- The Accreditation Council for Graduate Medical Education requires that anatomic pathology residency programs have sufficient volume and variety of material available for educational purposes to ensure that each resident examines at least fifteen hundred cytopathology specimens during his or her course of training in anatomic pathology. This material must include a variety of both exfoliative and aspiration specimens.
- Likewise with the goal of ensuring a reasonable expectation that all residents will achieve competency, the American Society of Cytopathology recommends a cumulative minimum of not less than three months training in cytopathology during each resident’s course of training in anatomic pathology. This training should be offered in multi-week segments and distributed over each resident’s period of training in anatomic pathology a) to avoid loss of skill by lack of use and b) to facilitate assimilation of cytopathology specific diagnostic skills and concepts at all levels of sophistication achieved over the course of residency training. A pathologist with cytopathology certification, fellowship training, or equivalent qualification should participate in each resident’s training in cytopathology.
- Because cytopathology training in medical school is already less extensive than histopathology, and pathology residency training time allotted to cytopathology is also less than that for histopathology, the usual method of teaching histopathology, which relies on current case material, does not suffice to teach cytopathology. New residents in anatomic pathology are truly novices in cytopathology and, though the teaching of cytopathology should still be primarily at the microscope, organized teaching sets as well as current cases should be utilized, supplemented by didactic lectures and independent study of textbooks, journal articles, and audiovisual materials.
- Initial rotations in cytopathology should therefore be surveys with balanced emphasis between gynecologic and non-gynecologic specimens, recognizing that cytotechnologists will signout most gynecologic cases, leaving pathologists with proportionally increased responsibility for non-gynecologic cytopathology. Graduated responsibility for residents in cytopathology should commence with acquisition of advanced beginner status at the end of these initial rotations, with progression to competency by the end of their course of training in anatomic pathology.
The distinction between residency training and fellowship training in cytopathology is in the depth rather than in the breadth of the trainee’s understanding and experience: a well trained resident is competent safely and effectively to diagnose or to refer all usual cytopathology specimens; a well trained fellow is proficient in the diagnosis of all usual cytopathology specimens. Unusual specimens in all areas of diagnostic pathology will occasionally require consultation even among expert pathologists.
Specific area goals and objectives of training in cytopathology include the following:
Skill Level I (Learning of those skills necessary to move from novice to advanced beginner; from basic acquaintance with cytopathology to readiness to commence independent learning of cytopathology.)
- Gynecologic cytopathology: familiarity with current specimen sampling devices, preservation modalities, and preparatory processes, including conventional smears and liquid based preparations, and the Papanicolaou staining technique; understanding of the principles and application of Human Papilloma Virus probe analysis. Screening of gynecologic cytopathology specimens encompassing assessment of adequacy and the diagnostic spectrum from normal through reactive, infectious, dysplastic and malignant diagnoses, and familiarity with the use of the Bethesda System for the diagnosis and signout of gynecologic cytopathology cases.
- Non-gynecologic cytopathology: familiarity with the various types of specimens, methods of sampling, preservation techniques, and laboratory preparatory processes, including the indications for and preparation of conventional smears, liquid based preparations and cell blocks, and Romanowsky staining techniques. Screening of a broad range of non-gynecologic specimen types including fine needle aspiration specimens encompassing assessment of adequacy, normal and a wide spectrum of abnormal cases.
Skill Level II (Learning of those skills necessary to move from advanced beginner to competent practitioner; from independent learning of cytopathology to readiness to commence safe practice of cytopathology.)
- Rapid evaluation of cytopathology specimens: familiarity with the rapid interpretation and triage of specimens, including determination of adequacy and necessary ancillary techniques, and appropriate collection of materials for such techniques.
- Fine needle aspiration biopsy: familiarity with the technical aspects of correct performance of fine needle aspiration biopsy, including the instruments and materials needed to perform fine needle aspiration biopsies, preparation of conventional smears and collection of materials with proper handling for the various laboratory preparatory processes described above for non-gynecologic cytopathology and for the various ancillary anatomic pathology techniques described below.
Residents should learn the clinical aspects of correct performance of superficial fine needle aspiration biopsy, including appropriately taking history, correctly obtaining informed consent, competently examining the lesion to be biopsied, preparing the patient and biopsy instruments, physically procuring the specimen, and preparing and staining the smears, with preliminary interpretation of the smears and appropriate after-care of the patient.
- Ancillary anatomical pathology techniques applicable to cytopathology: familiarity with both principles and application of automated screening devices as well as with the use of image analysis, immunocytochemistry, flow cytometry, cytogenetics, electron microscopy, and molecular studies (FISH; PCR). Residents should learn about the application of these techniques to cytopathology predominantly in the setting of the cytopathology laboratory, though the time allocated to teaching the principles of these techniques should not come from that assigned for learning diagnostic cytopathology.
- Laboratory management: familiarity with the concepts of quality control, quality improvement, risk management, and adherence to federal and state regulations as they pertain to the practice of cytopathology including correct coding for billing compliance.
- Reporting to clinical colleagues: familiarity with appropriate techniques for clearly, concisely, and completely communicating the diagnostic interpretation of a broad range of cytopathology specimens, including the limitations of such specimens and appropriate recommendations for further diagnostic work-up or clinical follow-up.
- Integration of cytopathology as a field within anatomic pathology: understanding the clinical utility of diagnostic cytopathology and its function in the overall activities of an anatomic pathology laboratory, and familiarity with the role of the cytopathologist in working with his or her clinical colleagues in the optimal provision of patient care. An integrated approach to cytopathology teaching should be adopted: when not on a cytopathology rotation, resident exposure to cytopathology should be continued with stress on its correlation with other services. The following are suggestions for an integrated approach:
- Routine performance of cytopathology touch-preparations at the time of frozen section.
- Review of prior or concurrent cytopathology cases during surgical pathology signout.
- Involvement with gynecologic and non-gynecologic cytopathology quality assurance (correlation with surgical pathology specimens).
- Presentation of cytopathology cases at intra and extra departmental conferences.
- Please see as well the Cytopathology I and II sections in the Recommendations on Curriculum Content and Evaluation of Resident Competency in Anatomic Pathology of the Association of Directors of Anatomic and Surgical Pathology, which are adapted with permission from these recommendations by the American Society of Cytopathology Taskforce on Residency Training in Cytopathology.
Approved April 29, 2003