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National Standards in Pathology Education: Developing Competencies for Integrated Medical School Curricula.

The structure of medical education in North America emerged largely from the reforms that followed the 1910 Flexner (1) report that advocated for scientific research and clinical experience to be integrated into medical education and contributed to the standardization of licensure requirements. Indeed, licensure requirements contributed substantially to shaping the nature of medical education. What emerged was a fixed medical school curriculum with distinct disciplines. Medical education usually followed a format of 2 years of lecture followed by 2 years of clinical apprenticeship. (2)

During the past 2 decades, medical education has experienced a new wave of reform. As a reflection of changing attitudes toward education in general, medical education too has been viewed as too rigid in structure. The sentiment is captured nicely in the recommendations of the Carnegie Foundation report (2) that calls for modifying the educational experience in a manner termed "learner centered." Key to this thinking is the recognition that students may learn in a variety of ways, and may benefit from a learning environment that differs from the traditional lecture format. However, learning outcomes must be carefully assessed, and graduation (and licensure) must be tied to well-articulated competencies. This poses a difficulty because all medical students cannot be adequately prepared to enter all residency programs. Perhaps medical schools will need to offer postmatch electives just prior to graduation to enable all graduating students to meet level 1 milestones in their chosen specialty.

In the report "Scientific Foundations for Future Physicians," (3) the Association of American Medical Colleges and the Howard Hughes Medical Institute similarly called for "specific competencies in the sciences fundamental to medicine that all medical students should demonstrate before receiving the M.D. degree." These contemporary reforms are reshaping the nature of undergraduate medical education and licensure. Rather than didactic lectures, organized in vertical and isolated disciplines, most medical schools have already moved toward substantial horizontal integration of courses, incorporating small-group discussion, case presentation, and even direct patient contact experiences during the classroom phase of preclinical education. We see this trend continuing to evolve, with increasing mixture of patient contact into classroom education throughout the medical school experience. As lecture hours are reduced, students are increasingly studying through electronic media including online lectures, patient simulators, and socially shared study materials. Moreover, there is a recent movement to form interdisciplinary health care teams composed of various health care professionals during medical school, in preparation for the increasing role that teams play in patient care. (4) As noted, students "will need to be competent in the knowledge, skills, and attitudes of teams and teamwork." (4)

How do these changes affect the teaching of pathology? In many schools, the move to integrate disciplines has eliminated any class officially termed pathology. This has not reduced the importance of pathology, but only its visibility. Rather, it has increased the need to identify the essential contributions of pathology to understanding and treating disease, and to make certain that our students appreciate these contributions. One step toward this goal is to formulate essential content as competencies required for graduation from all medical schools.

COMPETENCIES FOR UNDERGRADUATE MEDICAL EDUCATION IN PATHOLOGY

Training to become a physician requires the acquisition of a foundation of knowledge, the understanding of how systems work normally and in pathologic states, and the ability to continue to improve in diagnosing and treating patients through ongoing experience. The Liaison Committee on Medical Education has acknowledged these principles in their standards for accrediting medical education programs in the United States and Canada. The standards are described in the document entitled "Functions and Structure of a Medical School." (5) In that document there are several educational objectives that apply to teaching pathology. In particular, objective ED-11 states, "The curriculum of a medical education program must include content from the biomedical sciences that supports students' mastery of the contemporary scientific knowledge, concepts, and methods fundamental to acquiring and applying science to the health of individuals and populations and to the contemporary practice of medicine." (5) Pathology is specifically named among the subobjectives of scientific disciplines to which this standard relates. Objective ED-17 states that educational opportunities must be available in clinical pathology. Thus, medical students must learn the basic mechanisms of disease, their manifestations in major organ systems, and how to apply that knowledge to clinical practice for diagnosis and management of patients. Another educational objective, ED-33, refers to an institutional curriculum committee and states, "There must be integrated institutional responsibility in a medical education program for the overall design, management, and evaluation of a coherent and coordinated curriculum." (5) Finally, the first educational objective, ED-1, states, "The faculty of an institution that offers a medical education program must define the objectives of its program. The objectives must serve as guides for establishing curriculum content and provide the basis for evaluating the effectiveness of the program." (5) As integrated curricula become common, we are concerned that pathology be appropriately represented in the curriculum committee to ensure that there is full integration for teaching pathologic processes, from basic mechanisms to organ system pathology to laboratory diagnosis. We propose developing national standards for teaching 3 basic competencies in pathology: disease mechanisms /processes, integration of disease mechanisms into organ system pathology, and application of pathology to diagnostic medicine. Each competency will include learning objectives, optional subobjectives, and a means to assess the acquisition, integration, and application of knowledge to demonstrate the development of competency. This national standard is being developed by academic pathologists nationwide (Table) and will continue to be curated as a living document for all to use (www.apcprods.org/ ume-umeds/learningobjectives). Adopting a set of standards for teaching pathology is an important step in guaranteeing the essentials of pathology in the medical curriculum even as formats change with time.

Below, we describe the broad competencies we desire for our medical school graduates. One specific learning objective is presented for each, representing the body of knowledge that should be acquired by all medical school graduates.

Disease Mechanisms/Processes

Competency.--Pathology is built on underlying foundation principles. These include chemistry and biochemistry, cell theory, genetic theory, anatomy, and physiology. Students must master these core principles in order to understand the pathology of organ systems and principles of diagnosis and treatment. These principles allow the student to make sense of the diverse initiating factors for cellular injury and the responses to that injury that result in resolution, local disease, or systemic consequences.

Emphasis on understanding mechanisms/processes enables the student to apply the same principles to the pathology of many diseases and decreases the need for rote memorization.

Basic mechanisms/processes in pathology include physical trauma, cellular damage and response, inflammation and immune response, tissue regeneration, hemostasis, vascular damage and response, genetic regulation, mutation (including mechanisms leading to neoplasia), infection and microbial biology, aging, and others. Attention to mechanism/process would allow a student to translate his or her knowledge derived from one example to changes observed in another context. For example, an appreciation of the cellular basis of inflammation will help a student to construct the description of an acute bronchopneumonia. In practical exercises, students should be able to explain which inflammatory cells will be seen in the lung, describe how the inflammatory cells enter the tissue, and explain clinical symptoms that may be seen in the patient. They should then be able to contrast this with an acute pyelonephritis and again explain cellular and morphologic changes and clinical symptoms. The students can then apply their knowledge of other processes, for example regeneration and repair, to explain long-term consequences of repeated acute pyelonephritis, including gross and microscopic changes such as scarring and thyroidization of the tubules.

Example.--An example of an essential learning objective in disease mechanisms/processes could be the understanding of inflammation.

Learning Objective.--Apply knowledge of the histology and molecular biology of inflammation to the clinical presentation of disease.

Every physician should understand inflammatory processes, including cellular components, signaling molecules (eg, cytokines), and biochemical pathways that are targets for drugs. To be a competent physician one must understand, to some degree, how common medications, such as steroidal and nonsteroidal anti-inflammatory agents or antihistamines, modulate inflammation. Beyond this basic competency, medical schools should certainly desire their graduates to acquire a deeper level of understanding. Hence, we intend to provide more detailed subobjectives and specific examples that can be used for tailoring a curriculum. However, one should not lose sight of the essential competency among the many possible subobjectives.

Optional Subobjectives.--Compare and contrast the cellular components of acute and chronic inflammation to include their primary function and the molecules and mediators responsible for cellular recruitment and interactions.

Describe the appearance and mechanism of the 5 cardinal signs of inflammation.

Define the following types of extravascular fluids associated with injury: exudates, transudates, edema, pus (purulence).

Describe the molecular mechanisms of intracellular killing.

Characterize the systemic effects and manifestations of inflammation to include the acute phase reactants.

Recognize the primary mechanisms and cellular constituents of major inflammatory patterns.

Explain the dynamics (ie, time/duration) of leukocytic infiltrates and possible outcomes of inflammation.

Organ System Pathology

Competency.--Knowledge of the fundamental mechanisms and processes for causing, sustaining, extending, or resolving injury can be integrated with concrete examples revealing how diseases present at their initial pathologic site, affect multiple organ systems, and affect the overall well-being of the patient.

Graduating students should be able to apply their knowledge of mechanisms to disorders arising in the major organ systems. Students should be familiar with the epidemiology, gross and microscopic features, and diagnostic techniques associated with common disorders as well as the presentation, the natural history if untreated, and the likely outcome when treated.

Students should recognize that most disorders can be broadly categorized as vascular, infectious, toxicologic, metabolic, immunologic (autoimmune versus hypersensitivity subtypes), mechanical, neoplastic, or developmental. For an individual organ system, one set of mechanisms often predominates. For example, disorders leading to neoplasia are prominent in breast pathology, but are of less importance in cardiac disorders, where vascular mechanisms are most relevant in Western civilization.

Example.--An example of an essential learning objective in organ system pathology follows.

Learning Objective.--Apply knowledge of anatomy, physiology, and general pathophysiologic principles to an understanding of how atherosclerosis leads to heart disease and death.

Beyond this basic competency, several subobjectives would certainly be desirable.

Optional Subobjectives.--Explain how vascular heart disease can progress while remaining entirely free of symptoms for many years.

Distinguish the microscopic differences between exercise-induced angina and unstable angina.

Contrast the behavior of myocardium that has been subjected to chronic ischemia alone with that of reperfused myocardium following therapy for infarction.

Contrast the immediate and long-term physiologic challenges of myocardial infarction.

Diagnostic Medicine

Competency.--The competencies discussed above are concerned with theory: how do we categorize, interpret, and predict disease behavior from underlying principles? A clinician in practice is less concerned about generalization. Diagnosis and patient management require the student to learn how to apply knowledge of disease mechanisms and processes to the unique patient at hand. Both induction (to allow generalization and prediction) and deduction (to interpret gaps in knowledge and make sense of findings) are tools of the physician. We are especially concerned that students acquire the skills needed to make diagnostic and therapeutic decisions accurately and economically. Toward this end, we propose a clinical competency in diagnostic medicine. History and physical examination reveal signs and symptoms that the clinician uses to focus on the clinical problem. When these alone are insufficient to yield a reliable conclusion, it is necessary to order laboratory or imaging tests. The student must discern from the clinical presentation the appropriate diagnostic tests (laboratory and imaging) to provide a diagnosis that will enable optimal treatment. The efficient and effective use of clinical laboratory tests, that is, the right test at the right time, not only optimizes the use of the health care dollar but also improves clinical outcome. The student can begin learning the proper use of clinical laboratory tests to enable diagnosis and optimal treatment selection early and throughout medical school.

Special attention should be made to introduce the autopsy as a valuable type of laboratory test. It plays an essential role in quality assurance and patient safety. Early experience with autopsy, in medical school, can also provide the student with the valuable experience of considering the death of a patient, and the issues of death reporting and medical-legal concerns.

Teaching Effective Laboratory Test Utilization.--The

Affordable Care Act and the development of accountable care organizations and pay-for-performance models are driving health care systems to deliver better outcomes at lower costs. This will require all physicians to have a better understanding of the branch of pathology concerned with laboratory diagnostics and test utilization. We intend to expand the teaching of diagnostic medicine throughout the 4 years of medical school in a way that makes it available to all students at an experience-appropriate level. To accomplish this we will develop learning objectives that first teach the students to evaluate the limitation of diagnostic tests. Once students know how to evaluate the usefulness of a test, we can teach them how to use their basic understanding of pathophysiology in the clinical setting. The student needs to develop a thought process that integrates data from clinical signs and symptoms into a working clinical diagnosis that can be confirmed using the proper diagnostic tests. The learning objectives for this competency will establish the essential elements that all medical students should know. A future goal will be to develop an online interactive course that will teach optimal laboratory utilization, incorporating knowledge of basic science, patient safety, health care economics, and clinical outcome.

Example.--A sample learning objective that could be used in the first year of medical school to teach how to evaluate diagnostic tests follows.

Learning Objective.--Apply knowledge of pathology and statistics to determine the utility of a laboratory test in making a diagnosis. For example, explain how the measurement of a myocardial protein in serum could and should be used in the diagnosis of myocardial infarction.

All physicians should have a minimal appreciation of the statistical treatment of data that underlies false-positive and false-negative laboratory results.

In cancer diagnosis, the student should be able to identify the tests required to make a diagnosis and guide therapy. Here the subobjectives could explore the technology of testing and the impact on resource utilization and clinical outcome. The optional subobjective below is an example.

Optional Subobjective.--Contrast the use of morphology, immunohistochemistry, and DNA mutational analysis in diagnosing lung cancers and guiding therapy. (6)

A set of learning objectives for diagnostic medicine is available at www.apcprods.org/ume-umeds/learningobjectives. The learning objectives will continue to be developed by a nationwide representation of pathologists. In addition, we plan to design cases to emphasize clinical reasoning that will complement teaching throughout the medical school curriculum from the introduction to the patient in the first year to complicated decision making for senior medical students. The cases will review basic concepts in the context of a clinical case that will teach the effective use of laboratory diagnostics to enable the student to reach a diagnosis and develop an optimal treatment plan for the patient. Because this online method of teaching moves away from time-based education, it allows students to learn at their own pace through independent study and to repeat segments of training as needed while also making the best use of clinicians' time in the balance between education and practice. Access to the proposed learning tool allows the student to experience any case at any time and to return to the learning experience whenever necessary.

COMMENT

Why are we making the effort to create and curate competencies in pathology? In the narrowest view, we do this because it is now mandated by the Liaison Committee on Medical Education, the organization that accredits medical schools in the United States and Canada. The standards for accrediting medical education programs (as described in "Functions and Structure of a Medical School" (5)) specify, in objective ED-11, that "the curriculum of a medical education program must include content from the biomedical sciences that supports students' mastery of the contemporary scientific knowledge, concepts, and methods fundamental to acquiring and applying science to the health of individuals and populations and to the contemporary practice of medicine." (5) Pathology is specifically named among the scientific disciplines to which this standard relates. Thus, whether pathology is taught as its own course or is amalgamated into integrated programs, the content of pathology is required. Our efforts in this manuscript begin a process that will help define those aspects of pathology we as a community will define as essential.

Of course there are broader reasons for this effort. Specifying learning objectives is a tool the value of which is well established in the literature of pedagogy. There are 3 far-reaching goals for these efforts (as summarized from Knowing What Students Know: The Science and Design of Educational Assessment (7)). They are: (1) Improve the teaching and learning from the perspective of the student. (2) Improve the quality of assessment of individuals, including criteria for licensure. (3) Improve the opportunity for large-scale assessment, providing opportunity for institutional and societal feedback. From our perspective, we see value in all these categories emerging from this effort.

As alluded to earlier, the trajectory of medical education appears to be one of decreased emphasis on large-format lecture and increasing degrees of team-based learning incorporating recorded media, online simulations, and live access to text and graphic data. This will reduce the importance of pure factual recall in lieu of the ability to follow associated ideas and interact with databases. Rather than rewarding a student who knows something in preference to another who knows nothing, the ready availability of a torrent of data demands more of a student's ability to discriminate the quality of the information at hand and assimilate data for diagnosis and treatment. We pathologists are not in a position to make the world according to our desire, but we can shape the discourse that determines what we feel is essential for all medical student graduates to understand. This alone will have a significant impact on the shape of medical school education in the foreseeable future.

The development of learning objectives as outlined in this article is supported by the Association of Pathology Chairs, in part through a grant from the Academic Mission Group fund (a legacy of the Universities Associated for Research and Education in Pathology).

References

(1.) Flexner A. (1910), Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching, p. 346, OCLC 9795002 Available online: http://www.carnegiefoundation.org/publications/ medical-education-united-states-and-canada-bulletin-number-four-flexner-report- 0. Accessed September 18, 2013.

(2.) Irby DM, Cooke M, O'Brien BC. Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Acad Med. 2010; 85(2):220-227.

(3.) Association of American Medical Colleges; Howard Hughes Medical Institute. Scientific foundations for future physicians. http://www.hhmi.org/ grants/pdf/08-209_AAMC-HHMI_report.pdf. Published 2009. Accessed July 28, 2013.

(4.) Morrison G, Goldfarb S, Lanken PN. Team training of medical students in the 21st century: would Flexner approve? Acad Med. 2010; 85(2):254-259.

(5.) Liaison Committee on Medical Education. Functions and structure of a medical school: standards for accreditation of medical education programs leading to the MD degree. http://www.lcme.org/functions.pdf. Published 2013. Accessed July 28, 2013.

(6.) Lindeman NI, Cagle PT, Beasley MB, et al. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Arch Pathol Lab Med. 2013; 137(6):828-860.

(7.) Pellegrino JW, Chudowsky N, Glaser R, eds; Committee on the Foundations of Assessment. Knowing what Students Know: The Science and Design of Educational Assessment. Washington, DC; National Academy Press: 2001. http:// www.nap.edu/openbook.php?isbn=0309072727. Accessed July 28, 2013.

Moshe Sadofsky, MD, PhD; Barbara Knollmann-Ritschel, MD; Richard M. Conran, MD, PhD, JD; Michael B. Prystowsky, MD, PhD

Accepted for publication August 22, 2013.

From the Department of Pathology, Albert Einstein College of Medicine, Bronx, New York (Drs Prystowsky and Sadofsky); and the Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, Maryland (Drs Knollmann-Ritschel and Conran).

The authors have no relevant financial interest in the products or companies described in this article.

The opinions expressed are those of the authors and do not reflect the official positions of the Uniformed Services University or the Department of Defense.

Reprints: Michael B. Prystowsky, MD, PhD, Department of Pathology, Belfer 713, Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461 (e-mail: Michael.Prystowsky@ einstein.yu.edu).
Pathologists Contributing to the Online Competency Document

Last Name            First Name     Degree(s)

Atkinson             James         MD, PhD
Baerer               Elaine        MD, PhD
Borowitz             Michael       MD, PhD
Boyer                Philip        MD, PhD
Cao                  Jeffrey       MD
Carnevale            Kevin         MD
Conran               Richard       MD, PhD, JD

Evans                Maria         MD
Findeis-Hosey        Jennifer      MD
Flanagan             Melina        MD
Ford                 Jason         MD
Galli                Steve         MD
Gandour-Edwards      Regina        MD
Geiss                Roger         MD
Gohara               Amira         MD
Goldman              Bruce         MD
Gorstein             Fred          MD
Harter               Josephine     MD
Hernandez            James         MD, MS
Hitchcock            Charles       MD, PhD
Howell               Lydia         MD
Husain               Mujtaba       MD
Joseph               Lija          MD
Kane                 Agnes         MD, PhD
Kluzak               Thomas        MD
Knollmann-Ritschel   Barbara       MD

Kumar                Vinay         MD
Laposata             Michael       MD, PhD
Libien               Jenny         MD, PhD
Louis                David         MD
Magid                Margret       MD
Magnani              Barbarajean   MD, PhD
McGrath              Cindy         MD
Olson                Kristin       MD
Parslow              Tris          MD, PhD
Peiper               Stephen       MD
Prystowsky           Michael       MD, PhD
Pullman              James         MD, PhD
Ramachandran         Raga          MD, PhD
Rendi                Mara          MD, PhD
Richter              Sandra        MD
Robinson             Mary Jo       DO
Roth                 David         MD
Sadofsky             Moshe         MD, PhD
Schiffhauer          Linda         MD
Smith                Brian         MD
Tomaszewski          John          MD
Troxell              Megan         MD, PhD
Villanueva-Siles     Esperanza     MD
Wagar                Elizabeth     MD
Weissman             David         MD
Wheeler              Tom           MD
Whitney-Miller       Christa       MD
Wilkinson            David         MD, PhD
Williams             Jim           MD
Yang                 David         MD
Yeaney               Gabrielle     MD

Last Name                                School

Atkinson             Vanderbilt University
Baerer               University of New Mexico
Borowitz             Johns Hopkins University
Boyer                University of Colorado
Cao                  Loma Linda University
Carnevale            Des Moines University
Conran               Uniformed Services University of the
                       Health Sciences
Evans                Kirksville College of Osteopathic Medicine
Findeis-Hosey        University of Rochester
Flanagan             West Virginia University
Ford                 University of British Columbia
Galli                Stanford University
Gandour-Edwards      University of California, Davis
Geiss                University of Illinois, Peoria
Gohara               University of Toledo College of Medicine
Goldman              University of Rochester
Gorstein             Thomas Jefferson University
Harter               University of Wisconsin, Madison
Hernandez            Mayo Clinic, College of Medicine
Hitchcock            The Ohio State University
Howell               University of California, Davis
Husain               University of Central Florida
Joseph               Boston University
Kane                 Brown University
Kluzak               University of Kansas
Knollmann-Ritschel   Uniformed Services University of the
                       Health Sciences
Kumar                University of Chicago
Laposata             Vanderbilt University
Libien               The State University of New York, Downstate
Louis                Massachusetts General Hospital
Magid                Mount Sinai Hospital
Magnani              Tufts University
McGrath              University of Pennsylvania
Olson                University of California, Davis
Parslow              Emory University
Peiper               Thomas Jefferson University
Prystowsky           Albert Einstein College of Medicine
Pullman              Montefiore Medical Center
Ramachandran         University of California, San Francisco
Rendi                University of Washington
Richter              Cleveland Clinic
Robinson             Pacific Northwest University
Roth                 University of Pennsylvania
Sadofsky             Albert Einstein College of Medicine
Schiffhauer          University of Rochester
Smith                Yale University
Tomaszewski          The State University of New York, Buffalo
Troxell              Oregon Health & Science University
Villanueva-Siles     Montefiore Medical Center
Wagar                University of Texas, MD Anderson Cancer Center
Weissman             Robert Wood Johnson University Hospital
Wheeler              Baylor University
Whitney-Miller       University of Rochester
Wilkinson            Virginia Commonwealth University
Williams             West Virginia University
Yang                 University of Wisconsin
Yeaney               University of Rochester

Last Name                          Location

Atkinson             Nashville, Tennessee
Baerer               Albuquerque, New Mexico
Borowitz             Baltimore, Maryland
Boyer                Aurora, Colorado
Cao                  Loma Linda, California
Carnevale            Des Moines, Iowa
Conran               Bethesda, Maryland

Evans                Kirksville, Missouri
Findeis-Hosey        Rochester, New York
Flanagan             Morgantown, West Virginia
Ford                 Vancouver, British Columbia, Canada
Galli                Stanford, California
Gandour-Edwards      Sacramento, California
Geiss                Peoria, Illinois
Gohara               Toledo, Ohio
Goldman              Rochester, New York
Gorstein             Philadelphia, Pennsylvania
Harter               Madison, Wisconsin
Hernandez            Phoenix, Arizona
Hitchcock            Columbus, Ohio
Howell               Sacramento, California
Husain               Orlando, Florida
Joseph               Boston, Massachusetts
Kane                 Providence, Rhode Island
Kluzak               Wichita, Kansas
Knollmann-Ritschel   Bethesda, Maryland

Kumar                Chicago, Illinois
Laposata             Nashville, Tennessee
Libien               Brooklyn, New York
Louis                Boston, Massachusetts
Magid                New York, New York
Magnani              Boston, Massachusetts
McGrath              Philadelphia, Pennsylvania
Olson                Sacramento, California
Parslow              Atlanta, Georgia
Peiper               Philadelphia, Pennsylvania
Prystowsky           Bronx, New York
Pullman              Bronx, New York
Ramachandran         San Francisco, California
Rendi                Seattle, Washington
Richter              Cleveland, Ohio
Robinson             Yakima, Washington
Roth                 Philadelphia, Pennsylvania
Sadofsky             Bronx, New York
Schiffhauer          Rochester, New York
Smith                New Haven, Connecticut
Tomaszewski          Buffalo, New York
Troxell              Portland, Oregon
Villanueva-Siles     Bronx, New York
Wagar                Houston, Texas
Weissman             New Brunswick, New Jersey
Wheeler              Houston, Texas
Whitney-Miller       Rochester, New York
Wilkinson            Richmond, Virginia
Williams             Morgantown, West Virginia
Yang                 Madison, Wisconsin
Yeaney               Rochester, New York
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Author:Sadofsky, Moshe; Knollmann-Ritschel, Barbara; Conran, Richard M.; Prystowsky, Michael B.
Publication:Archives of Pathology & Laboratory Medicine
Date:Mar 1, 2014
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