Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 34
RE: Resident Responsibilities
Revised June 21, 2010
NAME OF ROTATION:
Cytopathology
YEAR(S) OF RESIDENCY ROTATIONS IS TAKEN AND DURATIONS:
PGY II-IV 4 months minimum
GOALS: To provide the resident with the basic cytopathology training to become proficient in
evaluating routine gynecologic and non-gynecologic cytological specimens including
performance and interpretation of fine need aspirations, to arrive at a correct cytological
diagnosis, recognize the value and limitations of the method and appreciate the impact of a
particular cytological diagnosis in the clinical decision making and patient care.
OBJECTIVES: (per modification of ASC Taskforce on Residency Training in
Cytopathology, per ADASP)
Skill Level I (Those skills necessary to move from novice to advanced beginner; from basic
acquaintance with cytopathology to readiness for independent learning in that discipline)
Months 1-2; regular participation in conferences and proficiency testing
Objectives: Medical knowledge and application to patient care; communication:
 Be able to verify that cytopathology requisitions are completed correctly.
 Demonstrate familiarity with the methods of collection, cytopreparatory processing, and
turn around times for common cytopathology specimens, in order to be able to answer
clinicians' questions concerning expected results from the cytopathology laboratory.
 Demonstrate knowledge of the current Bethesda System terminology for reporting on
gynecologic cytopathology specimens, and of the principles and application of human
papillomavirus probe analysis.
 Demonstrate knowledge of the elements of adequacy and the current laboratory reporting
system (such as negative, inflammatory/reactive, atypical/suspicious, neoplastic or
malignant) for fine needle aspiration (FNA) biopsy and exfoliative non-gynecologic
cytopathology specimens from the various commonly sampled body sites.
 Demonstrate knowledge of the cytopathologic features of normal, reactive, infectious,
dysplastic and neoplastic conditions as seen in common cytopathology specimens.
 Demonstrate knowledge of how common cytopathology specimens are screened.
 Demonstrate knowledge of how to evaluate common cytopathology specimens
comprehensively.
To achieve competency at this skill level:
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 35
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
Gynecologic Cytopathology:
The resident should demonstrate the ability to:
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Explain the differences among conventional smear and liquid-based preparations in
gynecologic cytopathology.
Examine any gynecologic cytopathology specimen, either a conventional smear or a
liquid-based preparation, and properly classify it by The Bethesda System 2001.
List the common inflammatory etiologies and identify their presentation in gynecologic
cytopathology specimens.
List the various microbiological, immunocytochemical, and molecular diagnostic
techniques for confirmation of human papilloma virus and other infectious agents
common in gynecologic cytopathology specimens, and appropriately recommend their
cost-effective use.
List and demonstrate the proper application of The Bethesda System 2001 quality
indicators and criteria for unsatisfactory gynecologic cytopathology specimens, and
communicate their significance and rationale to clinicians in a concise and collegial
manner.
Communicate the proper methods of gynecologic cytopathology specimen collection for
both conventional smear and liquid-based preparations to clinicians in a concise and
collegial manner.
Non-Gynecologic Cytopathology:
The resident should demonstrate the ability to:
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Examine and properly classify using the current laboratory system (such as negative,
inflammatory/reactive, atypical/suspicious, neoplastic or malignant) both fine needle
aspiration (FNA) biopsies and exfoliative non-gynecologic cytopathology specimens
from the various commonly sampled body sites.
List the common inflammatory etiologies and identify their presentation in nongynecologic cytopathology specimens from the various commonly sampled body sites.
List the various microbiological, immunocytochemical, and molecular diagnostic
techniques for confirmation of infectious agents usually found in non-gynecologic
cytopathology specimens from the various commonly sampled body sites, and
appropriately recommend their cost-effective use.
List the criteria for limited and unsatisfactory non-gynecologic cytopathology specimens
from the various commonly sampled body sites, and communicate these criteria including
their significance and rationale to clinicians in a concise and collegial manner.
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 36
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
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Communicate the proper techniques for exfoliative cytopathology specimen collection to
clinicians in a concise and collegial manner.
Skill Level II (Those skills necessary to move from advanced beginner to practitioner; from
independent learning of cytopathology to readiness for the competent practice of
cytopathology.)3-4 months minimum
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Demonstrate knowledge of the application of ancillary techniques including image
analysis, immunocytochemistry, flow cytometry, cytogenetics, electron microscopy, and
molecular studies (FISH; PCR).
Demonstrate knowledge of how to rapidly evaluate common Fine Needle Aspiration
(FNA) biopsy specimens, including determination of specimen adequacy and the need for
ancillary techniques, and the appropriate collection of materials for such techniques.
Demonstrate knowledge of the content of training materials on correct performance of
FNA biopsies.
Demonstrate working familiarity with the instruments and materials needed to perform
FNA biopsies.
Demonstrate correct performance of FNA, including preparation of smears and collection
of diagnostic materials with proper handling for ancillary techniques, on appropriate
specimens at the surgical pathology gross cutting area.
Demonstrate competency under supervision of staff cytopathologists in the performance
of clinical superficial FNA biopsy, appropriately taking history, correctly obtaining
informed consent, competently examining the lesion to be biopsied, preparing the patient
and biopsy instruments, physically procuring the specimen, and preparing and staining
the smears, with preliminary interpretation of the smears and appropriate after-care of the
patient.
Demonstrate knowledge of how clearly, concisely, and completely to compose a
cytopathology report for specimens from various commonly sampled body sites based
upon the final diagnostic findings, and of how appropriately to recommend clinical
follow-up.
Demonstrate familiarity with the principles of automated screening for gynecologic
cytopathology specimens.
Demonstrate knowledge of how to perform quality assurance, including the correlation of
gynecologic and non-gynecologic cytopathology with surgical pathology, both in
aggregate for quality assurance purposes and on a case-by-case basis for diagnostic
purposes.
Demonstrate knowledge of how to apply concepts of quality control, quality
improvement, risk management, and of regulatory compliance including correct coding
as these pertain to the practice of cytopathology.
To achieve competency at this skill level:
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 37
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
FNA Procedural Cytopathology:
The resident should demonstrate the ability to:
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Communicate the proper techniques for FNA biopsy specimen collection to clinicians in
a concise and collegial manner.
Communicate the various potential FNA biopsy procedural complications to patients in a
concise and professional manner.
Appropriately evaluate suitability for, correctly obtain consent from, and then
competently demonstrate the performance of diagnostic superficial FNA biopsy on
patients.
Explain and demonstrate the proper management of potential complications of FNA
biopsy including fainting, arterial bleeding, pneumothorax, and needle-stick injury.
Advanced General Cytopathology:
The resident should demonstrate the ability to:
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Explain and demonstrate the proper composition of a clear, concise, and complete
cytopathology report for gynecologic cytopathology specimens based upon their final
classification by The Bethesda System 2001, and recommend appropriate clinical followup.
Explain and demonstrate the proper composition of a clear, concise, and complete
cytopathology report for non-gynecologic cytopathology specimens from the various
commonly sampled body sites based upon the final diagnostic findings, and recommend
appropriate clinical follow-up.
Explain and demonstrate the proper interpretation and triage of cytopathology specimens
during rapid (intra-procedural) evaluation, including determination of specimen adequacy
and necessary ancillary techniques, and the appropriate collection of supplementary
diagnostic materials for such techniques.
List and explain the various potential causes of specimen identification errors in both
gynecologic and non-gynecologic cytopathology.
List and identify the causes of common preparatory artifacts and explain how to confirm
these causes and to manage such problems for quality assurance and diagnostic purposes.
List and identify the causes for common specimen contaminants and explain how to
confirm these causes and to manage such problems for quality assurance and diagnostic
purposes.
Explain and demonstrate the proper application of continuous quality assurance and
regulatory compliance methods including correct procedural and diagnostic coding both
for a gynecologic and for a non-gynecologic cytopathology service.
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 38
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
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Explain the importance of correlation of prior and subsequent histopathology with
cytopathology cases, both in aggregate for quality assurance purposes and on a case-bycase basis for diagnostic purposes.
Explain and demonstrate the proper prioritization of workflow so that the most urgent
cases are processed and examined first.
SUPERVISION AND EVALUATION:
All cases, including paperwork and all glass slides, are reviewed by a pathologist licensed to
practice in Texas, and is verified by that pathologist. At no time is a final report issued without
that verification.
Residents are evaluated on a monthly basis by each of the attendings involved in their training
that month, and by the program director on a quarterly basis; and finally on a yearly basis prior
to signing of new contracts. Both the resident and pathologist sign each one of these evaluation
forms at the time of evaluation. The monthly evaluation will serve to identify areas of
improvement early, as well as the resident’s achievement of the goals and objectives.
Subjective (Residency Competency Assessment) and Objective Evaluations
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The standard form (Residency Competency Assessment will be completed by each
attending pathologist on rotation with the resident each month (not just at the end of a
multimonth rotation), including the elements as noted previously for competency based
evaluation.
The results of additional objective evaluation tools used must be noted on the form, with
additional documentation as appropriate. This may be in the form of checklists. Such
checklists should promptly be completed by each supervising faculty member. The
evaluation should be discussed with the resident at the time of completion, with both the
attending physician and resident signing the form after discussion.
Pertinent constructive written comments are REQUIRED for evaluations of borderline
(4) or unsatisfactory (1-3) ratings.
Plans for remediation of borderline or unsatisfactory ratings must be documented in
writing.
LIST of specific evaluation tools other than case by case review [to include written or practical
quizzes, etc, with specific competency element to be evaluated; 360 evaluations (by technical
and transcription staff), etc (List here):
 Every day ingoing evaluation primarily at the microscope sign-out session.
 Evidence of reading and preparation of cases for sign out
 Performance during conference case presentations and preparations
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 39
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
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Performance on quarterly laboratory proficiency programs
RESIDENT DOCUMENTATION of activities for evaluation and ABP:
Residents must keep track of the numbers and organ system types of cases as they do them.
These numbers will be needed for application to the American Board of Pathology. This sheet
should be presented at the time of evaluation, and its contents entered into the ACGME Resident
Procedure Log.
FACULTY:
Mitchell Wachtel, M.D., Associate Professor
Irfan Warraich, M.D., Assistant Professor
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 40
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
CYTOPATHOLOGY APPENDIX
DUTIES AND RESPONSIBILITIES OF RESIDENTS:
FIRST ROTATION, ONE TO TWO MONTHS:
The first rotation will be devoted exclusively to achieving proficiency in GYN cytology.
WEEK ONE: After an introductory orientation talk given by a designated cytotechnologist the
resident will spend the first week of his/her first cytopathology rotation in the cytopathology
laboratory where, under the supervision of the cytopreparatory technician and/or the
cytotechnologists, the resident will participate in hands-on activities in order to become familiar
with:
1. The cytopathology workflow including specimen collection, accessioning and
cytopreparation including cytospin, ThinPrep and cell block preparations.
2. PAP and Diff Quik stains.
3. Use of Laboratory equipment.
4. QA and QC programs in compliance with CLIA regulations.
5. FNA technique. After becoming familiar with the theory of fine needle aspiration the
resident will perform at least 15 practice aspirates on surgical/autopsy specimens with
the preparation of alcohol fixed and air-dried smear which he/she will properly stain.
This material will be collected and presented to the cytopathologist on service during
the resident’s rotation for his/her evaluation. If considered appropriate, the attending
cytopathologist may at this point authorize the resident to participate in diagnostic
FNAs. The level of the resident’s participation will be at the discretion of the
attending cytopathologist who will supervise the procedure and will be responsible
for the final outcome and diagnosis of the FNA. The resident’s responsibility in the
FNA service will be gradually increased at the discretion of the attending
cytopathologist, however; no resident will be allowed to aspirate patients until having
presented evidence of completion of the practice FNAs to the satisfaction of the
attending cytopathologist.
WEEK TWO: The resident will be provided with the CytoFocus self-study cytopathology
program which he/she will study until completion. At any time the resident can and should bring
questions, doubts or poorly understood points to the attending cytopathologist for appropriate
discussion and clarification. At the end of the week, the resident will be given a test to evaluate
the progress made with this program. Points to be explored will include, but will not be limited
to, the basic understanding of The Bethesda System of Terminology in gynecologic cytology,
basic principles and methods in cytology, cytological criteria for the diagnosis of normal smears,
benign cellular changes and epithelial cell abnormalities.
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 41
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
During the remaining rotations, the resident will learn the appropriate method of screening PAP
smears, both conventional and ThinPrep preparations, the reporting of the normal and abnormal
PAP smears using TBS, as well as maintaining adequate QA and QC programs to comply with
CLIA regulations and preparation for laboratory inspections. The resident will do primary
screening of at least 10 PAP smears a day, including cytohistologic correlation when appropriate,
which will then be reviewed with the attending cytopathologist for final sign-out, after
appropriate discussion of each case. At the discretion of the attending cytopathologist, the
number of PAP smears to be screened may be gradually increased.
The resident will be responsible for the presentation and discussion of any gyn cytology case
presented at the weekly unknowns conference.
An end of the rotation, a written and/or practical exam will be given to the resident.
The resident will evaluate the program and his/her attending cytopathologists at the end of the
rotation noting strengths and/or deficiencies and suggesting possible mechanisms for
improvement.
SECOND ROTATION 1 TO 2 MONTHS. NON-GYN CYTOLOGY:
The resident will complete the reading assignments and review the corresponding teaching
materials and study sets according to the proposed program. The length of the rotation will be
divided in equal periods of time, which will be dedicated to each of the following subjects:
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Respiratory cytology.
Pulmonary and breast FNA cytology.
GI tract cytology and Liver FNA cytology.
Cytology of effusions and Head and Neck FNA cytology.
At completion of each of these parts a written evaluation will be provided.
During the entire rotation all current non-gyn cytology cases from the daily workload will be
reviewed as unknowns by the resident and then discussed with the attending cytopathologist
during sign out.
At completion of the rotation an end of rotation exam will be given to the resident.
The resident will evaluate the rotation and the attending cytopathologist/s noting strengths and/or
deficiencies and suggesting appropriate measures for improvement.
THIRD ROTATION: 1 TO 2 MONTHS, NON-GYN CYTOLOGY:
As in the second rotation the resident will divide the entire length of the rotation in equal time
periods which will be dedicated to complete the reading assignments and review the appropriate
teaching materials according to the following program:
Texas Tech University Health Sciences Center
Department of Pathology
Resident Guidelines
VIII
Page 42
RE: Resident Responsibilities
Cytopathology
Revised June 21, 2010
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CSF cytology and Head and Neck FNA cytology.
Urinary tract cytology and Renal FNA cytology.
Lymph Node FNA cytology and other FNA cytology sites.
Comprehensive review.
Similar evaluations as in the second rotation will be conducted during the entire third rotation
including interim and end of rotation evaluations.
All current non-gyn cases will be reviewed by the resident and signed out with the attending
cytopathologist.
The resident will evaluate the rotation and the attending cytopathologist noting strengths and/or
deficiencies and suggesting mechanisms for improvement.
At all times during the cytopathology rotations the residents in cytopathology are required to
attend all FNA procedures, superficial and CT or US guided. The resident should be available at
all times and respond promptly when called for a FNA. When necessary the resident will assist
the attending cytopathologist in preparing and staining smears for on site evaluation, and under
the direct supervision of the attending cytopathologist may perform the aspirate, prepare and
stain the smears and evaluate the material for adequacy. In all cases, however the attending
cytopathologist will be responsible for the final outcome and diagnostic quality of the material
obtained.
RESEARCH:
Under the supervision of an attending cytopathologist, the resident will develop a cytologyrelated research project and work to its completion and submit it for publication in a peer
reviewed journal before the end of his/her pathology training.