Laboratory of Pathology - Staff

1. Patient Care
   The resident will learn the technical and clinical skills for the practice of cytopathology. Some of these skills include:
   
   
   1. Learn to recognize cytomorphologic features of different cell types and range of normal morphology
   2. Learn the appropriate use of ancillary techniques such as immunocytochemistry and electron microscopy in the work-up of diagnostic problems encountered in cytopathology
   3. Learn rapid triage of specimens in order to utilize patient material to best advantage in diagnostic work-up and avoid contamination of stains by highly cellular malignant fluids
   4. Learn to recognize cell patterns that indicate a possible infectious process in order to consider options such as sending material to microbiology and/or obtaining special stains for organisms
   5. Learn fundamentals of various specimen preparation techniques, including advantages and drawbacks of cytocentrifugation, membrane filtration, smears, and the new technology of monolayer Thin Preps
   6. Appreciate the advantages and drawbacks of different staining methods such as wet-fixed Papanicolaou versus air-dried modified Wright-Giemsa stains
   7. Learn proper specimen collection techniques for various specimen types including cervical/vaginal smears and fine needle aspiration (FNA) specimens
   8. Learn to perform fine needle aspirates of superficial palpable lesion
      
      
2. Medical Knowledge
   The resident will develop a fund of knowledge in cytopathology as well as how to apply this knowledge in his/her daily practice. Some of the tools used to achieve this include:
   
   
   1. Learn criteria of malignancy in various body sites and types of specimens
   2. Gain experience in screening of cytology specimens to detect possibly rare abnormal cells amid a predominance of normal cells
   3. Learn cytodiagnostic terminology for cervical/vaginal specimens
   4. Learn limitations of cytopathology diagnosis as compared to histopathologic diagnosis
      
      
3. Practice-Based Learning and Improvement
   The resident will learn to make effective use of conferences, lectures, review of interesting cases collection, and the reading of medical literature (texts, journals and other medical databases) related to cytopathology to inform his/her day-to-day practice.
   
   
4. Interpersonal and Communication Skills
   1. The resident will learn to communicate (written format and verbally) cytology related information effectively with health care providers, laboratory staff members, administrators, and other individuals in the course of his/her rotation. The communication must be clear, concise and accurate.
      
      
   2. The resident will learn to work as an effective member of a cytopathology health care team by striving to be responsible, cooperative and facilitating the tasks of other team members.
      
      
5. Professionalism
   The residents must learn to be courteous and respectful and to be collegial in all interactions with health care providers (clinicians, surgeons, nurses, etc.) as well as other members of the cytopathology health care team.
   
   
6. System-based Practice
   1. The resident must acquire knowledge of practice and health care delivery system and awareness of the role of cytology in the context of the greater health care system.
   2. The resident will develop an understanding of the general administrative and managerial aspects of a cytopathology laboratory, in part by:
      1. Learning the fundamentals of quality assurance methods applied to cytopathology
      2. Participating in a day-to-day administrative and managerial discussions in the cytopathology laboratory

The residents will rotate for 2 sequential months during the last 6 months of their first year of residency in the Cytopathology Section. Evaluation will be based on participation in tasks below.

1. The resident will be assigned to one cytotech per week and will be responsible for the screening of material with that technician sees. He/she will be expected to be available in the cytology section from 8:30 AM until 5:00 PM.
   
2. The resident will be expected to go with the cytotechnologist on all aspirates (deep and superficial) and will be expected to do at least one pass on all superficial aspirates.
3. The resident will be responsible for getting all appropriate follow-up on cytology cases that have related surgical pathology specimens.
4. The resident will be trained in cytopreparatory/staining techniques and will be called upon to prove proficiency for the preparation of cytospins, smears, Diff-Quik and PAP staining techniques, as well as special stains for organisms (GMS, AFB).
5. The resident is welcome to spend elective time in our section and will be encouraged to work on research projects with members of the cytology section.

In order to maximize the residents' learning and understanding of Cytopathology they are required to have completed several months on either autopsy or surgical pathology before they rotate through Cytopathology.

The first 2 months of the Cytopathology rotations are in-house at the NIH. During this time the resident gains experience in the preparation and microscopic examination of cytology material. The first few days on the cytology rotation the resident is assigned to the specimen preparatory area and is taught the essentials of the various types of cytology preparations and the philosophy behind them. They are also expected to become proficient in the preparation of cytospins, smears, Diff Quik stains and Grocott Methenamine silver stains.

The resident is expected to review all of the daily cytology material after it has been screened by the cytotechnologists. He/she may either do this alone or with the Cytopathology Fellow. After the cases are completed they are reviewed with the attending cytopathologist on service. During the sign-out the resident is also instructed in the utilization of routine and immunohistochemical stains on cytologic preparations.

During the NIH cytopathology rotations the residents have the opportunity on a daily basis to discuss relevant clinical aspects of the cases with the clinicians. Residents call clinicians to obtain additional history, if required, and call clinicians to report urgent diagnoses. Clinicians frequently visit the cytopathology laboratory to review their cases. Residents review cases with clinicians at a multiheaded microscope and illustrate pertinent findings.

Residents are instructed in FNA techniques by the Cytopathology Fellow and the attending on service. Their initial instruction takes place on table foods that simulate clinical samples (Orange, apple and liver placed sequentially into a hole in a sponge), which are then utilized for instruction in smear preparation. After this initial instruction residents are advised on the proper introduction of FNA on the clinical ward -- what to tell the patient regarding the procedure, limitations, possible side effects, etc. Residents are encouraged to participate actively on the FNA service and are encouraged to do at least 15 FNAs while on the service over 2 months. While participating on the FNA service they also take part in the immediate adequacy assessment that takes place on the ward.

Biopsies of previous and concurrent surgical pathology material are correlated with cytology cases on virtually all cases during sign-out when the material is available. The rotations at George Washington University (GWU) Medical Center are provided to present the residents with a spectrum of cytology that is a high volume in Gyn samples and more like that of a community hospital. During these 2 months off-ite, the residents' role is similar to those mentioned above. At GWU, the residents screen FNA material obtained in the clinic and rescreen all other specimens. They provide microscopic descriptions and diagnoses for each case and then review with the attending cytopathologist.

Cytopathologists are frequently called upon to consult on cases with the clinician. This interchange includes both discussing the clinical aspects of the cases as well as a microscopic review. It is customary for the resident to discuss the clinical aspects of the case with the clinician, relate the diagnosis to the clinician and also take part in the microscopic review. Generally it will be the attending or the fellow who runs the actual microscopic review. The resident may be called upon to present cytopathology cases at various clinicopathologic conferences while on the service, if the cytopathology fellow is not available. In this scenario, the attending will review all aspects of the case with the resident and fully prepare him or her for the presentation.

Although residents are expected to review all of the cytology cases while on the cytopathology service, rendering diagnosis and reviewing all of the cases with the attending or Fellow-on-service, the resident does not assume independent sign-out responsibility. The resident does, however, become trained in the performance of fine needle aspirations, and does perform fine needle aspirations under the supervision of an attending or fellow.

Residents rotate through the cytology section for 2 months during the first year at NIH and for 2 months at George Washington University Medical Center during the second year of residency. The resident is responsible for previewing all of the cases as time allows. The cytopathology attending who is on service is responsible for going over all aspects of all cases with the resident. Since the fellow is on service 75% of the time, this responsibility is partly enacted by him/her. This process involves training in performance of FNAs, triaging of specimens, morphologic review, ordering of special stains, communicating with clinicians, and discussion of the differential diagnosis. The cytology fellow is involved in the education of residents on an ongoing basis through case reviews, case presentation at regular working clinical/pathologic conferences and challenging case conferences. He/she is also responsible for giving a total of several formal resident lectures per year (three at NIH and one at NNMC). As time goes on during the year the fellow assumes graduated responsibility for the primary sign-out of cases. The resident does not assume independent sign-out responsibility for cytopathology cases.

4. On-Call Schedule

1. The resident is expected to be facile with cytopreparatory techniques that may be utilized during on-call assignments (e.g., preparation of smears, cytospins, Diff-Quik stain, GMS stain for fungus.
2. Ensure that the case is indeed a STAT (i.e., the patient needs an immediate diagnosis for treatment, and cannot wait until the next usual day of operation).
3. Call the anatomic pathology attending that is on-call, and review the case with that attending.
4. If after reviewing the slides, the on-call attending does not feel competent to make a diagnosis, then you may call the cytopathologist back-up beeper (104-4070-7). This service is provided as a courtesy and should be considered back up, not first line.

5. George Washington University Medical Center Rotation

During the second year of residency, the resident will spend 2 sequential months rotating through the Cytopathology Section at George Washington University (GWU). The focus will be on cervical/vaginal cytology and on the performance and interpretation of fine needle aspirations.

6. Additional Information

Further information about the Laboratory of Pathology (LP) can be found on our public Web site.   This site contains the detailed Specimen Collection Guide and LP Staff Directory. The LP Web site is a useful supplement to this manual.

 

 

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