Pathology Competencies in Medical Education and Educational Cases: Update 2023

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The publication of the Pathology Competencies for Medical Education is supported by the Association of Pathology Chairs.

Since the first publication of the PCME in 2017, there have been many opportunities for comments of the learning objectives. In addition to the formal survey noted above, faculty have provided direct input to the authors of the PCME and sessions have been devoted to the PCME at conferences. Many authors who have submitted educational cases have commented on the PCME; in turn, the editors of the educational cases identified gaps when reviewing submitted cases. We have taken the comments from these many sources and have systematically reviewed, reorganized, and revised the PCME. In order to decide whether an objective merited inclusion we used standard pathology textbooks and a recent comprehensive reference to assess whether information was necessary to include. 3 , 4 , 5 As Fig. 1 illustrates, the revision of the PCME is a cyclic process that includes incorporation of comments from constituents through multiple processes mentioned above. Fig. 1 Review cycle of the Pathology Competencies in Medical Education. To ensure the learning objectives stay current with the practice of medicine, objectives are reviewed periodically to incorporate comments by constituents, reviewed by an editorial group, and published as a revised version. Fig. 1 Review cycle of the Pathology Competencies in Medical Education. To ensure the learning objectives stay current with the practice of medicine, objectives are reviewed periodically to incorporate comments by constituents, reviewed by an editorial group, and published as a revised version. We have removed redundancies and made some significant shifts in several topic areas so that the learning objectives are more appropriately aligned with the 3 major competency areas. We also added significant amounts of new content. For example, in genomics, several mechanistic objectives in competency 3 were moved to competency 1. In hematopathology, pathophysiologic objectives formerly in competency 3 were moved to competency 2; diagnostic objectives are now collected in competency 3. To fill gaps, we sometimes introduced brand new learning goals, such as those representing vascular disorders, multisystem disease, or HN pathology; other gaps were filled by adding objectives within an existing learning goal. Competency 3 was significantly revised to expand the CHEM and the transfusion sections; learning objectives throughout this competency are now focused more specifically on diagnostic testing. Finally, several learning objectives have been retired because they either did not fit with current pathology teaching or duplicated other learning objectives. The nomenclature of the original learning objectives has been retained, and notes have included to indicate any change from the prior PCME edition. If a learning objective was moved to a different competency, we have used the nomenclature “C” for competency along with the prior learning goal and objective to indicate its origin. For example: “Objective GM1.7 (Formerly C3, GE1.4): Linkage Analysis. Outline the principles that underlie genetic linkage analysis and association studies and how they are used to identify genes associated with diseases.” This learning objective of linkage analysis is now objective GM1.7 in competency 1 under genetic mechanisms (GMs), and was moved from competency 3, GE 1.4, genomics. We hope this nomenclature will allow continued easy cross reference for both prior and current learning objectives to allow for consistent mapping of any previously published educational case attached to an earlier learning objective. Publication in Academic Pathology ensures wide access to the revised learning objectives.

The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences or the Department of Defense.

Diagnosis and patient management require the student to apply their knowledge of disease mechanisms and organ system pathology to achieve efficient and effective use of clinical and anatomic laboratory testing. In addition, the student should learn the proper use of blood/blood product utilization to enable optimal diagnosis, treatment, and patient care. There are 10 topics within this competency area. Each topic includes general learning goals and specific objectives that medical students should be able to meet upon graduation from medical school. Table 3 lists the topic areas and shows the number of goals and objectives for each. Table 3 Diagnostic medicine and therapeutic pathology. Table 3 Topic Number of Goals Number of Objectives Reference Code General principles 1 11 GP Health informatics 2 6 HI Transfusion medicine 1 9 TM Hematology 4 16 H Microbiology 6 33 M Chemistry 3 19 CHEM Immunology 1 4 IMM Molecular pathology, genomics, cytogenetics 5 14 GE Autopsy 3 10 AU Surgical pathology 4 11 SP Cytopathology 2 8 CYP Diagnostic medicine and therapeutic pathology. Every physician should have an appreciation for the preanalytical, analytical, and postanalytical phases of laboratory testing. In addition, physicians need an appreciation of the statistical treatment of data that underlies test utilization. This includes, but is not limited to, the ability to choose the correct test to make a diagnosis and facilitate treatment selection and to employ the appropriate testing paradigm to monitor patients with chronic diseases, enabling optimal clinical management. Apply knowledge of clinical medicine, pathology, and statistics to determine the utility of a laboratory test in making a diagnosis and in monitoring chronic disease management. Explain the interpretation and limitations of clinical laboratory assays. Objective GP1.1: Laboratory Errors . Discuss, with examples of each, differences among preanalytical, analytical, and postanalytical mistakes that lead to laboratory or diagnostic errors. Objective GP1.2: Sensitivity and Specificity . Evaluate the quality of an assay in differentiating disease versus non-disease states, including graphically presenting and interpreting the data. Determine the relationship between sensitivity and specificity for an assay. Objective GP1.3: Pretest Probability . Determine the value of an assay by evaluating the impact of differing pretest probabilities such as prevalence on the positive and negative predictive value of the test. Give examples of the laboratory tests used to evaluate clinical disorders where predictive values are used to develop screening, diagnostic, prognostic, and patient management protocols. Objective GP1.4: Reference Intervals . Describe the methods and statistics used to establish reference intervals; the effect of demographics, treatments, or disease states on reference interval variability; and the difference between reference ranges and therapeutic ranges. Objective GP1.5: Test Variability . Explain the difference between technical variability and biologic variability, including how physical and chemical parameters such as sample size, hemolysis, and lipemia can affect test results. Define analytical uncertainty, precision, accuracy, and coefficient of variation and describe factors that contribute to each. Objective GP1.6: Turn-around Time . Compare and contrast appropriate uses of “stat” and “routine” test priorities with discussion of critical values and the elements of “turn-around time.” Predict which elements affect turn-around time the most. Objective GP1.7: Regulatory Issues . Explain the basic differences between Food and Drug Administration (FDA)-approved tests and laboratory-developed tests, including Clinical Laboratory Improvement Amendments waived and non-waived tests and discuss the primary regulatory issues involved in physician-office laboratories, home testing, and provider-performed microscopy. Objective GP1.8: Point-of-Care Testing . Explain how “point-of-care” (POC) testing in the physician office, multispecialty clinic, and hospital can enable better patient and population management of acute and chronic disease and why values generated using POC methods could differ from values generated in a high-throughput laboratory. Objective GP1.9: Test Utilization . Discuss a laboratory testing decision tree to make a diagnosis for a patient with a chronic disease or a protocol for monitoring such a patient, the use of appropriate testing and the impact on healthcare cost for overutilization or underutilization of laboratory testing, and the potential impact on cost. Objective GP1.10: Test Economics . Compare and contrast the cost of several common laboratory diagnostic tests and discuss the difference between the cost of a test and the charge to a patient. Objective GP 1.11: Pathologists as Clinical Consultants . Describe the roles the pathologist plays to communicate among the laboratory, patients, and members of the health care team. Every physician needs an understanding of the role informatics plays in healthcare delivery and outcomes. Apply knowledge of clinical medicine, medical records, laboratory medicine (diagnostic tests), computer science, statistics, and data analysis to improve healthcare delivery and patient care. Objective HI 1.1: Informatics . Define informatics, contrast it with information technology, and discuss how different types of informatics are used to improve healthcare. Objective HI 1.2: Data Analysis . Outline how data acquisition and analysis, including data mining and machine learning, can improve healthcare delivery and improve patient outcomes. Objective HI 1.3: Laboratory Medicine Informatics . Describe the role laboratory information systems play in laboratory operations and in healthcare delivery. Objective HI 1.4: Telepathology . Discuss the circumstances in which telepathology can be used as a diagnostic modality and describe its advantages and limitations. Apply knowledge of computer hardware, search engines, data analytics, and machine learning to the delivery of healthcare. Objective HI 2.1: AI . Define AI and discuss different types of AI tools that can be employed in patient care. Objective HI 2.2: AI in Pathology . Outline how AI can be used to enhance laboratory operations and to improve clinical decision making by providing focused diagnostic information to the clinical team. Every physician needs an understanding of transfusion medicine, which encompasses the transfusion of RBCs, platelets, and plasma products in order to correct deficiencies in patients or remove offending antibodies. Transfusions are not without risk, and knowledge of the pathophysiology of the disease and risks of transfusion are vital for physicians for optimal patient outcomes. Apply knowledge of pathology, hematopoietic cell physiology, and immunology to explain concepts of blood component transfusion and the therapeutic interventions in transfusion medicine. Objective TM1.1: Cellular Blood Components . Define the cellular blood components and blood component substitutes available for clinical use, the evidence-based indications and dosing for transfusion of these components, and how the efficacy of transfusion may be monitored. Objective TM1.2: Transfusion Reactions . Compare and contrast the pathophysiology, presentations, prophylaxis, and management of the different types of transfusion reactions. Objective TM1.3: Infectious Risks . Discuss infectious disease risks of transfusion. Objective TM1.4: HLA . Explain the HLA system and its role in both transfusion and transplantation. Objective TM1.5: Apheresis . Explain the clinical role of therapeutic apheresis in the management of the following disorders: sickle cell anemia, TTP, acute and chronic inflammatory demyelinating polyneuropathy, myasthenia gravis, anti-glomerular basement membrane disease, organ transplantation, plasma cell dyscrasias, leukemia, and lymphoma. Objective TM1.6: Paternity Testing . Retired Objective TM 1.7: Blood Group Antigens . Describe the major antigens present on RBCs and discuss their clinical relevance using the examples of specific clinical situations in which laboratory diagnosis is needed. Objective TM1.8: Plasma-derived Therapeutics . Define therapeutic agents that are derived from plasma, such as Rh immune globulin, clotting factors, immunoglobulin, and albumin; discuss the evidence-based indications for their use. Objective TM1.9: Pre-transfusion Procedures . Discuss the key elements necessary to ensure safe and appropriate donation and transfusion of blood products. Objective TM1.10: Blood Collection and Processing . Discuss the basic blood collection procedure, including screening of blood donors, methods used, and potential complications. Every physician needs a thorough understanding of one of the most common tests ordered from the laboratory, the complete blood count (CBC). Differentiating tests needed for diagnosis and treatment of anemia and coagulation disorders is important for appropriate treatment and monitoring of these disorders. Apply knowledge of biochemistry, pharmacology, and pathology to describe the basic cellular and molecular events associated with blood coagulation and explain laboratory tests for the diagnosis and management of coagulation disorders. Objective H1.1: Platelet Aggregation After Injury . Retired. Objective H1.2: Platelet Inhibitors . Moved to C3 H2.8. Objective H1.3: Coagulation Cascade . Retired. Use C1 HDTD2.1. Objective H1.4: Anticoagulants . Moved to C3 H2.9. Apply knowledge of biochemistry, pharmacology, and pathology to describe the use of specific laboratory tests to diagnose and manage coagulation disorders. Objective H2.1: Monitoring Anticoagulation Therapy . Explain the selection of appropriate tests for identifying the cause(s) of bleeding and to monitor therapeutic anticoagulation. Objective H2.2: Platelet Function Testing . Explain platelet function testing and discuss how platelet function testing can be used to differentiate among disorders causing abnormal function of platelets. Objective H2.3: Clotting Factor Deficiencies . Describe how routine coagulation tests can be used to identify the likely deficiency of different clotting factor(s). Objective H2.4: Evaluations of Coagulopathies . Compare and contrast the roles of the following in evaluating coagulopathies: clinical history, prothrombin time (PT) test, partial thromboplastin time (PTT) test, D-dimer assay, platelet count, and platelet function tests. Objective H2.5: Evaluation of the Bleeding Patient . Describe how to evaluate a bleeding patient with a hemorrhagic disorder and explain how the history influences testing, including the uses and limitations of screening PT, PTT, and platelet counts. Objective H2.6: Disseminated Intravascular Coagulation . Retired. Use C3 H2.5. Objective H2.7: Hereditary and Acquired Causes of Thrombosis . Describe the major hereditary and acquired risk factors for thrombosis and how coagulation testing is used to confirm the diagnosis. Objective H2.8: Platelet Inhibitors . Explain the action and the clinical use of common platelet function inhibitor drugs, including, but not limited to, aspirin and clopidogrel. Objective H2.9: Anticoagulants . Explain the actions and clinical use of commonly used anticoagulants, including warfarin, the heparins, and the oral direct inhibitors of thrombin and factor Xa. Apply knowledge of RBC structure/function and nutrient metabolism, the mechanisms of anemia, and the clinical and pathological features of common causes of anemia to develop an appropriate differential diagnosis. Objective H3.1: RBC Function . Summarize laboratory testing for key cellular structures and functions of the RBC. Objective H3.2: Nutrients Required for Erythropoiesis . Discuss the laboratory testing for specific nutrients, including iron and vitamins, needed for erythropoiesis. Objective H3.3: Blood Loss. Retired. Use C2 HRC1.8. Apply knowledge of RBC structure/function and nutrient metabolism, the mechanisms of anemia, and the clinical and pathological features of common causes of anemia to develop an appropriate differential diagnosis of anemia. Objective H4.1: Classification and Diagnosis of Anemia . Discuss how anemia is classified; what tests are used in classification, and how follow-up testing is used to narrow differential diagnosis in different types of anemia. Objective H4.2: Interpreting the CBC . Explain the contribution of each of the measurements of the CBC, how they are derived, and how they can help diagnose blood cell disorders using specific examples. Objective H4.3: Peripheral Smear Evaluation in Anemia . Discuss the RBC and WBC morphology on a peripheral smear to develop a differential diagnosis for a patient with anemia. Objective H4.4: Inherited Anemia . Retired. Use C2-specific anemia Learning Objectives. Objective H4.5: Acquired Anemia . Retired. Use C2 HRC1.5. Objective H4.6: Treatment of Anemia . Retired. Objective H4.7: Lab diagnosis . Retired. Use C3 H4.1. Apply knowledge of WBC structure, function, and development for patients with white cell disorders. Objective H5.1: WBC Count and Differential . Describe, with examples, how abnormalities of WBC count and WBC differential count can be used along with patient history to direct laboratory testing in the workup of a patient. Objective H5.2: Lymphocyte Subsets . Describe the subsets of lymphocytes that can be found in the peripheral blood and discuss how they are measured and how they may be altered in disease. Objective H5.3: Neutrophils . Discuss genetic factors that produce quantitative and qualitative abnormalities of neutrophils and how laboratory testing can diagnose diseases with these abnormalities. Objective H5.4: Flow Cytometry . Outline the principles of flow cytometry and describe, with examples, how it may be used to diagnose and monitor neoplastic and non-neoplastic WBC disorders. Infectious diseases are extremely common, and every physician needs to be able to correlate clinical findings with the appropriate testing needed. Some infectious disorders will require immediate organism identification and susceptibility to pharmacotherapy, and understanding principles underlying the different types of microorganisms and their identification is essential. Many newer techniques have been recently implemented, including molecular techniques, that allow more definitive identification and specialized treatment for infectious organisms. Apply knowledge of infectious organisms to explain the pathogenesis of disease and clinical syndromes, appropriate collection of patient samples, organism identification and classification, antibiotic choice, and selection of medical/surgical interventions. Objective M1.1: Preanalytic Factors in Microbiology . Explain the types of preanalytical variables that affect diagnostic accuracy, including site and sterile/non-sterile specimens, and discuss factors that affect length of turn-around time for microbiological workups. Objective M1.2: Gram Stain . Moved to C3 M2.14. Objective M1.3: Organism Identification . Give examples of the types of testing performed in microbiology including cultures and their optimal usage to identify an infectious disease. Objective M1.4: Coordination of Treatment . Retired. Objective M1.5: Rapid Testing in Microbiology . Describe the uses and limitations of POC testing for infectious diseases from various body sites. Objective M1.6 (Formerly C3 M2.9): Molecular Testing in Microbiology . List examples of molecular tests that are commonly used in clinical microbiology and explain how they have an important impact on clinical care. Integrate concepts of bacteriology, susceptibility testing, and antimicrobial agents to identify bacterial infections and guide treatment. Objective M2.1: Mechanisms of Antibiosis . Associate mechanisms of action with antimicrobial agents, including the following: disruption of cell wall synthesis, inhibition of protein synthesis, inhibition of DNA synthesis, and antimetabolites. Objective M2.2: Antimicrobial Activity . State the spectrum of activity for common antimicrobial agents. Objective M2.3: Antibiotic Resistance . Describe mechanisms of resistance found in common pathogens including the following: penicillinase and mecA in Staphylococcus subspecies, vanA and vanB in Enterococcus subspecies, and extended spectrum beta-lactamases and carbapenemases in Enterobacteriaceae. Objective M2.4: Antimicrobial Susceptibility Testing . Describe the standardized techniques used in antimicrobial susceptibility testing, why standardization is important, and the differences between a qualitative and quantitative result. Objective M2.5: Genetics of Antibiotic Susceptibility . Name the genetic element detected by surrogate testing for cefoxitin and oxacillin susceptibility and describe how the results for Staphylococcus subspecies are used to predict activity of other beta-lactam antibiotics. Objective M2.6: Choice of Antibiotics . Describe how the microbiology laboratory determines if an isolate from a blood culture is susceptible or resistant. Describe how the pharmacokinetic/pharmacodynamic models may influence a clinician's choice of antibiotics given the susceptibility of an organism using specific examples. Objective M2.7: Antimicrobial Stewardship . Outline the principles that guide an institution's reporting cascade for the following: FDA indications, Clinical and Laboratory Standards Institute guidance, site of infection, institution formulary, and antimicrobial stewardship. Objective M2.8: Institutional Antibiogram . Use an institutional antibiogram to prescribe therapy before susceptibility test results are available. Objective M2.9: Molecular Testing in Microbiology . Moved to C3 M1.6. Objective M2.10: Mass Spectrometry in Microbiology . Explain how the application of matrix-assisted laser desorption/ionization-time of flight mass spectrometry in the clinical microbiology laboratory can impact patient care. Objective M2.11: Urine Studies for Cystitis . Explain the role of urine studies, including culture, in selecting antimicrobial therapy for infectious cystitis. Objective M2.12: Diagnosis of Urinary Tract Infections (UTI) . Describe a testing strategy for a typical uncomplicated community acquired UTI versus a nosocomial UTI in a patient with a Foley catheter and list the key microbiological tests in the diagnosis of UTIs. Objective M2.13: Diagnosis and Management of Syphilis . Explain the role of Venereal Disease Research Laboratory/rapid plasma reagin (VDRL/RPR) and Treponema -specific tests in the diagnosis and management of syphilis. Objective M2.14 (Formerly M1.2): Gram Stain . Compare and contrast the interpretations of Gram stains for rapid diagnosis of causative bacterial agents from sterile and contaminated sites and discuss the clinical settings where recognition of bacteria is most meaningful. Integrate concepts of virology with diagnostic techniques including culture, molecular, and antigen diagnostics to identify viral infections and guide treatment. Objective M3.1: Hepatotropic Viruses . Describe the laboratory findings that diagnose hepatitis and correlate with the different possible clinical outcomes for each of the major hepatotropic viruses. Objective M3.2: Influenza . Explain the diagnosis of influenza in terms of diagnostic tests used, major antigens present, and the implications of a major shift in these antigens. Objective M3.3: Serology, Nucleic acid amplification testing (NAAT), and Culture . Describe the role of serology, NAAT, and culture in the diagnosis of viral infections and discuss the advantages and disadvantages of each in terms of both accuracy and rapidity of diagnosis and with respect to evaluation in an epidemic or pandemic. Objective M3.4: HIV Infection . Explain the testing strategy used to diagnose HIV and the role of viral load and CD4 count in monitoring HIV infection. Objective M3.5: Response to HIV Treatment . Describe the tests available to examine the response of an HIV virus to therapeutic agents, explaining how each test works. Objective M3.6: Other Viral Infections . Describe the testing strategy for other viral infections, including SARS viruses, respiratory syncytial virus, and congenitally acquired viruses. Integrate concepts of mycobacteriology with diagnostic techniques, including culture, molecular, and antigen diagnostics, to identify mycobacterial infections and guide treatment. Objective M4.1: Identification of Mycobacteria . Describe the diagnostic tests available for the identification of mycobacteria, including culture methods and new molecular tests. Objective M4.2: Antimycobacterial Susceptibility . Compare and contrast the methods, culture, and molecular tests used to identify mycobacterial drug susceptibility and the time required for results by each method. Integrate concepts of mycology with diagnostic techniques, including culture, molecular, and antigen diagnostics to identify fungal infections and guide treatment. Objective M5.1: Types of Fungi and Yeast . Differentiate among filamentous fungi, dimorphic fungi, and yeast and describe the diagnostic approaches for each type. Objective M5.2: Sensitivity Testing for Yeast . Define sensitivity testing and describe its role and use in the management of yeast infections. Objective M5.3: Special Testing for Fungi and Pneumocystis . Explain the basis for the galactomannan and beta-glucan tests and how they are utilized to detect fungi and P neumocystis . Integrate concepts of parasitology with diagnostic techniques, including culture, molecular, and antigen diagnostics, to identify parasitic infections and guide treatment. Objective M6.1: Metazoan and Protozoan Parasites . Compare and contrast metazoan and protozoan parasites and the diagnostic approaches for each. Objective M6.2: Stool Testing for Parasites . Explain the role of stool samples, including number examined, role of microscopy, and detection, in the diagnosis of parasitic disease. Objective M6.3: Serologic Testing for Parasites . Summarize the role of serology and serological tests to diagnose toxoplasmosis and assess the risk of transmission during pregnancy. Objective M6.4: Malaria and Babesiosis . Contrast Plasmodium falciparum with other malaria species and babesiosis on a blood smear and explain the role of thick and thin smears in the diagnosis and management of malaria. Objective M6.5: Rapid Testing for Malaria . Name the rapid tests that do not require blood smears to identify malaria and explain how these tests work. Every physician needs to be able to differentiate among multiple different chemical tests in order to narrow differential diagnoses, confirm a diagnosis, or to follow disease progression. To treat patients appropriately, physicians need to understand the appropriate use of major clinical chemistry tests, the limitations of their use, and the pathophysiologic changes that produce alterations in their values. Apply knowledge of clinical chemistry and physiology to discuss the role of chemistry testing in the laboratory in the diagnosis and management of common disorders and to describe how the pathophysiology of disease is reflected in abnormalities in results of chemistry tests. Objective CHEM1.1: Thyroid Function Tests . Discuss the efficient use of laboratory tests to identify and manage patients with thyroid disorders, to define the pathogenesis of these disorders, and to help distinguish among diseases in the differential diagnosis. Objective CHEM1.2: Cardiac Disorders . Discuss the efficient use of laboratory tests to identify and manage patients with cardiac disorders, to define the pathogenesis of these disorders, and to help distinguish among diseases in the differential diagnosis. Objective CHEM1.3: Endocrine Disorders . Discuss the efficient use of laboratory tests to identify and manage patients with endocrine disorders, to define the pathogenesis of these disorders, and to help distinguish among diseases in the differential diagnosis. Objective CHEM1.4: Liver Disorders (Gastrointestinal Disease is moved to C3 CHEM1.9) . Discuss the efficient use of laboratory tests to identify and manage patients with liver disorders, to define the pathogenesis of these disorders, and to help distinguish among diseases in the differential diagnosis. Objective CHEM1.5: Renal Disorders . Discuss the efficient use of laboratory tests to identify and manage patients with renal disorders, to define the pathogenesis of these disorders, and to help distinguish among diseases in the differential diagnosis. Objective CHEM1.6: Lung Disease . Discuss the efficient use of laboratory tests to identify and manage patients with lung disease, to define the pathogenesis of these disorders, and to help distinguish among diseases in a differential diagnosis. Objective CHEM1.7: Toxicology . Outline the value of testing for drugs and toxins, accounting for the routes of administration, distribution, and metabolism of the agent of interest and including the specimen source, the analytes to be detected given the medical questions, and the timing constraints for specimen collection. Objective CHEM1.8: Cancer Diagnostics . Discuss the appropriate tests for specific cancer diagnostics, including tumor markers and serum monoclonal protein analysis. Objective CHEM1.9: Gastrointestinal Disorders (Formerly C3 CHEM1.4) . Discuss the efficient use of laboratory tests to identify and manage patients with gastrointestinal disorders, to define the pathogenesis of these disorders, and to help distinguish among diseases in the differential diagnosis. Objective CHEM 1.10: Muscle, Nerve, and Bone Disorders . Discuss the efficient use of laboratory tests to identify and manage patients with muscle, bone, and nerve disorders; to define the pathogenesis of these disorders; and to help distinguish among diseases in the differential diagnosis. Objective CHEM 1.11: Prenatal Disease . Discuss the efficient use of clinical chemistry tests to identify and manage patients with prenatal disease, to define the pathogenesis of these disorders, and to help distinguish among diseases in the differential diagnosis. Objective CHEM1.12: Diabetes Testing . Discuss the efficient use of laboratory tests to diagnose and manage patients with diabetes mellitus, to define the pathogenesis of this disorder, to determine risk of development, and to monitor the disease process. Objective CHEM 1.13: Therapeutic Drug Monitoring . Outline the value of testing for therapeutic drugs, accounting for the routes of administration, distribution, and metabolism of the agent of interest and including the timing constraints for specimen collection. Apply knowledge of chemistry and physiology to discuss the utility of panel testing in the laboratory in the diagnosis and management of common disorders and to describe how the pathophysiology of disease is reflected in abnormal results of chemistry tests. Objective CHEM 2.1: Basic and Comprehensive Metabolic Panel . Outline the components of the basic and comprehensive metabolic panels and describe their advantages and disadvantages as screening tests. Objective CHEM 2.2: Lipid Panel . Outline the components of the lipid panel and identify and describe how this test is used to diagnose and manage patients with lipid disorders. Apply knowledge of normal chemical and cellular contents of urine, cerebrospinal fluid, and body cavity fluids in the diagnosis and management of common disorders and describe how the pathophysiology of disease is reflected in abnormal results of fluid tests. Objective CHEM 3.1: Urinalysis . Discuss the advantages and disadvantages of routine urinalysis and describe how particular abnormalities can help in the diagnosis and/or monitoring of specific diseases. Objective CHEM 3.2: Body Fluid Testing . Discuss the role of examination of effusions in helping to elucidate their causes. Objective CHEM 3.3: Cerebral Spinal Fluid (CSF) Testing . Outline the components of spinal fluid testing and describe how this test is used to diagnose and manage patients with CSF disorders. Objective CHEM 3.4: Blood Gas Analysis . Discuss the components of a blood gas panel and describe how these tests are used to manage patients, particularly in the intensive care unit or in the surgical setting. Every physician needs an understanding of specific laboratory tests to differentiate between inflammatory and immune-mediated diseases. Many newer techniques have been recently implemented that allow more definitive diagnosis and specialized treatment for these disorders. Apply knowledge of immunology, biochemistry, and pathology to describe the basic cellular and molecular events associated with immune system diseases of specific tissues and organ systems and the use of laboratory tests to diagnose and manage these diseases. Objective IMM1.1: Markers of Inflammation . Compare and contrast markers of inflammation in terms of the pathophysiologic basis and stages of the inflammatory response. Objective IMM1.2: Immune Deficiencies and Allergen Testing . Select and interpret appropriate tests for workup and interpretation of immunodeficiencies and allergy testing. Objective IMM1.3: Serologic Testing for Infection . Discuss, with examples, the application of serological testing in infectious diseases to establish immune status and diagnose infection. Objective IMM1.4: Autoimmune Diseases . Discuss the efficient use of laboratory tests to make a definitive diagnosis and manage autoimmune diseases. Every physician needs an appreciation of the complex fields of molecular pathology, genomics, and cytogenetics, the ever-evolving molecular techniques that are essential for diagnosing diseases as accurately as possible, and the many diseases correlated with specific targeted immunotherapy or chemotherapy to maximize effectiveness of treatment, decrease side effects, and optimize patient survival. Apply knowledge of genetics including the structure and organization of the human genome and regulation of gene expression, genetic variation, and inheritance patterns to basic disease processes. Objective GE1.1: Mendelian Inheritance . Retired. Use C1, GM1.2. Objective GE1.2: Pedigrees . Interpret a pedigree and discuss how this information can be applied for focused diagnostic testing. Objective GE1.3: Inheritance Patterns . Compare diagnostic testing of single-gene disorders to diseases with complex inheritance patterns and include the role of rare, high-risk variants and common, low-risk variants. Objective GE1.4: Linkage Analysis . Objective moved. Use C1 GM1.7. Objective GE1.5: Population Genetics . Objective moved. Use C1 GM1.8. Objective GE1.6: Genetic Risk . Objective moved. Use C1 GM1.9. Objective GE1.7: Phenotypic Expression . Objective moved. Use C1 GM1.10. Objective GE1.8: Modifier Genes . Objective moved. Use C1 GM1.11. Objective GE1.9: Cytogenetics . Define the following cytogenetic terms and nomenclature: karyotype, euploidy, aneuploidy, monosomy, trisomy, deletion, ring chromosome, inversion, isochromosome, translocation, balanced reciprocal translocation, and Robertsonian translocation. Objective GE1.10: Mosaicism . Objective moved. Use C1 GM1.13. Apply knowledge of genetics to explain the molecular basis of single-gene and non-neoplastic chromosomal disorders. Objective GE2.1: Testing for Genetic Disorders . Describe, with disease examples, how laboratory tests are used to diagnose the following specific genetic disorders: Mendelian disorders, autosomal disorders (dominant and recessive), X-linked disorders, chromosomal disorders, and disorders of nonclassic inheritance. Apply knowledge of genetics to explain the genetic basis for neoplasia and the role of genetic testing in diagnosis and treatment of diseases. Objective GE3.1: Genetic Predisposition to Neoplasia . Retired. Use C1 N1.1. Objective GE3.2: Genetic Mechanisms of Neoplasia . Retired. Use C1 N1.1. Objective GE3.3: Molecular Testing in Oncology . Explain the application of molecular testing for diagnosis, prognostication, and therapeutic follow-up of oncologic diseases. Objective GE3.4: PCR Testing . Discuss the advantages and limitations of PCR testing in oncology. Objective GE3.5: Genome Testing . Compare gene panel sequencing, whole exome sequencing, whole genome sequencing, and transcriptome sequencing with respect to the information gained from each, cost, and turnaround time and discuss clinical situations in which each might be appropriate. Objective GE3.6: Chromosomal Alterations . Compare and contrast techniques used to identify structural or numerical alterations in chromosomes and discuss how these can be used in the diagnosis and monitoring of patients with neoplasia. Apply knowledge of genetics to explain the role of reproductive genetics and population screening. Objective GE4.1: Carrier Testing . Describe the role of preconception and prenatal carrier testing for genetic disorders depending upon family history and ethnic background. Objective GE4.2: Newborn Screening . Describe the rationale for newborn screening for genetic diseases and explain the difference between screening and diagnostic testing. Apply knowledge of genetics to explain the role of genetic testing in diagnosis and treatment of diseases and in counseling of patients and families. Objective GE5.1: Treatment Mechanisms . Retired. Objective GE5.2: Genetic Variation in Response to Treatment . Discuss, with examples, how laboratory testing is used to identify genetic polymorphisms that can predict efficacy of medications and risk for adverse effects. Objective GE5.3: Factors to Prevent Disease in the Genetically Predisposed . Retired. Please use specific learning objectives from C1 Environmental Mechanisms. Objective GE5.4: Genetic Counseling . Discuss, with examples, how collaborations between genetic counselors and the laboratory optimize laboratory genetic testing for efficient and cost-effective patient care. Objective GE5.5: Inherited Diseases . Discuss the approach used for establishing the diagnosis for inherited diseases, directing therapy, and optimizing cost effective care. Autopsy is a division of anatomic pathology that encompasses the examination of a deceased person, either for medical or legal reasons. Understanding the value of the autopsy, both for scientific investigation of potential inherited disorders and for understanding the diseases that led to a patient's demise, will allow physicians to appropriately discuss this end-of-life medical evaluation. Apply knowledge of clinical medicine, quality management, and medicolegal issues to discuss the value of the autopsy and procedures for obtaining permission. Objective AU1.1: Value of the A utopsy . Provide examples demonstrating the value of the autopsy toward improvement in clinical diagnosis and management, quality control, medical education, research, and elucidation of “new” diseases. Objective AU1.2: Consent for A utopsy . Discuss the general process to identify the legal next of kin or individual authorized to consent for an autopsy. Objective AU1.3: Obtaining Consent from the Family . Describe how to approach a family to request consent for an autopsy, including a discussion of the autopsy procedure in language that the patient's family can understand. Objective AU1.4: Professionalism in the A utopsy . Discuss the psychosocial–emotional aspects of the autopsy experience, including its role in closure, and the importance of communication and professionalism among the healthcare team. Objective AU1.5: Anatomic Findings in A utopsy . Describe the role of the autopsy in identifying dysmorphology and anatomic abnormalities to help diagnose and classify congenital disorders. Apply knowledge of quality management to discuss the utility of death certificates and proper approaches for completing them. Objective AU2.1: Public Health . Describe the importance of death certificates for tracking and analysis of public health trends. Objective AU2.2: Components of the Death Certificate . Discuss the key components of the death certificate and distinguish among the cause of death (immediate, intermediate, and underlying), contributing conditions, and manner of death. Objective AU2.3: Medical Errors . Explain how underutilization or overutilization of medical care and incorrect diagnoses, therapeutics, or informed consent can lead to medical errors and give examples of how an autopsy can identify errors, thereby improving health care and decision-making. Apply knowledge of clinical medicine and postmortem examination to discuss the indications for medical examiner referral and special procedures in the forensic postmortem examination. Objective AU3.1: Role of the Medical Examiner . Define the role of a medical examiner in terms of public health and protection of legal rights and describe differences between a forensic and medical autopsy. Objective AU3.2: Reportable Deaths . Identify circumstances of death that need to be reported to the medical examiner/coroner. Surgical pathology is the area of anatomic pathology where all tissues or hardware removed from a patient are evaluated. Specimens sent to surgical pathology may range from minute endoscopic biopsies to large limb resections. Special techniques are commonly used by pathologists in evaluating these specimens that allow for definitive diagnosis and the recommendation of appropriate treatment for both benign and malignant lesions. Apply knowledge of clinical medicine and pathology to describe the role surgical pathology plays in diagnosis and treatment of benign and malignant disorders. Use specific examples from the most common diseases and forms of cancer. Objective SP1.1: Specimen Types . Distinguish biopsies and excisions, describe the circumstances in which each is appropriate, and discuss the different types of information obtained from each type. Objective SP1.2: Differential Diagnosis . List the major differential diagnoses for a surgical pathology specimen obtained from a lesion or mass in a particular location, and describe appropriate further studies to resolve the differential. Objective SP1.3: Special Studies . Describe how a pathologist uses fresh, fixed, and frozen tissue for histochemical and immunohistochemical stains and genetic testing to arrive at a diagnosis, provide prognostic information, and direct specific therapy. Objective SP1.4: Staging . Describe the information that the pathologist obtains from a resected tissue specimen, how this information is reported, how it is combined with clinical information to stage the tumor, and how staging information is used to guide treatment. Objective SP 1.5: Frozen Section . Explain the use of frozen sections and how the pathologist works with the patient care team to optimize and prioritize diagnosis and patient management. Objective SP 1.6 (Formerly CI FECT2.7, FECT2.9, and FECT2.13): Special Stains for Infectious Organisms . Discuss, with examples, the use of special stains to identify bacteria, fungi, viruses, and parasites in tissues. Apply knowledge of clinical medicine and pathology to describe the roles surgical pathology plays in diagnosis and treatment of inflammatory disease, in particular those with immune or infectious etiologies. Objective SP2.1: Examples of Inflammatory Conditions . Give examples of specific sites and diseases in which certain pathologic diagnoses of inflammatory and/or infectious conditions are critical to treatment and prognosis. Learning Goal 3: Congenital Disorders—Retired. Use AU Learning Goal 1 Objectives. Apply knowledge of clinical medicine and communication skills to interpret pathology reports and communicate the results to patients in the context of risk assessment and patient prognosis. Determine appropriate action, including additional testing and clinical evaluation. Objective SP4.1: Explaining the Report to the Patient . Describe the components of a surgical pathology report, emphasizing how reports are structured to ensure clear communication of diagnostic information to the ordering physician. Apply knowledge of pathology and the application of differential diagnoses to discuss the diagnostic approach to leukemia and lymphomas and describe the relative roles of ancillary laboratory studies in classification. Objective SP5.1: Special Studies . Describe the roles of immunohistochemistry, flow cytometry, cytogenetics, and molecular diagnostics in the diagnosis and classification of lymphoma and explain how, with examples, different techniques are most appropriate in diagnosis, staging, and management of disease. Objective SP5.2: Use of Special Studies . Explain how the work up of lymph nodes at the frozen section bench differs from routine frozen sections. Objective SP5.3: Differential Diagnosis . Retired. Use C3 SP1.2. Objective SP5.4 Role of Morphology . Discuss how routine morphologic examination of bone marrow and tissue biopsies can be used to direct selection of testing required for the diagnosis of leukemia and lymphoma. Cytopathology focuses on the individual cellular components of disease. Cytopathological examination is an essential tool for its wide-ranging reach in screening, diagnostics, prognostics, and prevention of advanced disease states. Furthermore, the minimally and noninvasive nature of ascertaining most cytological specimens allows for immediate access to viable cellular material for advanced testing, molecular, and biochemical analyses. Apply knowledge of general and systems pathology to understand the meaning and context of cytologic diagnoses. Objective CYP1.1: Obtaining the Specimen . Compare and contrast the basic methods to obtain cytologic material for diagnosis, describe the settings in which these can be used to diagnose benign and malignant conditions, and discuss the limitations of each. Objective CYP1.2: Categorizing Diagnostic Certainty . Compare and contrast the degree of diagnostic certainty applied to general categorization in cytologic diagnosis. Objective CYP1.3: Identifying Infectious Diseases . Describe, with examples, the uses and limitations of cytology in identifying common infectious diseases. Objective CYP1.4: Use of Cytology for Staging of Neoplasms . Describe how cytologic specimens can add valuable information for tumor staging. Apply knowledge of clinical medicine, pathology, and healthcare delivery to describe the advantages cytopathologic examination offers over conventional pathologic tissue examination. Objective CYP2.1: Screening . Describe how cytopathology is used as a screening test and discuss its advantages and limitations. Objective CYP2.2: Ancillary Testing . Describe how ancillary testing such as flow cytometry, immunohistochemistry, and molecular diagnostic testing is used in conjunction with cytology examination. Objective CYP2.3: Cervical Cancer Screening . Describe how to utilize current algorithms for cervical screening and discuss how human papilloma virus testing is used for management. Objective CYP2.4: Fine Needle Aspiration . Discuss the advantages and limitations of fine needle aspiration.

The revised PCME highlight three major competencies in pathology, namely disease mechanisms and processes, organ system pathology, and diagnostic medicine and therapeutic pathology. The revisions have addressed gaps in the original PCME publication and reorganized and revised existing objectives to better align with the competencies. The nomenclature system was retained from the original PCME publication and was expanded to allow easy cross reference when learning objectives were moved and combined. The nomenclature system should allow for the continued referencing of educational cases to the pathology competencies. Knowledge of pathophysiology and laboratory diagnosis continues to be essential for the practice of medicine. The PCME serve as a national peer-reviewed resource of learning objectives that should be beneficial for both students and medical educators. However, the document is designed to be a living document that is periodically revised and updated to ensure relevance as medical practice evolves. We continue to encourage comments about the pathology competencies to be sent to the authors. We also encourage continued submission of educational cases to Academic Pathology to grow this international resource.

The PCME were originally designed to represent the minimum knowledge thought necessary for medical students to practice in medicine today. Through the revisions of the PCME, we have retained the three major competencies under which the learning objectives are now better aligned. These objectives are broad and comprehensive and can be applied to different curricula, whether in a free-standing course or adapted into the current model of integrated teaching. While relevant to a comprehensive pathology curriculum, we acknowledge that not all learning objectives need to be taught by pathologists. We hope that having peer-reviewed learning objectives as a national resource will encourage pathology educators to adapt some or all into their curricula or to refine their own learning objectives. As confirmation that a foundational understanding of pathology continues to be central to UME, approximately 50% of the questions in the United States Medical Licensing Exam (USMLE) Step 1 assess pathology material. 6 In addition to integrated curricula, some medical schools have shifted to competency-based medical education by endorsing Entrustable Professional Activities (EPAs). Several of the EPAs developed by the Association of American Medical Colleges tie directly to the foundational understanding of pathology. These include EPA 3 “Recommend and Interpret common diagnostic and screening tests”; EPA 2 “Prioritize a differential diagnosis following a clinical encounter”; EPA 9 “Collaborate as part of an interprofessional team.“. 7 In addition, the third pillar of medical education, Health System Science (HSS), 8 requires an understanding of the important role pathology plays to ensure safe, equitable, timely, and efficient patient care. This will lead to an increase in efficient use of laboratory testing and an increase of patient safety. Publications integrating HSS curriculum in UME include a 2016 publication from the American Medical Association describing the domains of HSS education. 9 While the learning objectives are designed as free-standing statements to capture the breadth and depth of necessary content in pathology, one of their major uses has been as an anchor for the development of educational cases. These are succinct peer-reviewed clinical case presentations that lead the reader through clinical reasoning to determine a differential diagnosis based on history, physical examination, and laboratory findings. The educational cases all have a primary learning objective and may have additional secondary learning objectives. An educational case focused on basic pathobiology would typically have a primary C1 learning objective, one focused on organ system pathology C2, and one on laboratory diagnosis of disease C3. Most cases have multiple objectives; the primary learning objective should be fully discussed in the educational case, but secondary learning objectives do not need full discussion. Teaching points at the end of each case discussion provide the key learning points of the primary learning objective and secondary objectives if used. The repository of educational cases that accompany the PCME continues to grow by approximately 40 new cases per year. Currently, 169 have been published in Academic Pathology ; additional cases are in production. Educational cases comprise 4 of the top 10 articles downloaded from Academic Pathology in 2022. In addition, 9 of the top 10 accessed publications from Academic Pathology in PubMed Central® are educational cases. We encourage authors to continue to submit educational cases, especially in the areas of new and revised learning objectives. Cases can easily be adapted into many different types of learning settings, including laboratories, small group discussions, and team-based learning exercises. The cases emphasize the use of clinical reasoning to devise a differential diagnosis and provide increasing amounts of information to the learner to refine a differential and arrive at a final diagnosis. The discussions that accompany the cases emphasize the clinical reasoning behind the conclusions and should fully explain all aspects of the primary learning objectives. By incorporating clinical, laboratory, and pathophysiologic information, these exercises help undergraduate medical students develop the critical thinking skills they will need as practicing physicians. With the nomenclature system developed for the PCME, educators can search for cases meeting specific objectives using the spreadsheet on the APC website. 10 The linkage between previous versions and this revision will allow them to find cases written under a previous leaning objective that was moved or retired. While medical educators are the primary audience of the PCME and the educational cases, students can also use the cases for study, review, and expansion of knowledge. While not designed to reflect what every student must master before beginning a residency, the PCME can serve as a checklist for students to follow as they learn the breadth and depth of pathology; the educational cases provide vehicles for them to see how that knowledge is applied. The most extensive changes in this revision are to the third competency on diagnostic medicine. A previous report indicated that nearly all inpatient care, just over half of emergency room visits, and about one third of outpatient visits result in laboratory testing, 11 underscoring the need for all medical students to understand laboratory medicine. We now include many new learning objectives in this competency, and its focus is now clearly to equip the medical student with a broad understanding of laboratory testing. Knowing when and how to order tests (including appropriate diagnostic use of tissue samples), what information they provide, and how disease processes produce the abnormalities detected all will help future physicians provide cost effective and efficient patient care. A recent publication highlighting the most common laboratory tests and the pathophysiology underlying changes in their values has been linked to the PCME. 5

A great shift in medical school curricula has occurred in the past 10 to 15 years from course-based curricula to integrated organ system-based curricula. This shift has allowed medical students to enter clerkships earlier and increase their clinical exposure. However, practicing medicine today, perhaps more than ever, requires a broad knowledge of normal and pathological processes. The rapid increase in the number of available laboratory tests, most notable in the explosion of genetic testing, makes it even more important for practicing physicians to have a solid understanding of mechanisms of disease, both to choose the most appropriate laboratory test(s) and to counsel their patients about their meaning. This project began approximately 10 years ago as a working group of the Association of Pathology Chairs (APC), which developed an initial set of pathology competencies described in “National Standards in Pathology Education." 1 In this initial publication, over 60 pathology course directors and pathology chairs submitted course objectives that were extensively reviewed and, in 2014, posted on the APC website. To further disseminate these learning objectives, the APC published a revision of them in Academic Pathology in July 2017 as the Pathology Competencies for Medical Education (PCME). 2 The objectives are placed within one of three competencies: (1) Disease Mechanisms and Processes, (2) Organ System Pathology, and (3) Diagnostic Pathology and Therapeutic Pathology. Just prior to its annual meeting in 2018, the APC sent a survey to its members to evaluate the impact of the PCME and to assess the extent to which these had been implemented in curricula. Forty-nine members from 48 different institutions responded to the survey. Of the responders, 42 (86%) responders indicated that they had read the PCME and 29 (59%) responders indicated that they had used information from the PCME to change, modify, or update the learning objectives at their own institution. Comments received indicated that members had altered lectures to align with the PCME; updated course content and/or learning objectives; mapped their own institution curriculum on to the PCME. Others found out about the PCME from the survey and indicated that they now plan to use them. Some responders commented that the PCME should be vetted nationally with other national society buy-in, and a rare comment mentioned that the objectives were too dense. Sixteen (34%) of responders indicated that the PMCE were useful in other ways, such as to negotiate for more time with institutional leadership, to develop 4th year electives, to map curriculum, to re-affirm what pathology course directors are teaching, and to add diagnostic medicine to the curriculum. There were also some suggestions for additions to fill gaps in objectives, including interstitial lung disease, head and neck (HN) pathology, multisystem disease and amyloidosis, urinalysis, and chemistry (CHEM). This current revision is an attempt to address the previous comments and the gaps in the PCME and to provide a more uniform and updated set of competencies for educators to use in undergraduate medical education (UME).

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.