Residency & Fellowship Programs: AP Rotations

Cytopathology

Cytogenetics Laboratory Director:


Genetics Diagnostic Laboratory Co-Director:


Cytogenetics Laboratory Location:



Recommended Rotation Length:
 

Residency Cytopathology Training at CUMC consists of a minimum of three 1-month rotations. Residents participate in the Fine-Needle Aspiration Service on all three rotations and have increased types of exfoliative specimens assigned to them on each successive rotation as stated below. The Goals and Objectives for each rotation apply accordingly. The specific assessment and evaluation of each resident’s rotation (1st, 2nd, and 3rd) are based on achieving the stated Goals and Objectives, which includes increased responsibilities as noted below.

Graduated responsibility for the FNA Service:

1st month:  The residents are always accompanied by a cytotechnologist or attending cytopathologist for the preparation and immediate assessment of the aspiration. Regarding the performance of superficial palpable FNAs, the resident first watches the attending perform one before being given the opportunity to perform the procedure. Practice on either resected surgical specimens or other appropriate material is encouraged but not required prior to aspirations on patients.

2nd month:  If the residents have shown competency in preparation of aspirates during their first rotation, then they may independently prepare the aspirate material before the cytotechnologist or attending cytopathologist arrives for the interpretation.

3rd month:  Similar to 2nd month.

Graduated responsibility for exfoliative cytopathology:

1st month:   Emphasis on screening Gynecologic pathology/Pap Tests (plus FNAs). May also screen other non-gyn cases.

2nd month: Emphasis on Respiratory and Body Fluids (plus gyns and FNAs).

3rd month:  Emphasis on Urines and CSF (plus gyns, respiratory, body fluids, and FNAs).


GOALS

Medical Knowledge

Develop competence in both assessing adequacy and accurately diagnosing aspiration and exfoliative cytology specimens expected of a general anatomic pathologist.

Patient Care

  1. Perform fine-needle aspirations on superficial palpable masses or abdominal fat pads if the opportunity arises under proper supervision of a cytology attending.
  2. Develop competency in preparing direct smears on aspirate material (including when and how to separate the specimen for special studies such as flow cytometry).

OBJECTIVES

Patient Care

  1. Perform and interpret FNAs, including assessment of adequacy, immediate diagnosis, and proper specimen preparation techniques under the supervision of an attending.
  2. Effectively utilize the different slide preparations, i.e., air-dried Diff-Quik stain, alcohol-fixed Papanicolaou stain, ThinPrep, and formalin-fixed cell blocks.
  3. Effectively use special studies, including immunoperoxidase stains, flow cytometry, and HPV analysis on cytology specimens.

Medical Knowledge

  1. Develop basic skills in exfoliative and fine-needle aspiration cytology. This is determined by having the resident review cases and:
    1. Designate a specimen as adequate, adequate but limited by, or unsatisfactory/non-diagnostic. 
    2. Correctly diagnose cases as benign, atypical, suspicious, or malignant.
    3. Correctly diagnose lesions as non-neoplastic vs. neoplastic.
    4. List the differential diagnoses of specific morphologic patterns and lesions in specific sites.
    5. Explain pitfalls germane to each organ system and specimen type.
    6. Explain pitfalls of inadequate history and poorly prepared specimens, including air-drying, crush artifact, and obscuring blood.
  2. Effectively review or screen specimens from each organ system, beginning with gynecologic specimens and continuing as outlined below. Screening of FNAs commences with gynecologic specimens during the first month of cytology and continues throughout the subsequent rotations. The resident may be assigned cases on a daily basis by the cytopathology attending assigned to him/her. The number of cases assigned for a particular organ system may increase over the course of the screening period.
    1. Exfoliative gynecologic specimens:  cervical/endocervical specimens and vaginal specimens.
    2. Exfoliative respiratory specimens:  bronchial washings, bronchial brushings, bronchioloalveolar lavages, and sputums.
    3. Body cavity fluids:  pleural fluids, ascitic fluids, pelvic and abdominal washings.
    4. Urine:  voided, catheterized, ileal, bladder washings, urethral washings, and ureteral washings.
    5. Cerebral spinal fluid:  lumbar, Ommaya, ventricular.
    6. Fine-needle aspirations.
  3. Effectively utilize the different slide preparations, i.e.,  air-dried Diff-Quik stain, alcohol-fixed Papanicolaou stain, ThinPrep, and formalin-fixed cell blocks.
  4. Efficiently and rapidly interpret specimens obtained through radiologically-guided FNA.
  5. Perform and interpret FNAs, including assessment of adequacy, immediate diagnosis, and proper specimen preparation techniques under supervision of a cytology attending.
  6. Effectively use special studies, including immunoperoxidase stains, flow cytometry, and HPV analysis on cytology specimens.

Practice-Based Learning and Improvement

  1. Familiarize oneself with key issues of laboratory management, administration, government regulations, self-assessment and QA and QC procedures. This is accomplished in part by interactions with the attendings and technical supervisor of cytopathology if necessary.
  2. When feasible, participate in QA activities with attending that are reviewing cytology cases do not correlate with the subsequent histopathologic findings, and follow-up of FNAs either performed by the resident or on which the resident assisted in rendering a rapid interpretation.
  3. Attend departmental cytopathology conferences, including Cytopathology lectures presented by attending staff. These lectures may be glass slide teaching session, Power Point presentations, Journal Club, cyto-histologic correlation conference, and presentation of current research.
  4. Upon evidence of satisfactory progressive scholarship and professional growth, accumulate graduated responsibilities including independent preparation and assessment of adequacy of fine-needle aspirations performed by clinicians and radiologists prior to the cytology attending arriving on-site to supervise.

Interpersonal and Communication Skills

  1. Effectively and professionally communicate with patients when performing fine-needle aspirations.
  2. Effectively and professionally communicate with clinicians and radiologists when either performing fine-needle aspirations or preparing the direct smears and assessing adequacy for them.
  3. Work and communicate effectively with all members of the pathology department, particularly those on the cytology service, including attending staff pathologists, fellows, residents, cytotechnologists, and medical transcriptionists.

Professionalism

  1. Carry out daily work responsibilities in a reliable, timely manner and perform these duties competently.
  2. Effectively and compassionately interact with patients and families of patients in order to obtain informed consents for fine-needle aspirations of superficial palpable lesions.
  3. Commitment to:  a) attend sign-out and departmental cytology lectures, b) pursue independent study, so as to achieve competence in the field of cytopathology that is expected of an Anatomic Pathologist.

Systems-Based Practice

  1. Familiarize oneself with key issues of laboratory management, administration, government regulations, self-assessment and QA and QC procedures. This is accomplished in part by interactions with the attendings and technical supervisor of cytopathology if necessary.
  2. When feasible, participate in QA activities with attending that are reviewing cytology cases do not correlate with the subsequent histopathologic findings, and follow-up of FNAs either performed by the resident or on which the resident assisted in rendering a rapid interpretation.

ACHIEVING THE STATED GOALS & OBJECTIVES

The residents follow the structured monthly schedule that provides a systematic approach to learning the basics of cytopathology. Over the course of the expected two to three 1-month rotations in cytology, the residents are taught criteria for adequacy and diagnostic accuracy for each organ system in didactic sessions and at the multi-head microscope during daily sign-out. Rotating residents are expected to attend cytology lectures that are given by the cytopathology staff attendings.

Exfoliative cytopathology specimens are systematically provided to the residents for screening in the order listed above in Objectives. The specimens are then reviewed again with the attending cytopathologist, who provides additional teaching. Future organization may include screening of specimens prior to cytotechnologist screening, in which case the cytotechnologists may provide feedback and additional teaching.

The residents are taught proper FNA technique of superficial palpable masses and slide preparation of aspiration material in their first month rotation. This is accomplished by on-hands teaching by cytopathology attendings. They are responsible for rapid assessment of FNAs performed by clinicians and radiologically-guided FNAs performed by the interventional radiologists under the supervision of cytotechnologists and cytopathology attendings.

OUTLINE OF ROTATIONS

  1. Monthly cytopathology attendings’ schedules detailing each day’s service responsibilities and attending/resident pairing are provided to the rotating resident(s).
  2. Residents screen assigned cases and formulate their own diagnoses in writing.
  3. Exfoliative specimens are reviewed with the cytology attending, who provides feedback and instruction.
  4. Screening of assigned exfoliative material should be completed and returned to the cytology attending in a timely manner. If this is not possible because of other service responsibilities, i.e., FNA coverage, then the unscreened slides should be returned to the attending for sign-out at a time designated by that attending.
  5. FNAs that a cytotechnologist attended for immediate assessment may re-screened by cytotechnologists prior to sign-out if they so choose.
  6. FNAs should be screened and returned to the responsible attending within a reasonable period of time (same day; should be coordinated with the responsible attending). For cases not screened by the resident within the designated time period, the requisitions should be submitted for “pre-typing” during the completion of screening by the resident or the requisition and slides should be returned to the attending Cytopathologist.
  7. Residents are expected to attend daily sign-out with the designated attending.

SUPERVISION

Xiaowei Chen, M.D.   Tel: 305-8876

Interact and teach rotating residents and fellows during case sign-out. Provide direct and visual supervision for assessment of adequacy of fine-needle aspirations and performance of superficial palpable FNAs.

John P. Crapanzano, M.D.  Tel: 342-4188

Interact and teach rotating residents and fellows during case sign-out. Provide direct and visual supervision for assessment of adequacy of fine-needle aspirations and performance of superficial palpable FNAs.

Diane Hamele-Bena, M.D.   Tel: 305-0288

Interact and teach rotating residents and fellows during case sign-out. Provide direct and visual supervision for assessment of adequacy of fine-needle aspirations and performance of superficial palpable FNAs.

Anjali Saqi, M.D.  Directotor of Cytopathology    Tel: 305-4079

Interact and teach rotating residents and fellows during case sign-out. Provide direct and visual supervision for assessment of adequacy of fine-needle aspirations and performance of superficial palpable FNAs.

Chain of Command

The cytopathology attending staff monthly schedule that designates which cytologist(s) is responsible for each day’s service work, including gynecologic cytology, non-gynecologic cytology, and FNA Service, is provided to each resident. The cytologist(s) on service is the individual responsible for the residents’ supervision on that particular day.

Onsite Supervision of FNAs

The cytology attending staff member on service retains the overall obligation of supervision and goes to the FNA site either with the resident or after the cytotechnologist and resident initiate the process of immediate assessment. Cytotechnologists also provide onsite supervision to the residents covering the FNA Service.

Documentation

When residents perform superficial palpable fine-needle aspirations, the attending cytopathologist covering the FNA Service on that particular day signs his/her name under the procedure note in the patient’s chart. The procedure note, whether written in the patient’s progress notes or on the cytology report, always clearly states if the resident performed the FNA. If the resident did perform the procedure, then the procedure note also includes that the FNA was performed under the appropriate supervision, as defined in the NYPH GME Policies and Procedures.

Schedules

The monthly cytology attending staff schedule clearly designates the cytologist(s) responsible for each day’s service work and the cytologist(s) responsible for each day’s supervision of rotating resident(s). These schedules are given to the rotating residents at the beginning of each month.

WORK HOURS

  1. FNA Service days:  9:00 a.m. - 5:00 p.m.

  2. If there is advance notification that a FNA will take place before 9:00 a.m. or after 5:00 p.m. and a resident is assigned to an attending who is covering the FNA Service, then the resident should be available to prepare the slides and provide the immediate assessment with the attending.
  3. All other days:  9:00 a.m. - 5:00 p.m.

  4. If signout continues past 5:00 p.m., fellows (and residents) are expected to remain until signout is completed at the discretion of the attending and within the bounds of House Staff Work Hours Regulations (ACGME).
  5. There are no call or weekend responsibilities.

EVALUATIONS

The residents are formally evaluated by all of the attending cytopathologists on the web-based E*Value system. In addition, the cytology attendings and staff members may informally discuss each resident’s performance periodically. Any problems requiring immediate attention are addressed by the Cytology Service Director. It is understood that the Residency Program Director discusses the results of the evaluations with the residents at designated times throughout the academic year.

TEACHING COLLECTION

The residents may be asked to assist in collecting cytology cases with corresponding histology recuts for the teaching sets.  If there is sufficient material in the Cytolyt vials, then extra ThinPrep slides will be requested to add to the study in order to avoid using the original slides. The residents are encouraged to follow-up on their fine-needle aspirations and exfoliative cases and have extra slides prepared when feasible for the study set.

PAP TEST/ BIOPSY QA

The PAP test/biopsy QA cases, which are reviewed by designated attendings every few weeks, may provide the additional function of reviewing diagnostic criteria of squamous and glandular lesions of the cervix with the resident.  The rotating resident(s) may be asked to review these cases if the attending they are assigned to is currently responsible for the QA cases. 

SIGN-OUT

The residents cannot sign-out cases without the co-signature or supervision of an attending.    However, they do need to gain experience in signing-out cases. To accomplish this, senior rotating residents that have performed well may be given the opportunity to review cases that have already been screened by cytotechnologists prior to the cytology attending reviewing the cases. 

EDUCATIONAL RESOURCES

1. Slide Teaching Sets
The cytology laboratory has teaching sets that contain example of normal or diagnostic cases for all areas of cytopathology. Exfoliative specimens include gynecologic, respiratory, body cavity fluids, urine, cerebrospinal fluids, and gastrointestinal. Aspiration specimens include all major organ systems.

2. Cytopathology Library
There are numerous current cytopathology textbooks in the residents’ room that are at the disposal of all house-staff.

3. Multiheaded Microscope and Lectures
a. Multi-head microscope and Power Point didactic conferences are given periodically by cytology attendings throughout the academic year, covering all organ systems and types of preparations.
b. The cytopathologists teach daily at their dual-headed microscope during sign-out.
c. The Pap Test/biopsy QA duties performed by the attendings provides an opportunity to review discrepant cervical smear/ThinPrep and biopsy results in order to identify errors that may have occurred on initial review. An additional function of the conference is to evaluate diagnostic criteria of squamous and glandular lesions of the cervix so that pathological and histological correlations can be improved. Rotating pathology residents may join the responsible attending if they are paired together at that time.

4. Internet access
The residents’ computers have Internet access, which is a source of additional cytopathology study material that is posted by other institutions and cytology organizations.

5. Pathology and Cytology Meetings
The residents may attend the New York Pathological Society Meetings, the New York Society of Cytotechnologists meetings, as well as regional and national cytology or pathology meetings if they present abstracts.

 

 
 
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