for the first one month as to see how specimens are processed prior to delivery for Histopathological

appraisal. Laboratory posting entails observership and hands on experience:

1. In routine specimen processing 2. Prevention of artefacts

3. Reagents‟ preparation. 4. Laboratory instrumentation 5. Maintenance of laboratory equipment

6. Prevention of laboratory hazards

The trainee in Anatomic Pathology (Morbid Anatomy and Histopathology) is expected within the first month to be able to understand the basic principles of tissue processing, microtomy, slide staining, mounting, appreciate artefacts and

reasons for artefacts.

b) Following the introductory period the trainee will receive instruction and practical experience in further aspects of Anatomic Pathology (Morbid Anatomy and Histopathology) for the rest of the 1st Year of training and through the 2nd

Year and Part I FMCPath Examination

The next six months will be for autopsy/postmortem dissection: This should entail:

o Analysing case notes prior to carry out post-mortem examinations o Principles of interpretation o Recognising structural alterations in tissues as basis for lesions

o Recognising age related changes/differences in anatomy o Preservation/Fixation of organs for autopsy demonstration

o Instrumentation (post-mortem dissection instruments and histopathology equipment)

The next five months is for participation and actual grossing of surgical pathology specimens and reporting for review with consultants.

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13.3.5 Table 2: Course Outlines for Morbid Anatomy and Histopathology

Junior Residency Training (JRT)

Topic: General Pathology (46 units) The units could be broken into modules to accommodate shorter units

S/N Topics Contact

Hours

Units

1. Autopsy Pathology: types of autopsy, techniques of dissection and interpretation.

1 1

2. Normal cell structure, type and extracellular matrix. 1 1

3. Mechanisms of cellular growth and differentiation. 1 1

4. Cellular injury: types, causes and mechanisms. 1 1 5. Cell death: Necrosis and Apoptosis. 1 1

6. Cellular adaptation of growth and differentiation. 1 1 7. Pathological calcification and intracellular

accumulation 1 1

8. Acute inflammation: definition, benefits, vascular and cellular response.

1 1

9. Chemical mediators of inflammation. 1 1 10. Chronic inflammation: Chronic non specific and

chronic granulomatous. 1 1

11. Types of wound, Mechanisms of tissue healing and repair.

1 1

12. Edema, hyperaemia and congestion. 1 1

13. Haemostasis and Thrombosis, haemorrhage 1 1 14. Embolism. Ischaemia and Infarction 1 1

15. Pathology of Shock. 1 1 16. Pathology of DIC. 1 1

17. Basis of inheritance: Chromosome, DNA structure, genes and mutation.

1 1

18. Mendelian disorders. 1 1

19. Cytogenetic disorders. 1 1 20. Single gene disorders with non-classic inheritance. 1

21. Molecular diagnosis of genetic disorders 1 1 22. Introduction to immunology: the normal immune

system and principles of immunopathology 1 1

23. Human Leucocyte Antigens and the Major Histocompatibility Complex

1 1

24. Cytokines 1 1

25. Hypersensitivity disorders 1 1 26. Autoimmune diseases 1 1

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27. Amyloidosis 1 1 28. Transplantation disorders 1 1

29. Definition, Nomenclature and characteristics of Neoplasms

1 1

30. Aetiology and epidemiology of Neoplasms 1 1

31. Biology of tumour growth and metastasis 1 1 32. Host response to Neoplasia and clinical features. 1 1

33. Laboratory diagnosis of Neoplasia 1 1 34. Microbial carcinogenesis 1 1

35. Chemical carcinogenesis 1 1 36. Radiation carcinogenesis 1 1

37. Paraneoplastic syndromes 1 1 38. Role of immunohistochemistry and tumour markers in

tumour diagnosis 1 1

39. Protein Energy malnutrition 1 1 40. Pathology of Obesity 1 1

41. Vitamin disorders (hypo and Hypervitaminosis) 1 1 42. Environmental diseases I: chemical and drugs –

Alcohol and street drugs 1 1

43. Air Pollution and Tobacco 1 1 44. Pathology of Radiation injury 1 1

45. Haemoglobinopathies 1 1 46 General principles of microbial pathogenesis 1 1

13.3.6 Table 3: Course Outlines for Anatomic Pathology (Morbid Anatomy

and Histopathology)

Junior Residency Training (JRT) Topic: Systemic Pathology (47 units)

The units could be broken into modules to accommodate shorter units S/N Topics Contact

Hours

Units

1. GIT I: Oesophageal and Gastric disorders 1 1 2. GIT II: Small and Large Intestine disorders I 1 1

3. GIT III: Small and Large Intestine disorders II 1 1 4. GIT IV: Liver diseases including viral hepatitis

and neoplasms 1 1

5. GIT V: Gall bladder and Exocrine Pancreatic diseases.

1 1

6. Respiratory System I: Congenital disorders 1 1

7. Respiratory System II: Upper respiratory tract 1 1

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infections and pneumonias 8. Respiratory System III : Tuberculosis and

Fungal infections 1 1

9. Respiratory IV: Lung abscess and Empyema thoracis

1 1

10. Respiratory V:Chronic obstructive pulmonary disease

1 1

11. Respiratory VI: Pneumoconiosis 1 1

12. Respiratory VII: Lung Neoplasms 1 1 13. Endocrine system I: Pancreas – Diabetes

Mellitus and Adrenal gland disorders 1 1

14. Endocrine system II: Pituitary gland disorders 1 1 15. Endocrine system III: Thyroid gland disorders 1 1

16. Skin I: Leprosy, Buruli ulcer and deep mycosis. 1 1 17. Skin II: Neoplasms 1 1

18. Male Reproductive tract disorders I: Congenital disorders, Infections and inflammatory disorders.

1 1

19. Male Reproductive tract disorders II: Neoplasms 1 1

20. Female Reproductive System I: Cervical and Uterine disorders

1 1

21. Female Reproductive System II: Ovarian disorders

1 1

22. Female Reproductive System III: Fallopian tubes

1 1

23. Breast Diseases: benign and malignant disorders 1 1 24. Cardiovascular I: Congenital heart disorders 1 1

25. Cardiovascular II: Hypertension 1 1

26. Cardiovascular III: Rheumatic heart disease and Infective Endocarditis

1 1

27. Cardiovascular IV: Cardiomyopathies 1 1 28. Cardiovascular V: Angina pectoris, Chronic

Ischaemic heart disease, Myocardial infarction, and Sudden cardiac death

1 1

29. CNS I: Congenital disorders 1 1 30. CNS II: CNS Infections. 1 1

31. CNS III: Neurotrauma and vascular lesions. 1 1 32. CNS IV: Neurodegenerative diseases 1 1

33. CNS V: CNS Neoplasms 1 1 34. Diseases of Head & Neck disorders including

Neoplasms 1 1

35. Ophthalmologic disorders including Neoplasms 1 1

87

36. Musculoskeletal System I: Infections 1 1 37. Musculoskeletal System II : Neoplasms 1 1

38. Musculoskeletal System III: Connective tissue disorders

1 1

39. Haematopathology I: Lymphomas 1 1

40. Haematopathology II: Myeloid, Spleen and Thymic disorders

1 1

41. Urinary system I: Kidney: Congenital disease, 1 1

42. Urinary system II: Renal Infections: Acute and Chronic Pyelonephritis

1 1

43. Urinary system III:: The Glomerulonephritides 1 1

44. Urinary Systemic IV: Kidney: Nephritic and Nephrotic Syndromes

1 1

45. Urinary System V: Pathology of Acute and Chronic Renal failure

1 1

46. Urinary System VI: Neoplasms and bladder diseases

1 1

47. Paediatric neoplasms 1 1

13.3.7 Table 4: Course Outlines for Anatomic Pathology (Morbid Anatomy

and Histopathology)

Junior Residency Training (JRT)

Topic: Tropical Pathology with emphasis on organ changes and tissue diagnosis on microscopy (9 units)

S/N Topics Contact

Hours

Units

1. Malaria 1 1

2. Leprosy 1 1 3. Fungal infections 1 1

4. Syphilis 1 1 5. HIV and AIDS with emphasis on disease presentation

and morphological variation in the tropics 1 1

6. Schistosomiasis 1 1 7. Tuberculosis and Atypical Mycobacterial infections 1 1

8. Leishmaniasis 1 1 9. Onchocerciasis 1 1

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13.3.8 Table 5: Course Outlines for Anatomic Pathology (Morbid Anatomy

and Histopathology)

Senior Residency Training (SRT) Topic: Forensic Medicine/Pathology

S/N Topics Contact

Hours

Unit

1. Overview of forensic autopsies 1 1

2. Overview of court procedures 1 1 3. The Nigerian coroner‟s system 1 1

4. Legal aspects of medical practice 1 1 5. Nigerian/international laws (civil and criminal) 1 1

6. Autopsy examination in mass casualties 1 1 7. Forensic aspects of haematology 1 1

8. Forensic paediatrics 1 1 9. Forensic psychiatry 1 1

10. Firearms injuires 1 1 11. Industrial injuries/occupational hazards 1 1

12. Sexual offences 1 1 13. Homicides and suicides 1 1

13.4.0 Methods of training

The trainee will require dedicated periods of training with a trainer consultant.

This will be especially important where skills are developed for recognition of various patterns cum morphological assessment with emphasis on disease variants and their clinical and prognostic significance. The trainee will also develop skills

in directed but self-motivated training (standard sub-specialty textbooks, CDs, DVDs, Atlases, journals, videos etc). Adequate time must be provided for such

learning (minimum half day per week). Library facilities should be provided and journal clubs, scientific and clinico-pathological seminars should be organised on a regular basis.

13.4.1 Second year of training

During the second year of RTAP, the trainee will externally rotate through other specialties in Pathology; namely, Chemical Pathology, Medical Microbiology and

Parasitology, and Haematology and Blood Transfusion. The trainee is expected to spend at least three months in each posting and is required to participate in all

the activities of each department. The trainee must be proficient in all the routine

89

laboratory procedures of each department, give seminars that will be graded and provide clinical service where appropriate (e.g. STI, Infectious Disease,

Endocrine and Metabolic and Haematology Day Clinics).

The trainee will be assessed at the end of each posting and a report of performance is forwarded to the trainer/Head of Department in Anatomic Pathology.

13.4.2 The place of didactic lectures by consultants in postgraduate

training

Consultants in department of Pathology should make it a matter of duty to make

presentations to residents and teach them on specific topics with appropriate illustrations. These will complement the seminars of the residents.

Guest lecturers could also be invited to give special lectures on a quarterly basis.

13.4.3 Assessment of Junior Residency Training

At the end of the first two years the trainee will be qualified to sit for the Part I FMCPath examination majoring in Anatomic Pathology.

13.4.4 Senior Residency Training

After the first two years the trainee will continue to broaden his diagnostic experience and understanding the principles of diagnostic pathology, mechanisms of diseases and pathophysiology of disorders, staging diseases and giving specific

reasons why death occurs as well as culpability or otherwise of healthcare providers.

By the time of entrance into the senior residency training, the trainee should have had a sound theoretical and practical knowledge of anatomical pathology practice

and is given some room to exercise some independence though not to sign out histopathology or autopsy reports without his consultants‟ consent/ authorization.

He is therefore groomed systematically and diligently to attain maturity, growing competence, boldness in the specialty. There will also be exposure to management issues and the trainee should be involved in the teaching of medical

and paramedical students. He is also expected to participate in the day to day

90

running of the department and oversee the presentation of junior residents as well as organise clinico-pathological meetings and join research groups.

At this period, he would develop special interest and seem to concentrate on a sub-specialty of Morbid Anatomy and Histopathology in which he hopes to later

sub-specialise. He would learn how to report on cytological specimens and also undertake a

relevant clinico-pathological research project certified by an ethical committee of his training centre and approved by the NPMCN and duly supervised by a fellow

of the Faculty. The findings will be presented in part fulfilment of the FMCPath Part II examination.

He is also expected to undertake a short course in hospital management and research methodology certified by the NPMCN as a prerequisite for applying to

take the Part II examination.

13.5.0 Sub-specialization in Anatomic Pathology (Morbid

Anatomy and Histopathology)

Trainees may wish to eventually sub-specialise in any aspect of Anatomic Pathology (Morbid Anatomy and Histopathology). This can take several forms

such as spending further time abroad post- fellowship training, or through local training in the field of choice.

91

Appendix

Table of Tasks, Learning Outcomes and Activities in Anatomic Pathology,

Indicating Functions of the Medical Specialist in the Laboratory

Tasks Learning Outcomes Learning Activities

Accession,

Management

and

Processing of

Specimens

Specimen Acquisition

- Advise clinicians on appropriate

choice and selection of specimens,

and the limitations of any

proposed investigation Specimen

Accession.

- Demonstrate the knowledge

required to establish and monitor a

reliable method for specimen

identification and laboratory

accession.

- learn to “trouble shoot” if error

identified.

Specimen Cut-Up

- Photograph specimens (and

indicate sites of block selection)

when appropriate.

- cut up specimens, and select

blocks, appropriately -know how

to handle fresh specimens and how

to triage

- Read laboratory manual

- Participate in daily laboratory activities

- Read laboratory manual

- Have a working knowledge of the

content of relevant guidelines (see

appendix in Rosai and Ackerman‟s

Surgical Pathology).

- Participate in daily laboratory activities

- Read laboratory manual.

- Participate in daily laboratory activities

- Read textbooks

Ancillary tests are required

- Understand the occupational

health and safety issues of dealing

with specific tissues.

Tissue Fixation:

- Select appropriate fixation

regimes, and be able to detect and

correct errors in this process.

Embedding and Sectioning

- Select appropriate embedding and

sectioning techniques, and detect

and correct errors in these

processes.

Staining

- Perform and interpret routine

stains, and detect and correct

errors in these processes.

- Select, perfo rm and interpret

appropriate special stains, and

- Read laboratory manual

- Spend sufficient time (minimum of a

week on at least three separate

rotations) in the pathology laboratory

learning about and being involved in

tissue fixat ion, embedding, sections,

staining (including special stains, histo-

and immuno-histochemistry) sections

92

detect and correct errors in these

processes.

Histochemistry

- Select appropriate fixat ion,

preparation and staining

techniques, and detect and correct

errors in these processes.

Immunology, Immunofluorescence

and Immunohistochemistry

- Select appropriate p reparative

techniques for the localisation of

antigens in tissue sections, and

detect and correct errors in these

processes.

Frozen Sections

- Prepare frozen sections when

appropriate, detect and correct

technical errors and artefacts.

- Understand the occupational

health and safety issues.

- Report frozen section results to

surgeons via „phone or in theatre

and convey any limitations of the

informat ion/interpretation

conveyed.

Cytology

- Select appropriate techniques for

collection and specimen

preparation, and detect and correct

errors in these processes.

Fine Needle Aspiration

- Select appropriate p reparative

techniques, and detect and correct

errors in these processes.

- Understand the occupational

health and safety issues.

- Perform per-cutaneous fine needle

aspirations.

Electron Microscopy

- Select appropriate fixat ion,

embedding, sectioning and

staining techniques, and detect and

correct errors in these processes.

- Interpret results of commonly used

electron microscopy (esp. renal

EM)

Read laboratory manual

Regularly accompany pathologists to

frozen sections

Attend sufficient frozen sections by

Part I exam to achieve learning

outcomes

Read laboratory manual.

Textbook reading

Read laboratory manual.

Textbook reading.

Participate in daily laboratory

activities- including attendance at

FNAs.

Participate in laboratory teaching

program for electron microscopy.

Read laboratory manual.

Textbook reading.

Participate in daily laboratory activities.

93

Training Curriculum - Medical

Microbiology & Parasitology

94

95

14. Residency Training in Medical Microbiology & Parasitology

14.0 Introduction

The specialty of Medical Microbiology involves the use of laboratory techniques to diagnose infectious diseases, manage and recommend therapy and to evaluate

aspects of the pathogenesis, epidemiology, prevention and management of infections.

Clinical Microbiologists work in diagnostic laboratories and Pathology departments in large hospitals and private practice. The work focuses on the

diagnosis, treatment and surveillance of infectious diseases. There are opportunities to carry out research and development projects in the subspecialties of bacteriology, virology, mycology, immunology and parasitology. They also run

outpatient sexually transmitted infections‟ (STI) clinics and/or infectious diseases clinics.

14.1 Aims of the Training Program

Ability to competently use a microscope to examine specimens and write a

relevant report that has clinical application

Ability to competently perform and examine cultures, interpret

antimicrobial susceptibility results and write a relevant report

Ability to competently perform and interpret serological/immunological

and molecular microbiology techniques and write a relevant report

Learn the technical skills necessary for the processing of all types of

specimens sent to the laboratory for the purposes of making a diagnosis, determining and monitoring progress of therapy, etc.

Apply laboratory information to clinical care

Apply clinical information to laboratory practice

Learn the skills necessary to supervise and manage a Medical Microbiology laboratory safely

Learn the skills necessary to participate in an infection control team. 14.1.1 Training Requirements

Training in Medical Microbiology is for a minimum of four years duration under

the supervision of a Medical Microbiologist in a Department accredited by the College. Only candidates with a pass in the primary examination of the Faculty

96

of Pathology, NPMCN or that of the West African College of Physicians (Laboratory Medicine) shall be eligible for entry into the programme.

14.1.2 The Scope of Residency Training

Residency training in medical microbiology is in two parts: junior and senior residency programmes. The junior residency is for a period of at least two years

during which sufficient time is allotted to clinical practice in infectious d iseases and allied specialties in Medicine. Within the first two yeas trainees will undergo

three months posting in each of the Departments of Chemical Pathology, Haematology and Blood Transfusion and Morbid Anatomy/Histopathology. All postings must be done in departments accredited by the College and under the

supervision of a Fellow in that specialty.

After successfully completing the part 1 programme, The trainee commences the senior residency training and shall undergo a three month rotation in medic ine, one-month each in surgery and paediatrics, and two weeks Radiology.

Trainees may be permitted to spend some time in an accredited Department of

another institution or a well developed medical or research laboratory for the purpose of gaining hands-on experience in some aspects of the curriculum, particularly some special procedures like PCR, Plasmid analysis etc.

After the part 1 any trainee who wishes to spend one year abroad as an attachment

in an area of academic research or clinical specialization may be encouraged to do so.

14.1.3 Research

Trainees who have successfully completed the Part I examination will, in addition to other programmes, begin research in an approved area of interest leading to the production of a dissertation for Part II examination. Trainees are

encouraged to participate in research activities within their Departments as part of their training.

14.2.0 Assessment (10.2.3-10.2.8)

Assessment in Medical Microbiology is in the form of the Part I and Part II examinations, each consisting of written {including the multiple choice questions

97

(MCQ)}, practical and oral examinations or as may be determined by the Faculty Board from time to time. The Part II examinations also include the defence of

dissertation and clinical examination (long and short cases). There are no automatic exemptions given to any Trainee for any component of the

examinations.

14.2.1 Part I Examination

The Part I Medical Microbiology Examination is taken after at least two years of

training in diagnostic and clinical Microbiology. Trainees should discuss in detail with their trainers how to achieve a sound knowledge and competence in all aspects of the specialty required to qualify for the Part I examinations in line with

the curriculum.

The Part I examination has an emphasis on the theoretical, practical and interpretative aspects of investigations in all fields of clinical Microbiology and has the following components:

A 3- hour multiple choice examination covering all the four major specialties of Pathology

A 3-hour essay writing paper – only on area of specialty

A 2-day practical paper

- Day 1 – Sample processing, examination of specimens and steeple chase

- Day 2 – Completion of sample processing

An oral examination – on all four Pathology specialties, and lasting

between 20-30 minutes

14.2.2 Part II Examination

Trainees who pass the Part I examinations or are exempted from it are eligible to

sit for the Part II examinations after at least two years of further training at a more advanced level. This level of training encourages diversity, specialization and investigation within fields of Medical Microbiology. Knowledge of the wide field

of Medical Microbiology and in particular, recent issues in Medical Microbiology is still expected. The final assessment consists of:

A 6-hour written divided into paper I and paper II of 3 hours each.

A 2-day practical paper

- Day 1 – Sample processing, examination of specimens and steeple chase

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- Day 2 – Completion of sample processing and a clinical examination comprising one long case and three short cases.The clinical

examination is for the duration of 1½ - 2 hours. - Defense of the dissertation and Oral Examination - – testing the

Trainees ability to formulate a research question, search the medical literature, carry out a scientific investigation in Medical Microbiology, present and discuss the results and draw conclusions. It also tests the

candidate‟s range of knowledge and skills in the specialty. This session of the examination is for a duration of between 1½ -2 hours.

14.3.0 Summary of Curriculum in Medical Microbiology and Parasitology

The following knowledge and experience requirements are to be read in

conjunction with the Table of Tasks, Learning Outcomes, Activities in Medical Microbiology, below.

14.3.1 Taxonomy and Biology of Human Pathogens

Taxonomy and biology of human pathogens (Bacteria, Viruses and Prions,

Parasites, Fungi, and vector of diseases) including ecology, evolution, metabolism and replication

Pathogenesis of infectious diseases

How pathogens cause disease, host susceptibility and host responses.

Virulence mechanisms

14.3.2 Clinical Management of Infectious Diseases

History Taking and Physical Examinations leading to a clinical diagnosis

Request for appropriate laboratory tests performed on appropriately collected, transported and /or stored samples; and other ancillary

investigations such as Xray, FBC, LFT etc

Correlation of clinical and laboratory findings in arriving at definitive

diagnosis and progress or prognostication of disease

Appropriate chemotherapy taking into consideration pharmacokinetic and pharmacodynamics parameters

14.3.3 Principles of Isolation

In-patient, out-patient and emergency case managements

Principles of team management and referrals

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14.3.4 Public Health and Preventive Medicine

Epidemiology of Infectious diseases

Demography and its influence on infectious diseases

Public Health interventions in infectious diseases

Public Health surveillance

Investigation of outbreak of infectious diseases

Immunization

14.3.5 Use of Antimicrobial Agents

Principles of pharmacokinetics and pharmacodynamics and their

application to the use of antimicrobial agents

Issues relevant to antimicrobial use and control in the context of

institutional drug committee activities

Mechanisms of Action of Antimicrobial agents

Mechanisms of Resistance of Antimicrobial agents

Antibiotic Resistance Issues/Antibiotic stewardship

14.3.6 Ecological Issues

Health and the environment – wastes and drainages, housing, crises, wars and disasters and their impact on health, especially infections

14.3.7 Infection Control

Principles of infection control construed in its broadest sense – hospital and community

Legislative and regulatory framework

Role of laboratory in supporting infection control initiatives

Principles of safety with specific reference to the medical microbiology laboratory, including use of sterilisation procedures, first aid, fire,

chemicals etc. 14.3.8 Administration

Strategic thinking and planning

Human and Material Resource planning, administration and control

Budget planning and control, purchasing and supply procedures

Stocking and inventory

Basic accounting procedures

Performance appraisal and evaluation

Proficiency testing

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Organisation and general administration

Laboratory Management

14.4.0 Laboratory Diagnosis 14.4.1 Pre-analytic Phase: Specimen Selection, Collection and

Transport and Storage:

How the biology of microorganisms and pathogenesis of infection

influence the optimal sampling of human tissue for diagnosis

Regulatory framework surrounding the collection and transport of

specimens and microbiological materials 14.4.2 Pre-analytic Phase: Selection of Tests:

The principles, methodology and performance of tests which are available in a large diagnostic laboratory

Evaluation of reagents and other materials for quality

14.4.3 Analytic Phase: Microscopy:

Principles of staining and microscopy

14.4.4 Analytic Phase: Culture

Principles of microbial culture, including selection and composition of culture media and incubation conditions as applied to bacteria, fungi,

viruses and protozoa

14.4.5 Analytic Phase: Identification of Microorganisms to a Species

Level

Principles of identification and speciation of human pathogens, including

bacteria, fungi, viruses and parasites

14.4.6 Analytic Phase: Non-Culture Detection of Microorganisms

(Excluding Microscopy)

Principles of serologic/immunological diagnosis of infection

Principles of molecular biologic diagnosis of infection

14.4.7 Analytic Phase: Susceptibility Testing

Principles of antibiotic susceptibility testing

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Principles of antifungal susceptibility testing

Principles of antiviral susceptibility testing

Principle of anti-parasitic susceptibility testing

14.4.8 Analytic Phase: Management of Specimens, Laboratory

Equipment and Laboratory Data

Principles underlying the storage and preservation of specimens and isolates

Regulatory framework governing retention of specimens and isolates

Quality controls for every method and reagent used in the laboratory

Operation and maintenance of equipment

Principles and regulatory requirements for storage and retrieval of

laboratory data

14.4.9 Post-analytic Phase: Report Generation

Principles involved in the formulation of an opinion and generation of a

laboratory report, including review, synthesis and interpretation of all relevant clinical and laboratory information

Relevant regulatory framework

14.5.0 Quality Assurance

Quality assurance in its broadest sense (all aspects of pathology services

laboratory including personnel, infrastructure, reagents, equipment, testing and reports)

Quality control

Quality assessment

Continuous quality improvement

14.6.0 Research Methodology

Study types – observational and experimental

Study designs

Sampling Methods

Data collection, collation, analysis, interpretation and conclusions

Basic statistics

Statistical packages – Epi- info, SPSS

Literature review/critical appraisal of literature

Writing paper for publication

Internet browsing

Computer appreciation – Microsoft word, excel, powerpoint.

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14.7.0 Competencies

14.7.1 Junior Residency Training

14.7.2 Goal:

The goal of the part 1 residency training is to produce a specialist resident with

basic understanding of infectious diseases and their clinical and laboratory diagnosis and management. In particular the resident should appreciate and

understand the relevance and key roles of the medical/clinical laboratory in the diagnosis and management of infectious diseases.

14.7.3 Specific Objectives

(1) Demonstrate a good understanding of infectious diseases

(2) Understand the principles of sample collection, transport, storage and processing for infectious diseases diagnosis.

(3) Perform common laboratory diagnostic tests on the laboratory benches

and interpret results. (4) Investigate infectious disease fully

(5) Interpret most data generated in the Medical Microbiology and Parasitology laboratory

(6) Communicate laboratory reports to clinicians and discuss their application

in the management of patients and advise on further investigations and line of management.

(7) Understand the concept of Quality Assurance.

14.7.4 First Year Programme:

At the end of the first year of the programme the resident should be able to: 1. Appropriately collect, transport and store patients‟ specimens

2. Analyse all types of samples received from patients. 3. Use basic equipment such as microscopes, weighing balance, ELISA

reader and washer, water bath, autoclave, centrifuge, counting chamber,

and other automated equipment available in the laboratory. 4. Prepare and use of basic Microbiological/Parasitological stains and media.

5. Isolate discrete bacterial colonies on the appropriate media 6. Identify common pathogenic organisms contained in specimens 7. Perform common stains like Gram stain, Acid Fast Stains, H/E stains etc.

8. Perform antibiotic sensitivity testing and interpret the results.

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9. Evaluate quality of specimen, and advise clinicians on the appropriateness of samples for an infectious disease condition.

10. Understand issues in laboratory safety. 11. Understand the basic structure of bacteria, parasites, viruses, fungi and the

principles of immunology. 12. Understand the pathogenesis of microorganisms. 13. Understand the virulence factors of microorganisms

14. Understand disease conditions associated with different groups of microorganisms

15. Manage common infections like malaria, tuberculosis, sepsis, pneumonia, meningitis, blood stream infections, sexually transmitted infections, pyogenic infections, typhoid, dysentery, ulcers, urinary tract infection,

infective diarrhoea, HIV, etc. 16 Take clinical and pathology services (medical) laboratory call duties with

little supervision The Part I examination will address such issues as, but not necessarily limited to:

The epidemiology, pathogenesis, laboratory diagnosis and prevention of infectious diseases

Sterilization and disinfection, media production, Quality assurance and laboratory safety

Basic microbial structure and metabolism and genetics

Host-pathogen relationships

Specimen collection, processing, identification and further testing (e.g. antimicrobial susceptibility) of the full range of likely samples and

pathogens to be experienced at the tertiary care level hospital, including bacteriology, mycology, virology, immunology and parasitology

Contemporary issues in Microbiology, including for example, emerging pathogens, bioterrorism

Molecular Biology techniques relevant to diagnostic Microbiology,

Microbiology research and Molecular epidemiology.

14.7.5 Second Year Residency

14.7.6 Specific Objectives

The trainee is expected to:

1. Demonstrate a good understanding of infectious diseases, their investigations and management.

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2. Interprete all Microbiology/Parasitology/viral/immunological/fungal results and make appropriate comments and advice.

3. Perform all forms of investigations including lumbar puncture, phlebotomy, aspirations, skill scrapping, skill snip etc.

4. Carry out sample processing to a more advanced level on the benches. 5. Trouble-shoot any problem associated with laboratory investigations. 6. Demonstrate an understanding of the management of a Medical

Microbiology laboratory and Quality Assurance. 7. Understand the concept of outbreak investigation and control.

8. Demonstrate skill and knowledge in the running of STI and Infectious diseases clinics

14.7.7 Competences:

At the end of the second year of residency the trainee should be able to:

1. Describe the structure of bacteria, viruses, parasites, fungi and their life-cycles; metabolism and genetics.

2. Describe the pathogenesis of different infectious diseases especially

prevalent ones in the local environment. 3. Take a comprehensive history from patients and carryout physical

examination and recommend relevant investigations and initiate appropriate therapy

4. Interpret chest x-ray and bone x-ray of both adults and paediatrics

5. Diagnose and manage infectious diseases in adults and children 6. Discuss individual pathogens and their pathogenic features.

7. Correlate laboratory data/findings with the clinical conditions of the patients and come up with diagnoses or decisions

8. Discuss the principles of antimicrobial chemotherapy

9. Discuss the mechanisms of actions and resistance of antimicrobial agents especially antibacterial

10. Discuss the pharmacokinetic and pharmacodynamics of antimicrobial agents, and their applications in the choice of agents and dosing

11. Demonstrate knowledge and skill in controlling nosocomial infections

12. Demonstrate skill in computer programmes such as words, excel and PowerPoint.

13 Present cases at the department or interdepartmental seminars or clinical grand round using PowerPoint.

14. Demonstrate empathy and humane approach towards patients and their

families, exhibiting interpersonal behaviour in accordance with prevailing societal norms and expectation.

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15. Protect the confidentiality of patients 16 Organise and supervise a General Hospital Medical Microbiology

Laboratory demonstrating adequate managerial skills in the hospital, ward, clinic and the laboratory

14.8.0 Rotations and Routines for Residency Training

The previous and following knowledge and experiencerequirements, are to be read in conjunction with the tables 1-7 below

The trainee will be required to be instructed in the major clinical and laboratory aspects of Medical Microbiology and Parasitology all through the period of

training.

All residents in Medical Microbiology and Parasitology will rotate through all sections of the laboratory including the bacteriology, mycobacteriology, mycology, parasitology, virology and immunology laboratories. They would also

be involved with in-and out-patient management. Clinical and laboratory calls would be taken to cover wards and laboratories respectively. Sexually transmitted

infections (STI) clinics would be run at least once a week or more frequently if required.

14.8.1 Weekly routines in Medical Microbiology and Parasitology are

Graphically Represented in Table 1: Table 1: Weekly Medical Microbiology and Parasitology Resident Routines

Time

schedules

SUN MON TUE WED THU FRI SAT

8am-4pm Lab & Clinical Calls

Laboratory Work: bacteriology, mycobacteriology, mycology, parasitology, virology and Immunology Clinical Responsibilities: outpatient clinics, ward coverage. Weekly Educational Programmes : Seminars, Tutorials, Journal review, Pathology grand rounds (with sister pathology depts), medical grand rounds (with internal medicine dept)

Lab & Clinical Calls

4pm-8am Lab & Clinical Calls

Notes on Table 1: The schedules are compulsory for all residents. Each resident will rotate through the various laboratory and clinical sections.

106

Log Books will be filled and signed by supervising consultants at the end of each rotation.

All activities are recorded and scored except during the Leave Periods (30

working days or 6 weeks annually). Time available for Pre-Part I Resident Programmes (excluding 3 months of leave

periods) is 21 months, which translate to 7 Semesters of 13 weeks each. The programmes are weighted in hours and the weights are recorded in units:

One Unit defines 1 hour of any of the following Seminar (S); Tutorials (T); Grand Rounds and Journal Review or 2-4 hours of Practicals (P)/Clinicals (day care, out- patient and in-patient care) per week over a semester.

Therefore a course that has 1 hour of seminar, 1 hour of tutorial, 3 hours of bench work and 8 hours of clinical rounds every week earns 5 units per semester.

*Mandatory Weekly Schedules for Every Resident in Hours are as follows:

Lectures/Seminars, 1hr

Tutorials, 1hr

Practicals, 6 hrs

Clinical rounds, 6hrs

Journal Review, 1hr

Minimum Credit Units per semester for Junior Resident Training should be 12

and 48 for the 4 semesters for the mandatory 12-working months before Part I Examination (excluding the 9 months of outside postings and the 3 months of leave) (Table 2).

Senior Residents have an extra Six (06) credit units for the Thesis, making a

cumulative of 70 before sitting for the Part II Examination * Excluding the equally compulsory Clinical and Laboratory Calls, from4pm-

8am every day; and 24 hours on weekends and public holidays

Tables 3-8 list the Mandatory Weekly Academic and Practical Activities for all residents, junior and senior.

14.8.2 Junior Residency Training (Table 2) This will begin with a general introduction to the Medical Microbiology and Parasitology laboratories during the first three months. This will be followed by rotation through the major laboratories, in-and out-patient managements of patients, calls from 4 pm to 8 am; and all-day during the week ends and public holidays. Clinical calls and laboratory calls are compulsory for all residents.

107

Following the introductory period the trainee will receive instruction and practical experience in further aspects of Medical Microbiology and Parasitology and rotate through other specialities in pathology, for the rest of the 1st Year of training and through the 2nd. Part I FMCPath Examination will be written after the 1st Two Years of Training (Table 2). Junior residents will also start formal academic and clinical components of the training, as indicated in the tables. 14.8.3 Table 2: Schedules for Junior Resident Postings First 24 Months

Programme Duration

in Months

Contact

Academic

Hrs/Wk

Contact

Bench

Work/Wk

Contact

Clinical

Rounds/Wk

Total Credit

Units

earned/module

of 3 months

Introduction to

General

Microbiology

Clin ical

Microbiology

3 4 12 16 12

Bacterial

Pathogens and

Associated

Diseases

3 4 12 16 12

Parasitology

and

Mycology

3 4 12 16 12

Virology and

Immunology

3 4 12 16 12

Chemical

Pathology

3

Outside Postings

Haematology 3

Histopathology 3

Leave Periods 3 - - - -

Total for the 4

semesters of 3

months each

24 192 576 960 48

Trainees in JRT programme will be Eligible to SIT for Part I FMCPath Examination only after he/she must have completed a minimum of 24 months of postings as follows

12 months (48 weeks) of Medical Microbiology and Parasitology postings 09 months (36 weeks) of outside postings 03 months (12 weeks) of leave

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Credit Units Earned During Outside Postings are Determined by Individuals Departments.

To be eligible to sit for Part I Examination, the trainee must have accumulated a total minimum credit points of 48 Units for Medical Microbiology and Parasitology, and he/she should have completed rotations in the 3 sister departments of Chemical Pathology, Haematology and Histopathology. The postings and Credit points Must be Confirmed in the appropriately Signed Log Book in all cases before the candidate is Allowed to Sit for the Part I FMCPath Examination. 14.8.4 Table 3:

Introduction to General Microbiology and Clinical Microbiology

S/N Topic 1 Classification of micro-organisms

2 Bacterial structure and function 3 Growth, nutrition and cultivation of bacteria

4 Bacterial Genetics

5 Normal Body Flora 6 Sterilization and Disinfection

7 Safety Procedures in The Laboratory 8 Culture media: Basic composition, classification and importance in classification

of micro-organisms

9 Antimicrobial Agents 10 Antimicrobial susceptibility testing

11 Rational Antibiotic Use Antibiotic Resistance

12 Fever of Unknown Origin

13 Sepsis Syndromes /Septic Shock 14 Infections of the Respiratory Tract

15 Central Nervous System Infections Laboratory Diagnosis of CNS Infections

16 Gastrointestinal Tract Infections

17 Sexually Transmitted Infections and Urinary Tract Infections Laboratory Diagnosis of STI Infections

18 Viral Hepatitis 19 Hemorrhagic fevers

20 Infections in Neutropenic/Immunocompromised Hosts 21 Nosocomial Infections

22 Zoonosis and Reverse Zoonosis

23 Skin, Soft Tissue and Infections

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14.8.5 Table 4:

Bacterial Pathogens and Associated Diseases. S/N Topic

1 Staphylococcus: Staphylococcus aureus and Coagulase negative Staphylococci

2 Streptococcus General classification, Lancefield classification, Anaerobic cocci

3 Enterococci 4 Bacillus

5 Listeria 6 Corynebacteria

7 Erysipelothrixrhusiopathiae 8 Pathogenic Neisseria

Neisseria meningitides Neisseria gonorrhoeae

9 Non-pathogenic Neisseria and Moraxella 10 Enterobacteriaceae: E.coli ,Klebsiella, Enterobacter, Proteus, Salmonella,

Shigella, Serratia Yersinia other genera

11 Vibrio 12 Heamophilus/HACEK organisms

13 Laboratory procedures: Identification of commonly isolated bacterial organisms 14 Campylobacter and Helicobacter

15 Pseudomonas, Aeromonas, and Acinetobacter 16 Brucella

17 Chlamydiae 18 Spirochetes: Treponema, Borrelia, Leptospira

19 Rickettsial Diseases

20 Legionella/Bartonella/ Bordetella/Francisella 21 Mycobacteria; M. tuberculosis, M. tb complex, M. avium complex, M.

lepraeNontuberculous Mycobacteria 22 Actinomyces and Nocardia

23 Mycoplasma and Ureaplasma

24 Laboratory Diagnosis of Anaerobic Infections 25 Clostridium

26 Bacteriodes, Prevotella, Porphromonas, Fusobacterium

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14.8.6 Table 5:

Parasitology/Mycology S/N

Topic

1 Classif ication of Parasitic Diseases

2 Entamoeba: E. histolytica, E. coli, E. hartmanni

3 Free Living Amoeba: Acanthamoeba, Naegleria,

4 Giardia lamblia, Balantidium coli

5 Cryptosporodia,Isospora, Cyclospora

6 Trichomonas

7 Plasmodia

8 Trypanosomiasis: East and West African, South American

9 Leishmanias is: Cutaeneous, Visceral, Mucocutaeneous

10 Toxoplasmosis

11 Hookworm: Necatoramericanus and Ancylostomaduodenale

12 Strongyloidias is,

13 Laboratory Diagnosis of Parasitic Diseases

14 Trichuristrichuria

15 Ascariasis, Enterobius

16 Trichinella

17 Toxocariasis

18 Cutaeneous larva migrans, Visceral larva migrans

19 Brugia, Loasis, ,OnchocerciasisWuchereriaDracunculus

20 Taeniaspp

21 Diphyllobothrium

22 Echinococcus

23 Hymenoleps is, Spirometra

24 Schistosomiasis

25 Fasciolaspp, Fasciolopsisbuski

26 Paragonimuswestermani

27 Clonorchissinensis

28 Myiasis

29 General properties and Classification of Fungi

30 Laboratory Diagnosis of Fungal Diseases

31 Superficial mycoses: PityriasisversicolorTineanigra White piedra Black piedra

32 Cutaneous mycoses: Dermatophytosis Candidiasis of skin, mucosa, or nails

33 Subcutaneous mycoses:

SporotrichosisChromoblastomycosisMycetomaPhaeohyphomycosis

34 Systemic mycoses:

CoccidioidomycosisHistoplasmosisBlastomycosisParacoccidioidomycosis

35 Opportunistic mycoses: Systemic candidiasis

CryptococcosisAspergillos isMucormycosis

36 Antifungal Drugs

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14.8.7 Table 6:

Virology and Immunology

S/N Topic

1 Properties and Classification of Viruses

2 Hepatitis Viruses 3 Herpesviridae

4 Papillomaviridae 5 Poxviridae

6 Adenoviridae 7 Polyomaviridae

8 Parvoviridae 9 Picornaviridae

10 Reoviridae andCaliciviridae 11 Coronaviridae

12 Flaviviridae 13 Filoviridae

14 Rhabdoviridae 15 Orthomyxoviridae

16 Paramyxoviridae

17 Arenaviridae 18 HIV and other retroviruses

19 Antiviral Therapy 20 Other RNA viruses

21 Prions 22 Diagnostic Techniques for Viral Infections

23 Innate Immunity 24 Acquired Immunity

25 Humoral Immunity 26 Cell Mediated Immunity

27 Disorders of Immunity 28 Immunization

29 Immunological/Serological Diagnosis of Microbial Infections

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14.9.0 Senior Residency Table 7: Senior Resident Training Rotations

Period 6months 3months 1month 1month 1month

1st

Year

Micro Internal Medicine

Micro/ Dissertation

Leave Paediatrics/ Dissertation

Period 1month 1month 2weeks 8½months 1month

2nd

Year

Surgery/ Dissertation

Micro Radiology Micro Leave

Period

3rd

Year

Part II FMCPath/ Micro

14.9.1 Specific Objectives

At this level, the trainee will be expected to:

1. Show competence in all areas stated in part I 2. Demonstrate knowledge, skill and competence in organizing an infection

control programme in the hospital

3. Demonstrate skill in carrying out a research, and carry out one as part of requirements.

4. Demonstrate skill in effective literature review. 5. Demonstrate skill in the setting up, organization and management of a

Medical Microbiology laboratory

6. Demonstrate understanding of all infectious diseases at the molecular, cellular, tissue and organ level, their investigations and complete management.

7 Perform more complex tests in the laboratory such as typing using various methods, electrophoresis etc.

8. Demonstrate knowledge, skill and competence in all matters pertaining to Quality Assurance, Quality Control, Quality Improvement, Proficiency tests, Continuous Quality Improvement.

9. Demonstrate competence in Resource Management and the writing of reports.

10. Demonstrate skill in coordinating or moderating a scientific meeting 11. Demonstrate competence in running an infectious diseases and sexually

transmitted clinics.

12. Demonstrate competence in patient review and in-patient management of infectious diseases.

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14.9.2 Competencies:

At the completion of the training the Resident should be able to:

(1) Perform all laboratory tests in Pathology services laboratory, and other competences stated in the part I section, and demonstrate a thorough

understanding of all of them. (2) Manage complicated infectious disease cases such as Pneumonias,

Meningitis, Tuberculosis, HIV, STIs UT/sm Blood stream Infectious,

other CNS infectious, Malaria and other systemic and local infections. (3) Discuss the epidemiology, aetiology, clinical presentation, pathogeneses,

laboratory investigations and management of infectious diseases in adults and children.

(4) Demonstrate full understanding and show competence in the investigation

of out breakers and their control (5) Demonstrate understanding of infectious diseases and antibiotic resistance

surveillance. (6) Demonstrate understanding of the setting up and running of infection

control committee and programme.

(7) Demonstrate understanding of the application of antibiotic resistance surveillance report in the control of antibiotic resistance.

(8) Demonstrate expertise in the performance of various tests, management of staff, equipment and inventory in the laboratory

(9) Demonstrate skill in the identification and handling of challenges. (10) Demonstrate skill in the use of PCR and other equipment (11) Perform and interpret complicated tests such as synergistic antibiotic

testing, serum drug level monitoring, etc. (12) Demonstrate confidence in discussing patients‟ problems with colleagues

in other specialties. (13) Show a high degree of responsibility in patient care, teaching and

interacting with colleagues, contemporaries, juniors and seniors in the hospital

(14) Demonstrate knowledge of the ethics of the Medical profession and code of conduct for Pathologists.

(15 Demonstrate knowledge of existing regulations pertaining to the practice of medicine and Pathology

(16 Demonstrate competence in basic concepts of research methodology and epidemiology, and be able to critically analyse relevant published research literature.

(17) Demonstrate knowledge of Quality assurance issues affecting the pre-analytic, analytic and post analytic phases of laboratory testing of samples.

(18) Demonstrate skill in writing a laboratory report. (19). Demonstrate competence in drawing up an antimicrobial formulary for a

hospital.

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Tasks Learning Outcomes Learning Activities

Public Health

and Preventive

Medicine

• Provide appropriate advice regarding detection, surveillance and intervention with respect to infectious diseases of public health importance. • Participate in regular meetings with public health units (or equivalent) • Formulate strategies to investigate and manage outbreaks of infectious disease • Ensure compliance with notification requirements • Provide immunisation advice

• Formal academic study such as MPH, • Regular interaction with Public Health Units (or equivalent) • Notification of the detection of infectious agents in accordance with local statutes

Use of Antimicrobial

Agents

• Provide appropriate advice on selection and use of antimicrobial agents to patients, colleagues and institutional bodies • Participate in institutional drug committee activities e.g.audits and meetings • Implement, support and develop antimicrobial control policy in training institution.

• Access relevant drug policies in training institution • Supervised clinical liaison e.g. telephone consultations or ward rounds • Involvement in drug committee activities • Attendance at relevant session Faculty Update

Infection Control

• Provide appropriate advice on infection control measures to

• Access relevant infection control policies in training institution • Involvement in infection control

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Pre-analytic

Phase: Specimen

Selection, Collection and

Transport

patients, colleagues and institutional bodies • Ensure compliance with legislative and regulatory framework in geographic area of practice • Participate in institutional infection control committee activities e.g. audits and meetings • Implement, support and develop infection control policies in training institution • Implement, support and develop procedures for safe laboratory practice • Liaise between laboratory practice and infection control requirements e.g. outbreak surveillance, subtyping • Provide appropriate advice regarding the selection, collection and transportation of specimens so as to optimise diagnostic yield • Refer to relevant sections of the laboratory manual • Resolve uncertainty in situations not addressed by the laboratory manual

committee activities • Access state and national guidelines, regulations and legislation • Prepare articles for sterilisation by various methods • Operate an autoclave safely and effectively • Detect faults in heat-sterilising apparatus • Practise safe handling and disposal of biohazardous materials, chemicals and radioactive materials • Supervised clinical liaison • Ensure appropriate collection and transport of specimens • Access relevant sections of the laboratory manual • Participate in relevant laboratory activities • Prepare specimens and isolates for transport in accordance with local and international postal and shipping regulations

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• Triage, examine and set up specimens

Pre-analytic

Phase: Selection

of Tests

• Provide appropriate advice regarding the optimal diagnostic algorithm for a given clinical problem • Refer to relevant sections of the laboratory manual • Resolve uncertainty in situations not addressed by the laboratory manual • Participate in evaluation and implementation of new and existing tests

• Supervised clinical liaison • Access relevant sections of the laboratory manual • Participate in relevant laboratory activities, including execution of individual tests

Analytic Phase:

Microscopy

• Prepare and use routine stains appropriately • Prepare specimens for microscopy • Effectively use a light microscope, including bright field, phase contrast, dark field and fluorescence microscopy • Interpret microscopy findings appropriately.

• Access relevant sections of the laboratory manual • Participate in relevant laboratory activities including, but not limited to: -preparation of faecal stains and concentrates -identification of ova cysts and parasites - preparation and examination of skin scrapings and other tissues for fungal examination - preparation and examination of specimens by Gram‟s, acid-fast, toluidine blue, India ink, Giemsa and fluorescent antibody stains - preparation and examination of blood films for blood-borne parasites.

Analytic Phase:

Culture

• Select media appropriately for specimen inoculation

• Access relevant sections of the laboratory manual • Participate in relevant sections of

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• Process specimens appropriately • Resolve uncertainty in situations not addressed by the laboratory manual Take charge of benches on rotational basis and take calls under the guidance and supervision of a Fellow

the laboratory, including but not limited to: - preparation of culture media and agar plates -plating out clinical specimens -setting up anaerobic cultures and obtaining pure cultures -maintenance and inoculation of tissue culture for virus isolation -Detection of viral replication in tissue culture -Determination of TCID values for viral isolates -Preparation of mycological slide cultures

Analytic Phase: Identification of

Microorganisms

to a Species Level

• Correctly identify organisms by culture • Resolve uncertainty in situations not addressed by the laboratory manual

• Access relevant sections of the laboratory manual • Participate in relevant sections of the laboratory, including but not limited to: - recognition of the colonial and microscopic appearance of commonly encountered or medically important organisms - performance and interpretation of tests commonly used to identify microorganisms - determination of viable counts in bacterial suspensions -use of automated apparatus to detect bacteraemia -Identification of medically important fungi

Analytic Phase:

Non-Culture

Detection of

Microorganisms (Excluding

Microscopy)

• Satisfactorily execute serologic assays, demonstrating familiarity with automated systems • Satisfactorily execute molecular biologic assays, demonstrating familiarity with automated systems • Resolve uncertainty in situations not covered by

• Access relevant sections of the laboratory manual • Participate in relevant sections of the laboratory, including but not limited to: -Preparation, reading and interpretation of assays for the detection of antigens and antibodies (including methods such as -Agglutination -Precipitation –Immunoassay

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laboratory manual - Complement fixation -Immunofluorescence -immunoperoxidase -immunoblotting) • Participate in relevant sections of the laboratory, including but not limited to: - Extraction of nucleic acids from specimens -set-up of a PCR assay - preparation and reading of gels

• Analytic Phase:

Susceptibility

Testing

• Satisfactorily execute and interpret antibiotic susceptibility tests • Satisfactorily execute and interpret antifungal susceptibility tests

• Access relevant sections of the laboratory manual • Participate in relevant sections of the laboratory, including but not limited to: -Preparation and interpretation of antibiotic susceptibility tests - Detection of beta-lactamases - Determination of the bactericidal activity of antibiotics or antibiotic-containing serum -Determination of synergy between combinations of antibiotics -Performance of antimicrobial assays on blood and body fluids by bioassay or other methods • Participate in relevant sections of the laboratory, including but not limited to: -Preparation and interpretation of antifungal susceptibility tests -Determination of synergy between combinations of antifungal agents

Analytic Phase: Management of

Specimens,

Laboratory

Equipment and

Laboratory Data

• Satisfactorily prepare specimens, bacterial, fungal and viral isolates and mammalian cells for retention and preservation • Satisfactorily execute quality controls for common tests, reagents and media

• Access relevant sections of the laboratory manual • Participate in relevant sections of the laboratory • Use and maintain laboratory equipment, including but not limited to: -Incubators -Centrifuges - Safety cabinets -Refrigerators

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• Recognise when quality controls have failed and institute remedial action • Use laboratory data proficiently for cost-efficient laboratory management and generation of statistics of statistics

Post-Analytic

Phase: Report

Generation

• Satisfactory report generation • Communication and interpretation of results to clinicians, including urgent results • Resolution of uncertainty in situations not covered by laboratory manual • Principles involved in the formulation of an opinion and generation of a laboratory report, including review, synthesis and interpretation of all relevant clinical and laboratory information • Relevant regulatory framework

• Familiarity with relevant sections of the laboratory manual • Participation in relevant sections of the laboratory, including but not limited to - recording, verification and interpretation of laboratory test results -Identification of parameters of measurement uncertainty -Development and application of action limits