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More Structure, Rigor Needed in Peripheral Blood Smear Training

May 16, 2023

June 2023

Thomas R. Collins

Thomas R. Collins is a medical journalist based in West Palm Beach, Florida.  

Peripheral blood smears can be performed far faster than advanced laboratory analyses – such as flow cytometry, cytogenetics, and next-generation sequencing – needed for diagnosis of acute leukemia and other diseases, allowing for more a timely diagnosis that could set a patient on a path to prompt treatment or avoid going down the wrong treatment path. Training in the review of peripheral blood smears in graduate hematology education should be done with a structured approach and with an emphasis on mastery of cases that could avert imminent clinical decompensation, according to a paper published in Blood Advances.

While trained and experienced clinicians can identify disease on sight after viewing a sample through a microscope, the required lab analysis can often take several days. The Accreditation Council of Graduate Medical Education mandates competency in interpretation of peripheral blood smears, but there is no “gold standard” for this skill, according to Matthew Chase, MD, of Beth Israel Deaconess Medical Center in Boston, and colleagues. Similarly, there are no peer-reviewed recommendations on how to teach peripheral blood smear review.

Dr. Chase said that although his center has a strong classical hematology program, it, like other institutions, lacks a structured training program for reading blood smears.

“I and most of my co-fellows would always feel like we didn’t know enough and we should know more, but there’s no way to determine when you’ve learned enough or when you’re good enough at this,” he said. “It was a clear hole in our education for a task that we use daily when we’re on the consult service and in the clinic.”

To address this gap, the researchers convened a multi-institutional focus group to establish the core components of an assessment tool. The focus group included academic hematologists well-versed in using peripheral blood smears in clinical practice and teaching the technique.

To generate consensus statements, researchers used constructivist grounded theory and the nominal group technique. Prompted by questions, the group discussed topics such as best practices for peripheral blood smear review and what constitutes competency. The text of their conversation was analyzed for categories such as morphology, diagnoses, and cell types to generate the consensus statements.

This format, Dr. Chase said, was used to allow “people to talk as much as they want and go into as much depth as they want.”

A main message from the group’s discussions was that this is an essential part of a hematology fellow’s education.

More specifically, the group emphasized the importance of identifying the small subset of disorders that can lead to rapid death – for instance, acute leukemia or thrombotic thrombocytopenia purpura or other thrombotic microangiopathies.

“Hours can be very important in those situations, and peripheral blood smear is absolutely necessary for those,” Dr. Chase said.

The first goal is to use these components to create an assessment tool that is validated as proof of concept and can be used by other institutions in an open-source format, he said. Beyond that, he hopes the American Society of Hematology might adopt the tool so that peripheral blood smear competency can be taught and assessed in a rigorous way.

Any conflicts of interest declared by the authors can be found in the original article.


Chase ML, Drews R, Zumberg M, et al. Consensus recommendations on peripheral blood smear review: defining curricular standards and fellow competency [published online, 2023 Mar 17]. Blood Adv. doi: 10.1182/bloodadvances.2023009843.


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