Cytology Rotations Goals and Objectives

DIRECTOR: Claire W. Michael, M.D.

The goal of the First Cytology Rotation (the introductory 2 week rotation) is for the resident to move from being a

Novice (A novice knows little about the subject, and rigidly adheres to rules with little situational perception. He/she does not feel responsible for outcomes. )

To

Advanced Beginner(The advanced beginner is still dependent on rules, but can adapt rules to changing circumstances. However, all attributes of a situation tend to be given equal importance, and there is still little feeling of personal responsibility for outcomes.)

First Rotation Goals / First Rotation Objectives
Medical Knowledge
Acquires knowledge of pathophysiology and laboratory manifestations of routinely-encountered conditions; knows where to access information to fill gaps in knowledge. / The resident will acquire knowledge of the basics cellular constituents of exfoliative cytology specimens, including (please see exfoliative cytology online learning outline):
  • Cytology of the squamous epithelium
  • Cytology of the glandular epithelium
  • An overview of the Bethesda system
  • Respiratory cytology
  • Fluids
  • The gastrointestinal tract
  • Urine
  • Cerebrospinal fluid

Patient Care
Is able to perform procedures necessary to generate laboratory information, gather clinical information needed to establish a diagnosis, and make observations relevant to the clinical situation. / With appropriate supervision (see below), the resident will
  • review study sets with cytotechnology staff
  • bring preliminary diagnoses of assigned unknown cases to microscope sessions with cytotechnologist

Practice-based Learning and Improvement
Uses feedback and evaluations to generate or modify learning plan and improve skills. / The resident:
  • uses feedback from cytotechnologist regarding unknown cases to develop observational skills
  • uses results of weekly quiz to guide learning

Interpersonal and Communication Skills
Establishes collegial interactive and communication skills in dealing with others; structures reports that are clear, succinct, and follow templates; listens to and fulfills requests from other providers. / The resident will
  • interact in a collegial way with technical staff, including cytotechnologists, cytopreparatory staff, and clerical staff
  • volunteers his/her observations of unknown cases to supervising cytotechnologist
  • uses recognized cytologic terminology to describe observations

Professionalism
Is honest, compassionate, and respectful of others; complies with laws and regulations pertaining to medical practice; fulfills patient care and educational responsibilities faithfully. Understands professional responsibility to appear for duty rested and fit to provide service. / The resident:
  • is present and ready to microscopic sessions at the agreed time
  • admits errors or omissions and takes steps to correct them
  • protects patient privacy
  • is sensitive to issues of race, gender, ethnic background, religion, sexual orientation and other social factors in dealing with cases, and in interactions with staff and other learners
  • treats colleagues at all levels with respect

Systems-based Practice
Identifies issues related to error, cost, and the need for interdisciplinary collaboration in the delivery of health care. Conducts handoff at the conclusion of rotation with care and thoroughness. / The resident:
  • participates in discussions of cost-effective case management in daily conferences

The goal of the Second Cytology Rotation is for the resident to move from being an

Advanced Beginner(The advanced beginner is still dependent on rules, but can adapt rules to changing circumstances. However, all attributes of a situation tend to be given equal importance, and there is still little feeling of personal responsibility for outcomes.)

To

Competent (The competent learner grasps the relevant facts, can sort information by relevance, can bring his/her own judgment to each case, and solve problems. Guidelines are adapted to unexpected events. He/she feels accountable for outcomes because of increasing decision-making.)

Second Rotation Goals / Second Rotation Objectives
Medical Knowledge
Acquires knowledge of less commonly-encountered conditions and laboratory techniques; critically evaluates knowledge sources and uses evidence-based approach to acquire new knowledge. / The resident will acquire knowledge about (see online learning outline for details):
  • Exfoliative cytology: common neoplastic and other proliferative disorders of the uterine cervix, respiratory tract, urinary tract, CSF, gastrointestinal tract, and body fluids
  • Fine needle aspiration cytology: common sarcomas, head and neck cysts, salivary glands, thyroid, lymph nodes, breast, lung, liver, pancreas, kidney

Patient Care
Uses laboratory data and own observations to generate accurate diagnoses and differential diagnoses; suggests appropriate ancillary studies as needed; responds to requests for consultation. / With appropriate supervision (see below), the resident will
  • properly screen the slides and locate relevant abnormalities accurately and in a timely manner.
  • perform on-site adequacy assessment for fine needle aspiration
  • learn how to properly triage an FNA based on provisional diagnosis
  • perform fine needle aspiration of palpable masses
  • perform smears on site
  • learn about specimen handling, safety requirements and technical issues involved in non-gynecologic sample preparations utilizing conventional smears, liquid-based preparations, and cell blocks.
  • Integrate patient clinical information with the manifested cytological features to formulate the appropriate diagnosis

Practice-based Learning and Improvement
Adapts practices based on literature review, case outcomes, peer reviews, and system demands; seeks and gives feedback to improve self and others. / The resident:
  • Continues to use feedback from preliminary diagnostic errors to improve diagnostic accuracy.
  • Uses information accessed on past cases to more efficiently arrive at a diagnosis in subsequent cases.
  • Seeks corresponding surgical pathology cases to correlate with cytologic findings, and responds to requests for surgical pathology services for correlation
  • Uses feedback and questions from clinicians to refine approach to reporting cases.
  • Selects a cytopathology textbook and develops a systematic reading program
  • Accesses learning sources (textbooks, medical literature, online resources) to fill gaps in medical knowledge before coming to signout.
  • Initiate review of study sets with emphasis on examples of common entities.

Interpersonal and Communication Skills
Effectively communicates in a variety of settings, including during conferences, while providing consultations, and teaching peers. / The resident will
  • Interact in a collegial way with treating physicians, other learners who request information or attend signout.
  • Be able to explain FNA procedure, potential complications to patients and acquire concent
  • Volunteer his/her opinion of cases to faculty, with explanations of rationale
  • Dictate reports that are designed to answer both the articulated and anticipated clinical questions.
  • Recognize cases that indicate the need to notify treating physicians, and suggest this need to faculty at signout.
  • Brings cases to morning conference and relays pertinent information
  • Assures successful transfer of cases to next rotating resident

Professionalism
Manages patient care duties and interacts with other providers with compassion and respect for diversity; recognizes and responds to need for help from colleagues. / The resident:
  • Attends daily morning conference , setting aside and preparing cases as directed
  • Is flexible and proactive in adjusting activities to help respond to clinical demands (for example responding to multiple simultaneous requests for adequacy evaluations or performance of aspirations).

Systems-based Practice
Improves patient outcomes and promotes efficiency by making decisions based on best evidence of outcomes, and by involvement in quality initiatives. / The resident:
  • Is knowledgeable about and suggests the most efficient and effective ancillary studies in difficult cases.
  • Gives feedback to laboratory about quality and timeliness of slides and case delivery
  • Initiates intradepartmental consultations so as to improve case turnaround time.

The goal of the Final Cytopathology Rotation is for the resident to move from being

Competent (The competent learner grasps the relevant facts, can sort information by relevance, can bring his/her own judgment to each case, and solve problems. Guidelines are adapted to unexpected events. He/she feels accountable for outcomes because of increasing decision-making.)

To

Proficient ((Characterised by the progress of the learner from step-by-step analysis and task performance to a holistic perception of the entirety of the situation.Uses pattern recognition arising from experience to identify problems. Perceives deviations from what is expected. Learns from the experience of others. Sense of responsibility grows with increasing decision-making.)

Final Rotation Goals / Final Rotation Objectives
Medical Knowledge
Exercises judgment in application of evidence-based knowledge to patient and to patient population; assists junior residents and other learners in accessing sources of medical knowledge. / The resident will continue to build on the Medical Knowledge acquired in the first 2 rotations, and add knowledge about uncommon disorders and neoplasms of
  • Soft tissues, such as sarcomas of adipose tissue, muscle, blood vessels, synovium, and nervous system
  • Head and neck, such as paraganglioma, nasopharyngeal carcinoma, and parathyroid lesions
  • Salivary glands
  • Thyroid, including the Bethesda reporting system
  • Lymph nodes
  • Breast
  • Lung, including patterns of metastatic neoplasia
  • Mediastinum, including thymic tumors and germ cell tumors
  • Liver
  • Pancreas, unusual tumors and non-neoplastic entities
  • Adrenal cortex and medulla
  • Gonads

Patient Care
Recognizes clinical cases and circumstances that are rare or unique and selects appropriate additional studies; initiates consultant role in unusual cases; directs other providers and learners in challenging situations. / The resident will
  • Demonstrate the ability to diagnose based on Bethesda Reporting Recommendations for gynecologic samples and thyroid aspirates.
  • Demonstrate knowledge of specimen handling, safety requirements, technical issues, and selection of the appropriate processing techniques
  • Understand quality assurance and quality control methods applicable to cytopathology
  • Demonstrate ability to perform on-site adequacy assessment and preliminary diagnosis for fine needle aspiration
  • Be able to successfully perform fine needle aspiration
  • Demonstrate ability to formulate appropriate diagnosis or differential diagnosis during sign out
  • Should be able to cover for the fellow adequately during the last two weeks of this rotation

Practice-based Learning and Improvement
Facilitates collaboration and teamwork to improve patient care and promote learning. / The resident:
  • Preview daily cases and formulate diagnoses, comparing them with final diagnoses at signout with faculty
  • Continue reading program designed during second rotation and complete reading one of the recommended cytology text books.
  • Independently progress through as many cytology study sets as time permits
  • Work with other learners, such as fellows, other residents, and medical students, to share tasks related to gathering knowledge
  • Recognize gaps in others’ learning (fellow, residents, students, and faculty) and contribute to filling the gaps.
  • Recognize circumstances in which the current state of clinical and scientific evidence is lacking.

Interpersonal and Communication Skills
Demonstrates skill in dealing with conflicting opinions or perspectives; responds independently to questions from other providers, patients, and families; generates sophisticated reports that relay information about complex cases. / The resident will
  • Manage conflicting opinions or perspectives in such a way that optimal patient care is protected.
  • Independently handle inquiries for clarification or additional information, and initiate tasks necessary to provide this.
  • Generate reports that convey diagnostic information about both simple and complex cases effectively, needing little or no editing by faculty.

Professionalism
Recognizes impairment in themselves and peers and takes steps to address this. Mentors others in use of inter-professional and multi-disciplinary collaboration; Is a role model to other learners regarding accountability to self and others. / The resident:
  • Can be viewed as a role model in understanding and managing the strengths and weaknesses of him/herself and others.

Systems-based Practice
Identifies sources of error and inefficiency and initiates action to assess and fix; acts as a consultant in conducting cost benefit analysis / The resident:
  • Identifies processes that lead to inefficiencies and potential errors, and suggests improvements.
  • Works to resolve cytologic/histologic discrepancies in ways that bring about the best possible patient care outcome

Plan for Training

  1. Introductory two week rotation

The rotation is supervised by cytotechnologists and consists of two-one week introductory rotations for gynecologic and non-gynecologic cytology.

  1. Cytopathology Core Rotations

Residents rotate a minimum of two-one month rotations. These rotations are focused on education and daily patient care. The residents alternate on a weekly basis between the fine needle aspiration and the hospital (Pap smears and exfoliative non-gynecology) services. Residents rotate with the designated fellow and should work together as a team. During the preview and sign out, resident should take the front seat and be responsible for the daily cases. In the first month the resident acquires the skill needed for daily service and become familiar with laboratory operation issues. In the second month the resident should become competent in all aspects of cytopathology.

  1. Conferences

Residents are expected to actively participate in the daily consensus conference and interesting case presentations. Residents are also expected to attend all other conferences scheduled during the one month rotation including the research conference, journal club and miscellaneous presentations conference.

Residents are also expected to achieve at least 70% attendance to the cytopathology house officer monthly conference and review all available on line learning modules pertinent to their level of training.

Supervision

The following activities are to be conducted with Direct Supervision (the supervising physician, who may be the cytopathology fellow, is physically present with the resident):

  • Fine needle aspirations performed on patients
  • Adequacy evaluations during first and second rotations, and until considered by the rotation director to be capable of indirect supervision in the third rotation
  • Signout and verification of diagnoses into patients’ medical records

The following activities may be conducted with Indirect Supervision (direct supervision immediately available either within the hospital of by telephonic or electronic communication):

  • Adequacy evaluations during third rotation, when considered capable by rotation director
  • Initial patient interactions (obtaining informed consent, initial aspirations, and initial slide preparation) for fine needle aspirations, during third rotation

The following activities may be conducted with Oversight (the supervising physician is available to review with feedback after activity is completed):

  • Case preview and formation of preliminary diagnosis

Evaluation

EVALUATION METHODS:

  1. Introductory two week rotation
  1. At the end of every subject or body site discussed, the resident receives an unknown slide quiz that is reviewed with the technologist the next day.
  2. At the end of each week, the resident receives a written test
  3. Scores of the tests and quizzes as well as an overall evaluation is rendered at the end of the rotation by the cytotechnologist on Med Hub.
  1. Cytopathology Core Rotations

First Rotation

  1. The resident receives an on-line Progressive Evaluation of Competency test administered by the ASC in the first and last week of the rotation. The scores are immediately posted as feedback for the resident and program director tabulated in the different fields of cytology; gynecologic, non-gynecologic, fine needle aspiration, ancillary techniques and laboratory operation. Scores are posted by the medical director on the Med Hub evaluation. This provides an objective assessment of strength and weakness and an opportunity to quickly identify areas of potential improvement.
  2. At the end of the month rotation, evaluations, based on direct observation,by the rotating faculty, are done on Med Hub.
  3. The resident receives feedback on a daily basis from the faculty based on the daily activity.

Second Rotation

  1. The resident performs the Progressive Evaluation of Competency on line test in the first and last week of rotation
  2. Evaluations based on direct observations are given by the rotating faculty at the end of rotation on Med Hub
  3. Daily feed back by the rotating faculty
  1. Cytology technical staff participate in semiannual 360 degree evaluation of residents that have recently rotated in cytopathology? How do you plan to do this, it takes forever to get it done for fellows. Would suggest evaluation by supervisor or designee at end of rotation which would be based on feed back from other techs.
  2. ASCP Resident Inservice Examination (RISE), annually