Graduate Medical Education Training Programs

CYTOPATHOLOGY

Resident Rotation Summary

Rotation Philosophy and General Purpose Statement:

The cytopathology rotation at West Virginia University is designed to instruct trainees in cytology in a tertiary care, academic setting and a large community hospital. As they evaluate patient specimens, physicians in training are instructed in acquisition and preparation of cytologic specimens, diagnostic evaluation, and ancillary studies. By providing residents with increasing responsibilities and duties, as their level of training increases, the teaching faculty hope to instill in the resident the skills and tools necessary to develop a life-long course of continued professional development.

Teaching Faculty Members: 

West Virginia University

James E. Coad, M.D.

Linda L. Cook, M.D.

Barbara S. Ducatman, M.D.

Jeffrey A. Stead, M.D.

H. James Williams, M.D.

Charleston Area Medical Center

Ho-Huang Chang, M.D.

David A. Hansen, M.D.

William E. Mangano, M.D.

Milton J. Plata, M.D.

EDUCATIONAL GOALS AND OBJECTIVES:

The goals and objectives of the cytopathology experience are to prepare and enable residents to:

• Demonstrate competency in the procedures involved in work-up and diagnosis of cytopathology specimens in order to effectively practice cytopathology independently
• Demonstrate professional behavior in all situations.
• Demonstrate a commitment to reviewing and improving their practice patterns and to life-long learning.
• Demonstrate an understanding of the scientific basis of pathology and the ability to utilize the medical literature and modern techniques to provide accurate cytopathology diagnoses.
• Communicate effectively in verbal and written form with their clinical colleagues, administrative, technical, and clerical personnel.
• Explain the policies and regulations affecting health care (i.e., CAP accreditation, HIPAA, compliance to Medicare and billing regulations, etc.) 

REQUIRED COMPETENCIES, DUTIES AND RESPONSIBILITIES:

PATIENT CARE

Residents preview cytology cases prior to faculty sign-out and formulate their own diagnoses. Residents are expected to perform more independently and accurately as they progress through training. Their diagnoses are compared to faculty diagnoses (agree/partially agree/disagree) and collated monthly. In order to properly formulate concise and accurate differential diagnoses, residents:

• Gather essential and accurate clinical information about the patients on whom they review cytopathology specimens.
• Discuss the history with clinical housestaff and/or attending physicians.
• Review reports/slides of previous pathologic specimens and correlate current results with previous specimens.
• Review the online medical record when applicable.
• Residents are able to actively be involved with immediate evaluations of FNAs with the cytotechnology staff, including
• Preparation and interpretation of FNAs.
• Timely and effective communication with radiologists, surgeons, endocrinologists, and other clinicians.

Residents demonstrate competence in the performance of procedures considered essential for cytopathology practices, including:

• Explain the principle and utilize a variety of cytopreparatory techniques such as direct smears, thin-layer, and cell blocks.
• Perform the interpretation of slides independently for both gynecologic and a wide variety of non-gynecologic cytology specimens.
• Concise and accurately state gross descriptions of cytopathology cases.

Residents make informed decisions regarding diagnostic workup of cytology specimens:

• They consider the use of additional studies such as special stains and immunohistochemistry, based on patients’ clinical history, up-to-date scientific evidence gleaned from textbooks, journal articles, internet-based searches, and clinical judgment. 
• They are expected to be able to handle more difficult cases and their approach and diagnosis should more closely correlate the final diagnosis as they progress through their residencies.
• Perform searches via available information technology (hospital and laboratory information systems, internet-based literature searches)
• To perform the workup and diagnosis of cytopathology patient specimens.
• To help educate clinicians by providing relevant literature references.

Residents work with health care providers, in the generation of accurate and clinically useful cytopathology reports and effective communication of results to clinicians.

Residents can independently perform FNAs on a variety of palpable locations.

Evaluation:

• Rotation evaluation

  Statistical analysis of a resident portfolio of cases generated by COPATH with concordance of resident vs. attending pathology diagnoses and cases screened (this is reviewed with regard to PGY)

• Global evaluation
• 360o evaluation

MEDICAL KNOWLEDGE

• Residents demonstrate an investigative and analytical thinking approach to clinical situations, including:
• Development of reasonable and complete differential diagnoses for cytopathology cases based on the available clinical information, gross and microscopic features, and current published information.
• As part of workup of cases, suggest appropriate additional testing (special stains, immunohistochemical studies, and further clinical testing such as serology, etc.) if applicable.
• Formulation in a comprehensive, cohesive, and coherent fashion for the above differential diagnoses and discussion of cytopathologic findings in the final cytopathology report.
• Explain and apply the basic and clinically supportive sciences which are appropriate to the specialty of cytopathology including:
• Explain epidemiology of various infections and neoplastic diseases during discussion of cytopathology cases, and use of such knowledge to formulate cytopathologic diagnoses.
• Explain the clinical presentations and manifestations of various diseases during discussion and workup of cytopathology cases, and use of such knowledge to formulate cytopathologic diagnoses.
• State the principle of basic histologic and immunohistologic stains, including biochemical and immunologic principles, methods, and applications.

Evaluation:

• Rotation evaluation

  Cytopathology score for the in-service examination compared to national means

• Global evaluation

PRACTICE-BASED LEARNING

Residents demonstrate the ability to analyze practice experience and perform practice-based improvement activities using a systematic methodology, including:

• Resident are given results of their concordance with staff diagnoses and are expected to use this information to direct their studying and improve their diagnostic acumen.
•  Senior residents, actively participate in monthly Anatomic Pathology Quality Assurance Committee meetings, learning how to identify and report on a variety of QA monitors (case turnaround time, 10% review and 5 year look back on pap tests, cyto-histologic correlation, etc.).
• ·Locate, appraise, and assimilate evidence from scientific studies related to patients’ health care problems, including:
• Perform literature search and review to find relevant scientific references to aid in the workup of cytopathology cases (computer-based searches).
• Obtain and incorporate information about their patient population (via COPATH computer searches and medical records chart review) for clinicopathologic study of selected diseases.
• ·Residents demonstrate competency in the use of information technology to manage information, access on-line medical information, and support their own education, including:
• Accessing of patient clinical information and previous pathology accessions via Medsite and Copath.
•  Performance of computer searches of the medical literature.
•  Demonstrating competence in the use of digital imaging technology. 

Residents actively participate in the teaching of medical students and other health care professionals rotating through the anatomic pathology section, including:

• Teaching students and residents from other disciplines during review of cytopathology cases
• Evaluation:
• Rotation evaluation

  Review of resident portfolio yearly to assess improvement and discuss self-education

INTERPERSONAL AND COMMUNICATION SKILLS

Residents demonstrate effective communication with other health care providers, patients, and patients’ families by:

• Presenting cases at in-house tumor boards and conferences under direct faculty supervision.
• Interacting with clinicians, patients, and patients’ families during performance of immediate cytopathology evaluations and by providing support to clinicians and families during on-call assignments.

Evaluation:

• Rotation evaluation
• Global resident evaluation
• 360o evaluation

PROFESSIONALISM

•  Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
• Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society with prompt response to calls from the cytopathology lab when on-call,and accountability for this.
• Exhibit a commitment to excellence and on-going professional development by utilizing the study materials within the department including the slide file, the image database, and books and journals for their own professional advancement.
• Demonstrate a commitment to ethical principles pertaining to provision of pathology services, confidentiality of patient information, informed consent, and business practices
• Demonstrate appropriate behavior with the faculty, clinicians, their peers, and the administrative, technical and clerical staff of the hospital.

Evaluation:

• Rotation evaluation
• 360o evaluation
• Global evaluation

SYSTEMS BASED PRACTICE

• Residents must demonstrate an awareness of, and responsiveness to the larger context and system of health care and the ability to call on system resources to provide pathology services that are of optimal value.
• Residents are expected to explain how cytopathology diagnoses affects health care decisions for patients and the health care system.
• Explain the types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.
• Practice cost-effective health care and resource allocation that does not compromise quality of care, understanding the need for and cost of special stains, immunohistochemistry and other adjunct techniques.
• As senior residents attend the AP QA committee meetings to be able to explain how to partner with the administrative and technical staff to assess, coordinate, and improve health care and know how these activities can affect system performance
• Residents may also inspect the cytopathology laboratory during a CAP inspection.

Evaluation:

• 360o evaluation
• Global evaluation

Supervisory Guidelines for Patient Care and Specimen Handling

The resident may obtain FNA specimens under direct faculty supervision. Residents discuss cytopreparatory techniques for unusual cases with the attending faculty member and cytology supervisor. The faculty pathologist is responsible for the final diagnoses of all cytopathology cases.

The on service teaching faculty members are physically present during standard operating hours; faculty members not physically present are rapidly available by phone or pager. At all times, a supervising faculty member is on-call for evening and weekend questions. No diagnosis is communicated to the clinicians before a faculty member has evaluated the case.

Daily Duties and Responsibilities - Cytopathology

Based on their level of training, residents are provided increasing autonomy with close faculty supervision. The residents should preview all specimens during their rotation. This includes review of the pertinent clinical history; performing FNAs when appropriate, review of the specimen for adequacy on site, discussion with the technical staff for cytopreparatory techniques when necessary, and screening and diagnosis of the slides. The residents also participate in any special procedures performed at the time of FNA, such as collection of material for flow cytometry.

Residents are required to screen and review the microscopic findings of each specimen. They are expected to preview as many of their cases as possible prior to signing them out. The resident has up to 1 p.m. (or the time designated by the faculty member) to preview the cases and formulate a cogent diagnosis. At this time, the resident will review the cases with the cytopathologist. With faculty guidance, residents are responsible for directly deciding what additional ancillary studies may be necessary in order to complete each case.

Each resident will be graded as to “agree, partially agree, or disagree” for each microscopic diagnosis. The resident will receive a written evaluation with summary statistics for him/herself compared to the overall resident mean. The resident can review all the cases in which he/she had a discrepancy with the faculty pathologist by requesting a print-out of such cases from Mr. Ed Grey, the informational technology specialist for Co-Path. The number of cases reviewed independently and the accuracy of both cytology diagnoses as measured by percentage agreement and the rotation evaluation are expected to increase with increasing resident seniority.

Surgical Pathology fellows follow basically the same schedule as residents. In addition, fellows may preview their cases and hand these to the supervising faculty when completely worked up. They do not need to review them with the attending faculty. However, fellows will be expected to function with minimal discrepancies with the faculty.

Opportunities to Function as Consultant to Other Physicians

Residents have the responsibility, under faculty supervision, of discussing the interpretive consultative reports on cytopathology cases with appropriate members of the clinical/surgical teams. Through their discussions with the clinical team members, the residents have the opportunity to directly impact patient care. Other departments on the WVUH campus, with ACGME approved post graduate training programs include, but are not limited to the following: Anesthesiology, Internal Medicine, Family Practice, Neurosurgery, Obstetrics & Gynecology, Ophthalmology, Otolaryngology, Orthopedic Surgery, Pediatrics, Radiology, Surgery, and Urology.

During the rotation the residents are exposed to laboratory correlation studies. These will include, but are not limited to, the following:

• Correlation of fine needle aspiration studies with subsequent surgical pathology specimens.
• Correlation of cervical Pap test findings with cervical biopsies.
• Correlation of ancillary studies with cytology in the work-up of lymphomas and hematologic disorders.
• Correlation of radiologic studies with FNA results.

On Call Duties:

• The residents communicate with surgeons and others who require rush processing for cytology/FNA specimens on evenings and weekends.
• The residents assist in obtaining and preparing rush cytology specimens whenever possible, particularly FNAs with direct smears.
• Residents assist the faculty in reaching accurate cytologic diagnoses, formulating their own prior to faculty review whenever possible.
• Residents communicate results of cytology cases to the clinical staff and answer questions about the diagnostic and prognostic implications.

During this rotation the residents will on average have at least one out of every seven days free of hospital duties. Due to the at-home nature of call and the limited number of emergencies, the call duties are constructed in the following fashion. The residents are on at-home/pager call every other week. The on-call periods last from 7:00 a.m. on Monday morning through the following weekend, ending at 7:00 a.m. on the subsequent Monday. While on-call, residents are supervised by a West Virginia University Teaching Faculty Member, who is available at all times, either via their office phone, pager, or home phone. On-call activities are reviewed with the residents on an on-going basis as evening and weekend calls are received. A faculty member is always present when a final diagnosis is established and at any time before, as necessary.

During the on-call period, the resident is responsible for handling clinical requests that arise during off hours, emergent operating room consultations, weekend rush biopsies, emergency off-hour autopsies with the approval of the on-call staff pathologist, and autopsies, which present before 2:00 P.M. on the weekends.

Charleston Area Medical Center

Same as WVUH except that there is no weekend on-call rotation.

Communication with On-duty Faculty

During general working hours, the on service teaching faculty is available in person; other faculty members are available by scheduled appointment, by phone, by pager, and most of the time residents may just feel free to walk into their offices. During the on call hours, the teaching faculty is continuously available either at home by phone or by pager.

Structured Education and Management of the Cytopathology Laboratory

The residents attend scheduled quality assurance, laboratory safety, and other appropriate staff meetings, as they relate tocytopathology. As opportunity provides, residents will be allowed to participate in CAP laboratory accreditation activities, including self-inspections and inspections of other institutions. Residents are urged to attend an Inspection Training Course provided by the CAP.