Pathological Basis of Disease —
Training activity: 5

Details

Prepare representative patient samples from a range of tissue types and identify the immune response and immunological disease in two of the following:

• Normal immune system
• Primary or secondary immunodeficiency
• Autoimmune disease
• Transplant rejection

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Differences between the types of physiological and pathological processes
• Associated normal and disease states
• Microscopical differences between normal tissue morphology and tissue undergoing these processes
• Local SOPs
• RCPath tissue pathways and cancer datasets
• Selection of histochemical, immunohistochemical, immunological and molecular techniques to demonstrate different cell types involved in the immune response

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to preparing samples and identifying immune responses or immunological diseases.
• Consider how the learning outcomes apply, specifically in relation to using histological techniques to demonstrate the different types of immunological disease.
• Discuss with your training officer to gain clarity of what is expected of you when preparing patient samples from a range of tissue types and identifying immune response and immunological diseases.

What is your prior experience of this activity?

• Think about your previous experience with sample preparation or microscopic identification of immune cells or features of immunological conditions.
• Consider possible challenges you might face, such as interpreting complex inflammatory infiltrates or recognising subtle signs of rejection/autoimmunity in different organs, and think about how you might handle them.
• Recognise the scope of your own practice; know when and from whom you will need to seek advice or help. You will need to seek advice from your Training Officer or a Pathologist specialising in immunological disease/transplantation when required, for example:
  • When the lymphoid infiltrate is dense and difficult to classify microscopically e.g., distinguishing a benign reactive process from an early lymphoproliferative disorder
  • If you are asked to assess a transplant biopsy where subtle signs of rejection must be interpreted according to complex grading systems
• Acknowledge how you feel about preparing the samples and identifying the range of diseases.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop in preparing samples and microscopically identifying features of immune responses and selected immunological diseases.
• Identify the specific insights you hope to gain into the histological manifestation of immune system activity and related disorders.

What additional considerations do you need to make?

• Consult actions identified following previous experience with sample preparation or examining slides for immunological conditions.
• Identify important information you need to consider before embarking on the activity, such as specific types of immune cells or characteristic histological patterns associated with autoimmunity or immunodeficiency.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst preparing the sample or identifying immune responses microscopically?
• Are you encountering situations such as:
  • The pattern of immune cells does not match the immediate expectation for the suspected condition e.g., a sample from an autoimmune patient shows a mixed infiltrate instead of the expected dominance
  • You are struggling to interpret the significance of the immune infiltrate e.g., distinguishing a benign reactive process from an early lymphoproliferative disorder, raising uncertainty about the diagnosis

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to correlation?
• Consider the steps you are taking in the moment, such as:
  • Actively trying to correlate the observed changes e.g., location, density, cell type of infiltrate with the specific immunological process
  • Pausing to identify the questions that are arising e.g., ‘Why is this cell type present here?’ or ‘Does this infiltrate meet the criteria for rejection?’
• How are you feeling in that moment? For instance, are you finding it difficult to apply complex grading systems (e.g., for transplant rejection)? Is it affecting your confidence in ensuring accurate interpretation?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying known criteria to classify the infiltrate? Or are you needing support because the grading or classification is complex and requires specialist interpretation such as a pathologist specialising in immunological disease/transplantation?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective strategy for differentiating between a normal immune presence and a pathological process? Or gaining insight into the key morphological markers of specific immunological diseases?

On action

What happened?

• Begin by summarising your assessment of the immune response or disease in this sample, focusing on the two selected conditions.
• Consider specific events, actions, or interactions which felt important, such as whether specific cellular infiltrates (e.g., T-cells vs. plasma cells) or tissue changes were key to your interpretation or were confusing.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, if the observed immune pattern did not align with your initial expectation for a known autoimmune disease and how this influenced your further examination. How did you feel during this experience, e.g., did you find the need to integrate clinical and microscopic data demanding?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding immunological disease. What strengths did you demonstrate, e.g., ability to distinguish between a normal immune presence and a pathological immune response? What skills and/or knowledge gaps were evident, e.g., difficulty interpreting complex grading systems for transplant rejection?
• Compare this experience against previous engagement with similar activities – Has your practice improved in your understanding of the histological manifestations of different immunological processes?
• Identify any challenges you experienced, such as needing to consult clinical history or specialist guidelines to aid in your interpretation, and what you learned about the significance of this contextual data.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including following any feedback you have received with regards to your ability to prepare patient samples across different tissue types. What actions are needed to develop your ability to identify immune responses and immunological diseases?
• What specific features of immune cell infiltrates and tissue changes will guide your assessment of immunological processes in the future, for instance, focusing on vascular changes in suspected transplant rejection?
• Do you need to practise any aspect of the activity further, such as reviewing specific immunological conditions or patterns e.g., immunodeficiency features?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences identifying immune responses or immunological diseases in different tissue types or conditions since completing this specific training activity led you to revisit your initial approach or decisions during that activity?
• Considering what you understand about the mechanisms and microscopic appearances of immunological disease, the different types of immune responses, and quality management standards now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your approach to preparing or identifying immune responses and immunological disease based on further learning and experiences?
• Has discussing cases involving immunological pathology, or the role of pathology in diagnosing immunological conditions, with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity?

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent experiences identifying immune responses/diseases, contributed to your overall confidence and competence in identifying the presence of an immunological response and disorders of the immune system when performing microscopical assessment of stained slides and practicing safely, particularly in preparing for assessments like DOPS?
• How has reflecting back on this specific training activity, combined with everything you’ve learned since about pathology, shaped your current approach to identifying immune responses and immunological disease? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation?
• Looking holistically at your training journey, how has this initial experience identifying immune responses/diseases, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to using histological techniques to demonstrate immunological disease and practicing safely?

Relevant learning outcomes

#	Outcome
# 5	Outcome Use histological techniques to demonstrate the different types of immunological disease.
# 9	Outcome Practice safely in accordance with quality management and accreditation standards.