Valerie Neff Newitt
July 2024—The CAP’s hematopathology online education program, HPATH, is now in its 10th year, with real-world cases for which there’s real-time feedback and hundreds enrolled each year.
Interesting cases, ones every hematopathologist should have experience with or be familiar with, are what the expert authors of the cases provide, says Kyle Bradley, MD, chair of the CAP Hematopathology Committee and associate professor of hematopathology at Emory University School of Medicine. Each case includes laboratory data, whole slide images, images of ancillary studies, feedback about the case and test results, and self-assessment questions. “And some of the high quality comes from brevity,” Dr. Bradley says. “We whittle down a lot of information into something very manageable and high yield for busy pathologists.”
More recently, the cases the experts select for the program reflect the two hematopathology classification systems from the World Health Organization (fifth edition) and the 2022 International Consensus Classification, says Megan Nakashima, MD, vice chair of the CAP Hematopathology Committee and staff hematopathologist at Cleveland Clinic. “We’ve been highlighting cases that show how best to apply the two classification systems,” she says, “and we use the terminology of both throughout.”
Five cases are made available two times yearly, for a total of 10. “One of the comments we get is that people wish we would do more cases every year,” Dr. Nakashima says. (The images appearing with this story are from 2020–2023 cases.)
The interactive program covers a variety of case types and resembles what happens in everyday practice, where multiple ancillary tests may be needed to arrive at a diagnosis. “Everything is typical of how a hematopathologist will work up a case,” Dr. Bradley says.
“When first going through the case,” Dr. Nakashima says, “the whole slide images are not annotated at all. You have to approach the case the way you would a live case that comes across your desk. Once you’ve gone through the morphology that way, you go to the next screen,” where a list of tests appears and the user has to decide which tests to order.
“If, for example, you decide yes, you want to do flow cytometry, then you click in the ‘yes’ box,” she says, and then you’ll be able to review the dot plots and receive immediate feedback about the study. “We prefer that the person who’s doing the exercise make the interpretation,” Dr. Nakashima explains. For tests that are less relevant to the case, the user will be told it wasn’t performed in this case because it would not add much and why.
Users synthesize the information taken from the morphologic review of the whole slide image and the results of the ancillary testing and move to the next page, where they’re asked to select the correct diagnosis from a list of about five entities that may enter the differential diagnosis. If the wrong diagnosis is selected, users receive a brief explanation about why it’s not correct but are not told what the diagnosis is. “You get to keep guessing,” Dr. Nakashima says, and users can go back and forth within the cases.
The aim of the program is not to present rarities, Dr. Bradley says. “It’s not meant to be case reports or rare entities you won’t see in practice. It’s meant to be practical, common things as well as some that are less common. And users get up-to-date information not only about how hematopathologists diagnose the entity but also what is important for subtyping,” including what “cutting-edge, novel testing is used.”
These are cases that are seen regularly in practice, he says, but accompanied by the latest known information according to the expertise of the case authors. “And the idea is that the user can feel comfortable knowing that the same approach is being done in their practice” or, in some instances, alerted to where their practice might not be performing what has become the standard of care.
Cases also teach optimal test ordering and thus cost control. “Usually, we put in a few ancillary study choices that are not as relevant as others or are unnecessary for the case,” Dr. Bradley says, “and this gets at effective ordering of tests to target what you need.”
For example, in a spleen case that appears to be lymphoma, the users might be asked if they want to do myeloid next-generation sequencing and have to respond yes or no. They would be given feedback that explains why that test was not performed. “Because it’s not relevant,” Dr. Bradley says. “Because we have the image that shows what looks like a lymphoid neoplasm, or the flow cytometry indicated a lymphoid population, not myeloid. So in these cases they’re getting feedback about each of the ancillary studies presented and can test their own knowledge.”
“It’s all about sharpening skills,” he says.
For ancillary testing, the approach is not whether an answer is correct or incorrect, “because that can be subjective,” he says, “and some of it depends on your practice and your workflow.” The feedback about each ancillary study provides the pros and cons of the test’s relevance to the case at hand.
The two mailings are in the spring and fall, and pathologists who complete one year in the program are awarded 12.5 category one CME credits.
What sets this program apart from other types of hematopathology education is its interactive nature, Dr. Nakashima says.
“It’s more of an active learning. You don’t just read a PDF and then answer CME questions,” though the cases are provided as PDFs so they can be compiled in a notebook if the user wishes. Then, too, there’s the expert Hematopathology Committee members who select and write the cases. “Experienced pathologists who are great teachers, each of whom is writing one case a year,” she says, each one followed by extensive peer review provided by three to four other hematopathologist committee members.
It’s that rigor that goes into each case that Dr. Bradley is proud of. “The quality of the writing, of the case presentation, and of the questions is unmatched. The best you can find out there for CME,” he says.
And it was a vision achieved collaboratively. In 2014, when Dr. Bradley was a member of the CAP Hematology and Clinical Microscopy Committee, he joined with William Karlon, MD, PhD, of the CAP Diagnostic Immunology and Flow Cytometry Committee, and Rajan Dewar, MBBS, PhD, of the Surgical Pathology Committee. Traditionally, he notes, CME activities consist of listening to lectures and answering multiple-choice questions. “We realized for hematopathology that was insufficient because we use so many different modalities to do the work. We envisioned a new learning activity,” one that would more closely align with what happens in everyday practice. “That was the goal,” he says. And with whole slide imaging, they knew it could be more interactive.
“We’re very visual learners in pathology. I want to see the flow cytometry, the immunohistochemical stains, the whole slide image, and put the information together. That’s how we practice. So it was a kind of meeting of the minds of leaders from each of these committees,” and together they proposed a new program.
Soon they and others were a working group, with the first HPATH program published in 2015. Later, in 2021, they became the Hematopathology Committee, backed by CAP staffer Stephanie Salansky, MS, MT(ASCP) (“an HPATH superstar,” Dr. Bradley says) and instructional designer Jennifer Livengood, PhD (“who makes sure the learning experience goes smoothly”).
Cases run the gamut, from benign to malignant, lymphoid and myeloid, and tissue, bone marrow, and blood, “to cover all of what hematopathology encompasses,” Dr. Nakashima says, including one pediatric hematopathology case each year.
“I learn from this program every time,” Dr. Bradley says. “I love reading the cases. They’re fantastic.”
Valerie Neff Newitt is a writer in Audubon, Pa. The HPATH program can be ordered through the CAP Surveys catalog at https://capatholo.gy/4bTHH8A.