FNA without cytology

[Arctic Char]

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Hey gang, quick question: would it be prudent for someone practicing in a small town to perform FNA's and read the cytology without having done a cytology fellowship and/or cyto boards?

my hunch is that this is generally common, but thought i'd ask the community . . .

thanks

 

[caffeinegirl]

Very common. In my practice, everybody performs and reads FNA's. We have a couple of boarded cytopath's who we show tough cases to. For new hires, there's a proctoring period before signing out independently (includes surgicals).
It definitely took some adjustment, but now I'm fine with it. It's definitely do-able, and more the norm than the exception IMHO.

 

[Arctic Char]

Very common. In my practice, everybody performs and reads FNA's. We have a couple of boarded cytopath's who we show tough cases to. For new hires, there's a proctoring period before signing out independently (includes surgicals).
It definitely took some adjustment, but now I'm fine with it. It's definitely do-able, and more the norm than the exception IMHO.

thanks for sharing.

 

[mlw03]

how do you feel comfortable doing that with only 2-4 months of residency in cyto? metastatic carcinoma is often a death sentence, and while i think my cyto training was good, i'd be very nervous signing out cyto without more training that residency alone provides.

i'm not trying to start a fight about the merits, rather i'm asking how does one get comfortable enough signing out something they're not specialty trained in?

Very common. In my practice, everybody performs and reads FNA's. We have a couple of boarded cytopath's who we show tough cases to. For new hires, there's a proctoring period before signing out independently (includes surgicals).
It definitely took some adjustment, but now I'm fine with it. It's definitely do-able, and more the norm than the exception IMHO.

 

[Arctic Char]

how do you feel comfortable doing that with only 2-4 months of residency in cyto? metastatic carcinoma is often a death sentence, and while i think my cyto training was good, i'd be very nervous signing out cyto without more training that residency alone provides.

i'm not trying to start a fight about the merits, rather i'm asking how does one get comfortable enough signing out something they're not specialty trained in?

I would imagine the most important part of that "comfort" is knowing one's limits. if you know your limits, you're more likely to make responsible decisions. I think this counts for a lot in the realm of community cytology, where most cases are benign

 

[Ruination]

All of my friends who have gone into the private world over the last 4 years sign out cytology, 5/6 of them without fellowship training.

 

[KCShaw]

...i'm asking how does one get comfortable enough signing out something they're not specialty trained in?

I'd say the same way they sign out general surg path, given that many people won't have done a "surg path" fellowship, and that those who do GI, etc., probably have not -also- done a "surg path" fellowship. From the small handful of people I've spoken with, those first few months to even a year aren't all comfortable -- experience and environment play a substantial role. As I think yaah said not too long ago, that basically you need to trust and be comfortable with the people you're working with, so you can show them cases without feeling guilty, are able to trust their judgement when you do show them things, and eventually settle into your own comfort zone. I think it's an uncommon person who could come out of residency, go into solo practice, and both be comfortable and accurate out of the gate without some kind of professional support; that may be more a comment on the state of residency training than anything else, but anyway.

 

[2121115]

You need to be ready to sign out everything. I think residents in general lack a sense of urgency when on rotations (I know I did sometimes), not thinking that they have to be ready to go after 3 months (or whatever) of cyto (or whatever else) even if that is in 3rd year.

Now, with that said, you don't have to it all independently. That would be impossible. You need to be able to show cases. But you need to know enough to know what to show. That is the kicker.

 

[Pathwrath]

There aren't enough cytology fellowships to train the people who must sign out all the FNA's performed out in the community. If you train at a program that produces competent general surgical patholgoists rather than fellowship applicants, you will be fine.

 

[KCShaw]

...If you train at a program that produces competent general surgical patholgoists rather than fellowship applicants, you will be fine.

👍

Important difference.

 

[caffeinegirl]

how do you feel comfortable doing that with only 2-4 months of residency in cyto? metastatic carcinoma is often a death sentence, and while i think my cyto training was good, i'd be very nervous signing out cyto without more training that residency alone provides.

i'm not trying to start a fight about the merits, rather i'm asking how does one get comfortable enough signing out something they're not specialty trained in?

I think that the others have already chimed in with the salient points. In the real world, the majority of community practices are general surg path and cytology. So, you should be comfortable signing out a metastatic carcinoma...I'm sure you were comfortable enough to pass the boards! I mentioned that the confidence is gained with experience, and as others have said, being in a supportive environment with encourages sharing cases. I don't have a gyn fellowship, but am more than comfortable signing out a debulking for serous carcinoma. With time, you gain not only confidence but also the internal knack for realizing when you're out of your league. That's why it helps to have subspecialists in your practice...I get the weird skin adnexal or melanocytic stuff from my colleagues and share the weird atypical thyroid FNA's with my cytology colleagues. What goes around comes around.

The most important thing is to realize when you DON'T know something, and when to show it around

 

[mlw03]

Big difference between choosing the right answer on a multiple choice exam and signing out a case. But agree in general with what you're saying.

I think that the others have already chimed in with the salient points. In the real world, the majority of community practices are general surg path and cytology. So, you should be comfortable signing out a metastatic carcinoma...I'm sure you were comfortable enough to pass the boards! I mentioned that the confidence is gained with experience, and as others have said, being in a supportive environment with encourages sharing cases. I don't have a gyn fellowship, but am more than comfortable signing out a debulking for serous carcinoma. With time, you gain not only confidence but also the internal knack for realizing when you're out of your league. That's why it helps to have subspecialists in your practice...I get the weird skin adnexal or melanocytic stuff from my colleagues and share the weird atypical thyroid FNA's with my cytology colleagues. What goes around comes around.

The most important thing is to realize when you DON'T know something, and when to show it around

 

[yaah]

It is acceptable almost everywhere. You don't need cytopath boards or training to perform and interpret FNAs adequately. Many private groups like to have at least one cytopath-boarded individual but that doesn't mean they are the only ones who can do it. Our group has four who do cytopath, two are boarded and two are not.

 

[sirenomelia]

FWIW our hospital (academic) requires cytopath board eligibility/ certification for privilges to read out FNA's, brushings and paps. Dont know if thats a trend or just us.

 

[lipomas]

FWIW our hospital (academic) requires cytopath board eligibility/ certification for privilges to read out FNA's, brushings and paps. Dont know if thats a trend or just us.

Just you. Well, not just you. A lot (a few?) of academic places are doing this. There isn't anything that requires it though. It's the whole superspecialization model. Only hemepath certified can signout hemepath. Some places are even moving to non-boarded subspecialties requiring fellowship for signout, with exceptions made for senior experienced faculty of course.

 

[Pathologee]

FNA without cytology is like Harold Melvin without the Blue Notes. You'll never go platinum.

All kidding aside, this thread just goes to show you that even though cytology may not be your area of interest, be sure to learn and see as much as you can while doing your three month rotation.

 

[2121115]

Same goes for heme, derm, GI, etc, etc.

 

[mlw03]

After the intense thought and effort that goes into diagnosing MDS and other tough heme diagnoses, I hope people signing that stuff out in the community are qualified to do so.

 

[caffeinegirl]

After the intense thought and effort that goes into diagnosing MDS and other tough heme diagnoses, I hope people signing that stuff out in the community are qualified to do so.

Huh? Am I sensing that you don't have a high opinion of "people signing that stuff out in the community"?

I don't sign out marrows, but there are several of my colleagues who have done so for several years who do, even without a hemepath fellowship..and who show our hemepath boarded colleague the tough cases. I think that several (5-10+) years practical experience does equal one year fellowship, if not more (of course there are exceptions to this, but I'm talking about somebody who is competent, has kept up with the literature and who has enough volume).

And even if I'm not signing out marrows..I do have enough experience to work up a lymphoma, read out flow reports, and check out smears or marrows for blasts when an emergent cases comes up. That's what a well rounded education gave me, and what being a well rounded pathologist is all about. When it's a weird, rare lymphoma, well then I'll show it around of course. Again, it all comes down to comfort level.

 

[mlw03]

I read enough community path reports as a resident to think that yes, some of them do not know enough to be signing out some of the stuff they do. I don't claim to either, for the record. And I'm not talking about CLL or fairly basic stuff. What I was referring to were tough, precise diagnoses based on very specific criteria in the new WHO book. Stuff I saw my attendings diffing 500 cells on, then doing it again, or showing it to another attending for them to do so.

I also saw a number of community pathologists overcall HL when the patient had mono. That stuff is scary.

I am by no means saying community pathologists all suck. Rather, I basically agree with your point that one has to know their comfort level.

Huh? Am I sensing that you don't have a high opinion of "people signing that stuff out in the community"?

I don't sign out marrows, but there are several of my colleagues who have done so for several years who do, even without a hemepath fellowship..and who show our hemepath boarded colleague the tough cases. I think that several (5-10+) years practical experience does equal one year fellowship, if not more (of course there are exceptions to this, but I'm talking about somebody who is competent, has kept up with the literature and who has enough volume).

And even if I'm not signing out marrows..I do have enough experience to work up a lymphoma, read out flow reports, and check out smears or marrows for blasts when an emergent cases comes up. That's what a well rounded education gave me, and what being a well rounded pathologist is all about. When it's a weird, rare lymphoma, well then I'll show it around of course. Again, it all comes down to comfort level.

 

[Tiki]

I read enough community path reports as a resident to think that yes, some of them do not know enough to be signing out some of the stuff they do. I don't claim to either, for the record. And I'm not talking about CLL or fairly basic stuff. What I was referring to were tough, precise diagnoses based on very specific criteria in the new WHO book. Stuff I saw my attendings diffing 500 cells on, then doing it again, or showing it to another attending for them to do so.

I also saw a number of community pathologists overcall HL when the patient had mono. That stuff is scary.

I am by no means saying community pathologists all suck. Rather, I basically agree with your point that one has to know their comfort level.

Our residency is hemepath heavy (I've had 6 months) so I don't think I need a heme fellowship to sign out the majority of the stuff. There will be things I consult on, but I feel like I have a grip on 90-95% off the stuff that comes in. I feel comfortable with flow, reading gene rearrangements and looking at marrows. And I'll most likely be going into the "community" to practice. If someone told me I had to have a heme fellowship to ever look at heme, I'd be a little annoyed.

 

[KCShaw]

I've watched enough academic pathologists who had to cover heme while the hemepath(s) were away to make me want to block it out. Like anything else, if you're not doing it regularly and/or not keeping up with the changes in terminology or diagnostic requirements, you're just not going to be able to do a quality job. Some folk have seen a lot of it from the time they finished training, and may do a decent job. But there are also a lot of fine points in heme (or other subspecialties) that many may not keep up with.

I'd disagree with the thought that -solely- having years in practice could equal a fellowship. I think it's pretty easy to be overly simplistic or outright wrong for years on end and not learn much of anything useful or keep up with advances/changes along the way. It's a matter of how well used that time is. We probably all know or know of people who have been in the field forever who really have no clue, and also know or know of those without certain boards who do a top notch job. Training helps, but the person generally makes the difference.

 

[lipomas]

Well I have read enough academic path reports to realize that they don't always know what they're talking about either. Sometimes our cases get sent certain places at patient request and we get a disagreement. Occasionally we think the disagreement is wrong and we send it out ourselves somewhere else to get our original dx supported.

A lot of academic departments suffer from a disease of excessive testing. We sent out a frigging lymph node that was a low grade lymphoma because the flow and histology were not entirely in agreement. 20 immunos (20!) and 3 PCR tests later, we get back a report that they don't know either.

I also saw a number of community pathologists overcall HL when the patient had mono. That stuff is scary.

Tell me about it. I have seen the other way around too - from both academics and community.

The point is that good and subpar pathologists exist everywhere. Unfortunately, some people hide their mediocrity behind an academic letterhead. In the community it is harder to hide if you are subpar. You learn your limitations but you also learn what is important more than in academics. There are certain cases that are just rare and "gray-area" type which need consultation and central review. Part of the reason academics are better at this is that they simply see more of them because the tough cases come to their institution.

 

[caffeinegirl]

+1 lipomas, well said

Well I have read enough academic path reports to realize that they don't always know what they're talking about either. Sometimes our cases get sent certain places at patient request and we get a disagreement. Occasionally we think the disagreement is wrong and we send it out ourselves somewhere else to get our original dx supported.

A lot of academic departments suffer from a disease of excessive testing. We sent out a frigging lymph node that was a low grade lymphoma because the flow and histology were not entirely in agreement. 20 immunos (20!) and 3 PCR tests later, we get back a report that they don't know either.



Tell me about it. I have seen the other way around too - from both academics and community.

The point is that good and subpar pathologists exist everywhere. Unfortunately, some people hide their mediocrity behind an academic letterhead. In the community it is harder to hide if you are subpar. You learn your limitations but you also learn what is important more than in academics. There are certain cases that are just rare and "gray-area" type which need consultation and central review. Part of the reason academics are better at this is that they simply see more of them because the tough cases come to their institution.

 

[cjw0918]

In academics I don't sign out hemepath. However I try to take them the case personally and hear their thoughts when I have a consult, so I don't TOTALLY lose touch with all things heme related.
At my training program, an attending who had been doing only surg path and cyto for years took a private job including hemepath. She called me 2 weeks later asking what to order for Hodgkin's. Scary.

 

[mlw03]

The point is that good and subpar pathologists exist everywhere.

Concur.

 

[2121115]

In the community it is harder to hide if you are subpar.

Totally agree.

There are certain cases that are just rare and "gray-area" type which need consultation and central review. Part of the reason academics are better at this is that they simply see more of them because the tough cases come to their institution.

Again, totally agree.

 

[Pathwrath]

In the community it is harder to hide if you are subpar.

Yes--residents may not realize that community pathologists' work is reviewed by experts as a matter of course, every single time the patient moves on to a tertiary care institution for treatment. And that means review by experts from not one academic institution, but all over the country. A mediocre academic's work most often gets reviewed by his or her colleagues at the same institution, if that.

I don't mean to pick on academics, but I do think our specialty exalts them all out of proportion. Wait until you've gotten burned by one, where you made the original correct diagnosis and some lousy academic disagrees, leading to a prolonged and agonizing wait to be finally vindicated. The academic gets the benefit of the doubt.

 

[lipomas]

Yes--residents may not realize that community pathologists' work is reviewed by experts as a matter of course, every single time the patient moves on to a tertiary care institution for treatment. And that means review by experts from not one academic institution, but all over the country. A mediocre academic's work most often gets reviewed by his or her colleagues at the same institution, if that.

I don't mean to pick on academics, but I do think our specialty exalts them all out of proportion. Wait until you've gotten burned by one, where you made the original correct diagnosis and some lousy academic disagrees, leading to a prolonged and agonizing wait to be finally vindicated. The academic gets the benefit of the doubt.

YES! I have gotten quite irritated at a reasonably close well known academic center because they have repeatedly issued minor disagreements on cases I had originally signed out - these are disagreements that are within the realm of opinion and not really evidenced based (try telling THAT to the patient!). You lose fans by doing that. Another person in my group is even more cheesed off and retaliates by sending the cases for a third opinion (which usually agrees with him) and then faxing the reports to all the clinicians involved.

If you have a good relationship with clinicians, this becomes less important. The clinician will trust you, and any discrepancies can be dealt with by a conversation discussing the significance (or lack of significance) and possibly by getting another opinion. But in the eyes of the patient, who are they going to think is "correct"? The local pathologist? Or the eminent "professor" at the UNIVERSITY? Even if said "eminent professor" has two months experience out of fellowship?

Now, most of our work does not get reviewed by academics. The routine stuff rarely does. It is the weird stuff that does, but that's the stuff that we are more likely to send out anyway. Bizarre unclassifiable lymphomas. Sarcomas that look like they could be reactive proliferations. Unclassifiable interstitial lung crap. Indeterminate follicular thyroid lesions.

And of course, to top it all off, when the academic finds that another academic agreed with you, they will make some bull**** excuse like, "oh, well we didn't have all the clinical information we needed" or something like that, a subtle jab trying to deflect blame back at you anyway.

What the good academics realize is that cultivating good relationships with community pathologists not only gets you respect but it also gets you consults. We in the community can usually pick who we send our cases to.

 

[BierstiefelAndy]

YES! I have gotten quite irritated at a reasonably close well known academic center because they have repeatedly issued minor disagreements on cases I had originally signed out - these are disagreements that are within the realm of opinion and not really evidenced based (try telling THAT to the patient!). You lose fans by doing that. Another person in my group is even more cheesed off and retaliates by sending the cases for a third opinion (which usually agrees with him) and then faxing the reports to all the clinicians involved.

If you have a good relationship with clinicians, this becomes less important. The clinician will trust you, and any discrepancies can be dealt with by a conversation discussing the significance (or lack of significance) and possibly by getting another opinion. But in the eyes of the patient, who are they going to think is "correct"? The local pathologist? Or the eminent "professor" at the UNIVERSITY? Even if said "eminent professor" has two months experience out of fellowship?

Now, most of our work does not get reviewed by academics. The routine stuff rarely does. It is the weird stuff that does, but that's the stuff that we are more likely to send out anyway. Bizarre unclassifiable lymphomas. Sarcomas that look like they could be reactive proliferations. Unclassifiable interstitial lung crap. Indeterminate follicular thyroid lesions.

And of course, to top it all off, when the academic finds that another academic agreed with you, they will make some bull**** excuse like, "oh, well we didn't have all the clinical information we needed" or something like that, a subtle jab trying to deflect blame back at you anyway.

What the good academics realize is that cultivating good relationships with community pathologists not only gets you respect but it also gets you consults. We in the community can usually pick who we send our cases to.

I don't concern myself with issuing minor disagreements that are of no clinical consequence, unlike others. I personally like to be as agreeable as possible because all of us pathologists are on the same team. We have bigger fish to fry than to engage in infighting by quibbling about minor details. We have better things to do than to "slap our dicks on the table" in pointing out minor disagreements. I like to use the analogy of college football replays...you have every right to disagree if there is irrefutable evidence contradicting the original diagnosis...the rest is a matter of interpretation and opinion.

Academics breeds authoritative, uncompromising behavior; this can be quite destructive when the individual is masking one's own sense of insecurity. Not enough people have the balls to say, "Yes, I was wrong" or "I'm sorry." Saying these things when errors are committed, in my opinion, is reflective of a sense of security as opposed to insecurity because secure people have insights into their strengths AND limitations.

 

[lipomas]

I don't concern myself with issuing minor disagreements that are of no clinical consequence, unlike others. I personally like to be as agreeable as possible because all of us pathologists are on the same team. We have bigger fish to fry than to engage in infighting by quibbling about minor details. We have better things to do than to "slap our dicks on the table" in pointing out minor disagreements. I like to use the analogy of college football replays...you have every right to disagree if there is irrefutable evidence contradicting the original diagnosis...the rest is a matter of interpretation and opinion.

Academics breeds authoritative, uncompromising behavior; this can be quite destructive when the individual is masking one's own sense of insecurity. Not enough people have the balls to say, "Yes, I was wrong" or "I'm sorry." Saying these things when errors are committed, in my opinion, is reflective of a sense of security as opposed to insecurity because secure people have insights into their strengths AND limitations.

You sir are a gentleman and make too much sense!

I hope you have a long future in academics and can be influential but I fear they may hound you out.

 

[KCShaw]

Just as I learned in residency, I re-learned the advantage of not looking at the previous diagnosis when reviewing a case. It's easier to feel smarter in residency by agreeing with what someone else wrote, but it's easier to be catastrophically wrong by agreeing with someone else when you're out. Not that I'm talking about so-called minor disagreements, mind you. But, I've sat there looking at a lesion thinking, gosh, there may be single cells out in areas of fibrosis/desmoplasia, and it looks bad..then seen the previous report calling it some sort of benign fibrosing lesion after intradepartmental consultation, and thinking well, I -guess- I can see what they're getting at.. then you remember it's 18 months later and the patient is deceased from metastatic disease. Point is, there's a difference between being agreeable and letting someone else's opinion overshadow your true impression.

If you have a difference of opinion, outline it; the beauty of consultations is that they're generally accompanied by more substantial comments or letters clarifying and/or explaining various opinions.

Frankly most times the consults we saw in residency were without a specific already signed-out diagnosis, but just a letter saying "I think it might be blah, but would like your opinion..".

 

[BierstiefelAndy]

Whether disagreements are minor or major is also a matter of opinion and interpretation. If I feel there is a difference in opinion worth commenting on, I prefer to call the pathologist and discuss the case over the phone. He/she may have information that I don't have access to or some mitigating factor that influenced his/her diagnosis. Then I try my best to reach a common ground. In my conversations, I like to say, "you could sign it out like this or that, etc." In the beginning of my letters, I stress the agreement aspects of the case first and foremost rather than harping on the discrepant aspects.

If there is a really major disagreement (and this does happen seldomly to occasionally) one thing I sometimes like to do is run a few ancillary tests with the block and then in my letter, I state that this was a difficult case which required additional testing (i.e., IHC). I don't know if this really accomplishes anything special but I like to THINK that this might give the pathologist a bit of wiggle room. I've talked to pathologists whose relationship with their clinicians have been ruined after disagreements issued by the academic institution. This is not good.

Again, the spirit of this approach has to do with teamwork, camaraderie, and the knowledge that we all make mistakes. If we don't acknowledge our errors, we cannot learn from our mistakes and become better. We're on the same side. The litigious atmosphere in medicine is our enemy.

 

[BierstiefelAndy]

You sir are a gentleman and make too much sense!

I hope you have a long future in academics and can be influential but I fear they may hound you out.

I'll get cynical when that time comes. But I will always believe that there is a place our profession for doing things "the right way."

 

[KCShaw]

Reminds me of my first day of medical school when one of the dean/sub-dean professors got up and described the educational breakdown as the first 2 years being pre-cynical years, and the last 2 as cynical years. Something akin to that probably starts all over again in residency and yet again with each new job -- at least for some people and some jobs.

At the time it got a big laugh, but of course we were still pre-cynical.