Cytopath

[yaah]

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Question to ponder for others:

What is the deal with Cytopath? It seems to me like most people (residents and attendings) dislike it, and want very little to do with it. Yet the fellowships are very competitive and popular. Even cyto fellows don't seem to like cytology. And when they look for jobs they look for jobs where they don't have to do cytology (both fellows here last year took great jobs where they aren't doing any cyto). And many people talk about how cytology doesn't reimburse well, except for FNAs. But even at most private places, you don't seem to do tons of FNAs - and you certainly don't NEED a cyto fellowship to get good at FNAs - as far as I can tell the only reason to have a board certified cytopathologist is so they can read pap smears (which don't reimburse anyway). Any AP trained person can read the rest and do the FNAs.

So why do people do cyto fellowships? And why do employers look for people trained in cytopath?

I don't get it.

I have met a few people who love cytopath, many others who tolerate it, and a LOT more who hate it.

 

[LADoc00]

Question to ponder for others:

What is the deal with Cytopath? It seems to me like most people (residents and attendings) dislike it, and want very little to do with it. Yet the fellowships are very competitive and popular. Even cyto fellows don't seem to like cytology. And when they look for jobs they look for jobs where they don't have to do cytology (both fellows here last year took great jobs where they aren't doing any cyto). And many people talk about how cytology doesn't reimburse well, except for FNAs. But even at most private places, you don't seem to do tons of FNAs - and you certainly don't NEED a cyto fellowship to get good at FNAs - as far as I can tell the only reason to have a board certified cytopathologist is so they can read pap smears (which don't reimburse anyway). Any AP trained person can read the rest and do the FNAs.

So why do people do cyto fellowships? And why do employers look for people trained in cytopath?

I don't get it.

I have met a few people who love cytopath, many others who tolerate it, and a LOT more who hate it.

I have been in groups...now read this...that are 80% cytology by specimen number as well as time spent! Crazy huh. I can say that in some areas/groups, cytology is really important. Others including the one Im currently involved with, do almost no cytology. Im doing maybe 1-2 non-gyns/day, sometimes none. I may go weeks without a thyroid FNA read and I do no procedures. In the past, I have done up to 150+ FNA procedures/month.

Cytology sucks the big monkey because even greats like Demay will profess it is a "statistical probability" form of diagnosis. Meaning, given X and Y, a majority of the time you are dealing with papillary carcinoma. Sounds real definitive right??

In this current age of immuno confirmation, Im still baffled that people sign out breast FNAs as definitively infiltrating carcinoma or soft tissue masses as definitively benign or malignant..but they do and frankly this nonsense has to end sometime.

Just in terms of reimbursement, not even considering accuracy of diagnosis which is WAY WAY behind traditional histology+immunos+molecular/in situ...cytology loses out, now watch:
lets say Im lucky enough to do the FNA procedure (and often you wont be)
I get 1 charge for the procedure, 1 for an adequacy read (assuming you are smart enuff to bill for one) and 1 for cytology interp. Wow, 3 phat charges...
time from start to finish: at least 45 minutes, occasionally longer.


Now, lets say I get a core breast biopsy from radiology..I get 1x88305, then its a difficult lesion and I get my breast cocktail stain which adds 3ximmuno charge (88342). My diagnosis is definitive, subclassifies as in situ vs. invasive, or lobular vs. ductal.
time from start to finish: 10 minutes.

 

[dermpathlover]

I didn't like cyto at first because I just didn't get it, but now I love it. I have been on a couple of FNAs for fibradenomas and lymph nodes and thought it was fun as hell. I can't wait to do my month of FNA as I love procedures and a chance to work in the clinics and wards. I don't even mind pap smears. The only thing I still have a really hard time with are BALs, but sooner or later I'll get a handle on them.

I am seriously considering Derm + Cyto vs. Derm + GI vs. Derm + Heme for my two fellowships.

I think Cytology is an incredibly powerful tool and is incredibly interesting.

 

[dermpathlover]

The question I think is interesting is will cytology get to the point where only cyto-boarded people should be signing stuff out for medicolegal reasons?

Hemepath, derm, and neuro have gotten to the point where only fellowship trained people should be signing it out (except for the old timers who trained befoer their were boarded fellowships and have been signing out that stuff for years and know what they are doing).

Will it get to the point that only Cyto trained people can set up an FNA service in a community hospital? FNAs aren't hard to do at all, but if an general pathologists tried to set up an FNA service will he be able to get business, and will he be putting himself at huge risk for malpractice should he screw up a case because he is not boarded?

 

[Cabbage Head]

I didn't like cyto at first because I just didn't get it, but now I love it. I have been on a couple of FNAs for fibradenomas and lymph nodes and thought it was fun as hell. I can't wait to do my month of FNA as I love procedures and a chance to work in the clinics and wards. I don't even mind pap smears. The only thing I still have a really hard time with are BALs, but sooner or later I'll get a handle on them.

I am seriously considering Derm + Cyto vs. Derm + GI vs. Derm + Heme for my two fellowships.

I think Cytology is an incredibly powerful tool and is incredibly interesting.
----
Winner fellowships : GU/GI/DERM
Intermediate: Cytology/Heme
Borderline: Breast/Gyn/TM/Lung/NP
Loser fellowships: Microbiology/Medical Kidney/Liver/Soft Tissue/Peds

Wait, won't that make you "intermediate" on your Winner-Loser Scale?

On another note, it's interesting how practice patterns are different in different places. I don't see many breast FNAs at all. Most seem like they are done on superficial lumps or liver/lung masses. I feel like they are most useful in cases where you don't care about specifics, just, "Is this recurrent metastatic breast ca in this node?"

 

[LADoc00]

The question I think is interesting is will cytology get to the point where only cyto-boarded people should be signing stuff out for medicolegal reasons?

Hemepath, derm, and neuro have gotten to the point where only fellowship trained people should be signing it out (except for the old timers who trained befoer their were boarded fellowships and have been signing out that stuff for years and know what they are doing).

Will it get to the point that only Cyto trained people can set up an FNA service in a community hospital? FNAs aren't hard to do at all, but if an general pathologists tried to set up an FNA service will he be able to get business, and will he be putting himself at huge risk for malpractice should he screw up a case because he is not boarded?

Im my experience, outpatient FNA centers run by pathologists have for the most part gone bankrupt. They require a referral base so large to be profitable, that they are rarely successful. Cyto boards definitely do NOT protect you in a lawsuit, that is common misconception. Nor does being boarded in cyto somehow lower your malprac insurance for FNA procedures, at least with the insurance companies Im familiar with.

 

[dermpathlover]

Im my experience, outpatient FNA centers run by pathologists have for the most part gone bankrupt. They require a referral base so large to be profitable, that they are rarely successful. Cyto boards definitely do NOT protect you in a lawsuit, that is common misconception. Nor does being boarded in cyto somehow lower your malprac insurance for FNA procedures, at least with the insurance companies Im familiar with.

My idea, assuming I end up in a hospital based practice, would be to set up a little "office" within the lab where patients could just drop by and I would stick them and give their doc a diagnosis within an hour (assuming it is a straightforward case). I could do this all while doing my grossing or signing out or whatever I'm doing that day.

It would seem to cost nothing to set up. All you need is a few 10cc syringes and a few 25 guage needles and slides. All the stains would be in the lab. you could only make money.

 

[dermpathlover]

Wait, won't that make you "intermediate" on your Winner-Loser Scale?

On another note, it's interesting how practice patterns are different in different places. I don't see many breast FNAs at all. Most seem like they are done on superficial lumps or liver/lung masses. I feel like they are most useful in cases where you don't care about specifics, just, "Is this recurrent metastatic breast ca in this node?"

Cyto and heme aren't the cash cows that GI/Derm/GU are, but they are still worthy. I'm OK with doing one winner and one intermediate fellowship. Heck, I would even be OK with HEME-CYTO.

We seem to do a ton of benign breast disease. When on cyto, I went with the FNA fellow, and we just did case after case of breast lumps in co-eds from the local university. They were all obviously FAs clinically that you could easily feel. It was sweet and fast. We did like ten in 2 hours and I got to do a couple of the girls myself.

There were no "suspicious" lesions. All ten were FAs or fibrocystic changes.

 

[yaah]

In my experience, cytology can be definitive, but it is rarely definitive in the absence of a convincing clinical history and/or biopsy confirmation. Thus, an atypical urine that looks like cancer in a patient with a cytoscopically described "large papillary tumor" will be called "positive for UC" but yet in a patient who has no cystoscopy yet, will be called "atypical urothelial cells." Cytology seems, despite what its proponents say, to be a screening tool and not a diagnostic tool. Yes, if a lump is called benign on FNA, it often will be left alone, but even then they still watch it or rebiopsy if it persists. Even the experts who have done fellowships and practice only cytology will act like this. They are a bit more definitive and it is definitely more educational to sign out with them, but yet it is still a gray area.

But like I say, is doing a fellowship really necessary? Personally, we get a couple of months of cyto in training. If I wanted to do a lot of cyto, i doubt I would need a year to get that comfortable with it. Maybe another two rotations?

I just don't understand why the fellowships are so popular and/or desirable. Is it just because it's something to do, and it's relatively easy to get for a boarded subspecialty?

Does anyone know if there are benefits to being boarded in cytology beyond being able to read pap smears?

We seem to do a ton of benign breast disease. When on cyto, I went with the FNA fellow, and we just did case after case of breast lumps in co-eds from the local university. They were all obviously FAs clinically that you could easily feel. It was sweet and fast. We did like ten in 2 hours and I got to do a couple of the girls myself.

cough cough bull**** cough

It takes almost a half hour to just set up all the crap you need - getting consent, making smears, staining the slides, getting the needles out, etc etc. Unless you are paying assistants to help you. And where is the profit there?

 

[djmd]

When on cyto, I went with the FNA fellow, and we just did case after case of breast lumps in co-eds from the local university. They were all obviously FAs clinically that you could easily feel. It was sweet and fast. We did like ten in 2 hours and I got to do a couple of the girls myself.

There were no "suspicious" lesions. All ten were FAs or fibrocystic changes.

Holy crap, you are creepy.

And what the hell is the point of FNA of fibrocystic? I guess they say reduce the cyst and watch for recurrence, but a negative FNA almost never rules anything out...

 

[DarksideAllstar]

Holy crap, you are creepy.

 

[dermpathlover]

cough cough bull**** cough

It takes almost a half hour to just set up all the crap you need - getting consent, making smears, staining the slides, getting the needles out, etc etc. Unless you are paying assistants to help you. And where is the profit there?

We had all the stuff set up on a cart with extra supplies below it, the cart had a microscope for adequacy, we had stickers with the patient's names and ID numbers premade for the slides. There were 3 rooms, so all the girls were ready and waiting for us to come. We just went from one room to another. I was basically the assistant. The fellow was experienced and let me do one pass except for the last two where I got to do them by myself. We just went along Bap Bap Bap Bap...It took no more than 20 minutes per case. Getting adequate material out of a girl's fibroadenoma is pretty easy. It isn't like a bloody colloid nodule where you can make 15 slides all with blood only. So maybe it took 3 hours total. Jeesh. Don't be so techy.

 

[dermpathlover]

Holy crap, you are creepy.

And what the hell is the point of FNA of fibrocystic? I guess they say reduce the cyst and watch for recurrence, but a negative FNA almost never rules anything out...

What's so creepy about a doing an FNA? It's a medical procedure.

Regarding FNAs of fibrocystic change, I doubt it's standard practice, but clinically Fibrocystic change can present like a fibroadenoma (moblie discrete mass).

I remember one girl where I felt one of her breasts, I was sure it was going to be fibrocystic change as the breast felt a little bumpy. So I asked to feel her other one and it was also kind of bumpy. However, the nodule that the fellow hit was a classic FA.

On a second case I was sure this girl had a fibroadenoma, as her breast felt like it had a clear mobile encapsulated mass, but the attending signed it out as fibrocystic change. Maybe the fellow missed? I don't know what happened next.

 

[EUA]

There were 3 rooms, so all the girls were ready and waiting for us to come. We just went from one room to another. I was basically the assistant. The fellow was experienced and let me do one pass except for the last two where I got to do them by myself. We just went along Bap Bap Bap Bap...

Sorry. It IS creepy and somewhat pornographic, but I am quite amused right now.

 

[LADoc00]

What's so creepy about a doing an FNA?

I remember one girl where I felt one of her breasts.

Hmmm it sounds like:

 

[yaah]

all the girls were ready and waiting for us to come.

I'll bet they were.

 

[djmd]

What's so creepy about a doing an FNA? It's a medical procedure.

in co-eds from the local university

It is the way you say it...

 

[dermpathlover]

You guys are funny...and a little dirty minded. I wasn't going that way at all. But when you put stuff in that context, it does sound a little, well, a little unprofessional.

Jeesh!

OK, gotta go finish stuff up, I hate leaving past 5pm.

 

[torero]

Sorry. It IS creepy and somewhat pornographic, but I am quite amused right now.

I agree, the direction this thread has taken is quite amusing!

 

[torero]

You guys are funny...and a little dirty minded. I wasn't going that way at all. But when you put stuff in that context, it does sound a little, well, a little unprofessional.

Jeesh!

OK, gotta go finish stuff up, I hate leaving past 5pm.

It’s remarkable you still hang around here in spite of all this criticism. On the positive side, by now you should realize that self-awareness is not your forte, and it’s something you should probably work on, if you want to have a shot at any of your fellowship combos, not to mention a job.

 

[EUA]

It’s remarkable you still hang around here in spite of all this criticism. On the positive side, by now you should realize that self-awareness is not your forte, and it’s something you should probably work on, if you want to have a shot at any of your fellowship combos, not to mention a job.

Hey, isn't tenacity a positive attribute?

 

[yaah]

OK, gotta go finish stuff up, I hate leaving past 5pm.

Not gonna get those competitive fellowships with that attitude!

 

[Brian Pavlovitz]

I'll bet they were.

OMFG!!!!

 

[Brian Pavlovitz]

In my experience, cytology can be definitive, but it is rarely definitive in the absence of a convincing clinical history and/or biopsy confirmation. Thus, an atypical urine that looks like cancer in a patient with a cytoscopically described "large papillary tumor" will be called "positive for UC" but yet in a patient who has no cystoscopy yet, will be called "atypical urothelial cells." Cytology seems, despite what its proponents say, to be a screening tool and not a diagnostic tool. Yes, if a lump is called benign on FNA, it often will be left alone, but even then they still watch it or rebiopsy if it persists. Even the experts who have done fellowships and practice only cytology will act like this. They are a bit more definitive and it is definitely more educational to sign out with them, but yet it is still a gray area.

But like I say, is doing a fellowship really necessary? Personally, we get a couple of months of cyto in training. If I wanted to do a lot of cyto, i doubt I would need a year to get that comfortable with it. Maybe another two rotations?

I just don't understand why the fellowships are so popular and/or desirable. Is it just because it's something to do, and it's relatively easy to get for a boarded subspecialty?

Does anyone know if there are benefits to being boarded in cytology beyond being able to read pap smears?



cough cough bull**** cough

It takes almost a half hour to just set up all the crap you need - getting consent, making smears, staining the slides, getting the needles out, etc etc. Unless you are paying assistants to help you. And where is the profit there?

I'm wondering about this, too. Of course, I am but a newbie resident (one with 5 years of cytology, but still a newbie). Most people where I am seem to think I will "naturally" try for a cytology fellowship. Granted, the fellowship might be a bit easier for me (not that any fellowship would be easy, but having 5 years of screening does help), but you don't NEED to be boarded in order to sign out cyto (as was stated earlier). So, why do a fellowship in something I already have done (more or less)?

The residents where I am seem to gravitate towards cyto either because they really like it, or because they feel they don't get enough exposure to it (I want to say we only get 3 mandatory months on cyto, but don't quote me on that).

 

[Mrbojangles]

For some reason I feel I should do a cytology fellowship. I have to admit I don't love it, but I keep telling myself I will learn to like it.

 

[Gut Shot]

For some reason I feel I should do a cytology fellowship. I have to admit I don't love it, but I keep telling myself I will learn to like it.

For Chrissakes, why? Why, man, why??? So you can be the poor schlub in the practice who gets all the Paps?

 

[yaah]

The residents where I am seem to gravitate towards cyto either because they really like it, or because they feel they don't get enough exposure to it (I want to say we only get 3 mandatory months on cyto, but don't quote me on that).

I sometimes feel like residents gravitate towards cyto because the don't feel they are competitive for another type. That may be off base, but I'm not sure...

I do feel like we don't get a ton of exposure to it, yet at the same time we get enough to figure out the general rules, and after that it's based on experience with the specimens you see. It becomes hard to really screw up cytology after a couple of months and some studying, etc, (can always say "atypical" or "suspicious") although it remains hard to master.

 

[Mrbojangles]

So is it just academic hospitals and some community hospitals that have cytotechs?

 

[dermpathlover]

So is it just academic hospitals and some community hospitals that have cytotechs?

What else is there? Do you mean reference labs? They probably have them too. Otherwise doing Cytology for Ameripath or Quest would be the world's ****tiest job ever.

 

[beary]

Hmmm it sounds like:

I just read this guy ran a daycare center. Who would leave their children with this guy??

 

[beary]

OMFG!!!!

BP!!! How's residency treating you?

 

[beary]

For some reason I feel I should do a cytology fellowship. I have to admit I don't love it, but I keep telling myself I will learn to like it.

I haven't done any cyto, but definitely don't see myself doing any additional cyto from what I do know about it.

With my vast 2 months of path residency under my belt 😳 , I must say I really like renal. But I know that is not a high-demand fellowship.

 

[Mrbojangles]

What else is there? Do you mean reference labs? They probably have them too. Otherwise doing Cytology for Ameripath or Quest would be the world's ****tiest job ever.

I would have thought they wouldn't have cytotechs but I have no idea. And that really would be a s****y job. Can anyone speak to this?

Also it seems that people here say that a Gyn fellowship isn't of much use, why is that?

 

[Brian Pavlovitz]

Oh sure--anyplace that has a cytology lab, there's probably a cytotech--especially a high-volume lab. Otherwise, the pathologist would have to screen everything. Most of them wouldn't enjoy that, and many will tell you that they really aren't too good at it.

 

[Brian Pavlovitz]

BP!!! How's residency treating you?

It's going pretty well so far, beary! I finally start some surg path in September, so I'll really find out then! Hope things are going well with you, too!

 

[quant]

It's going pretty well so far, beary! I finally start some surg path in September, so I'll really find out then! Hope things are going well with you, too!

Hey Brian!!!!!!!!
How is life treating you as a resident?
Trust everything is well with you!
Regards
Quant

 

[Brian Pavlovitz]

Hey Brian!!!!!!!!
How is life treating you as a resident?
Trust everything is well with you!
Regards
Quant

Well, I'm still alive (and they haven't asked me to leave yet!!) 😉