Dr. Davey is a trustee of the American Board of Pathology. However, the comments are the opinion of the author and do not represent the opinions of the American Board of Pathology or the American Society of Cytopathology.
Preparing our profession for the future†
The 2007 Papanicolaou Address
Article first published online: 7 FEB 2008
Copyright © 2008 American Cancer Society
Volume 114, Issue 2, pages 67–70, 25 April 2008
How to Cite
Davis Davey, D. (2008), Preparing our profession for the future. Cancer, 114: 67–70. doi: 10.1002/cncr.23342
Presented at the American Society of Cytopathology Annual Scientific Meeting, November 2-6, 2007, Houston, Texas.
- Issue published online: 11 APR 2008
- Article first published online: 7 FEB 2008
- Manuscript Accepted: 14 DEC 2007
- Manuscript Revised: 13 DEC 2007
- Manuscript Received: 4 DEC 2007
Thank you very much for honoring me with the Papanicolaou Award. Receiving this award is one of the high points of my career. Being active in cytopathology and the American Society of Cytopathology has provided many positive benefits: I have learned a lot, made many lifelong friends, and my involvement has kept my career interesting. Whatever I have achieved in cytopathology is the result of support from numerous individuals in the profession. I want to thank everyone who has worked with me in the field, my family, and the faculty and staff at the University of Kentucky. Indeed, it is not about one's individual achievements, but what we can accomplish for patients and the profession together. It's about mentoring individuals in the field and leaving a legacy.
Today I first want to honor Dr. Papanicolaou by talking about his achievements in cervical cytology, then discuss the current status of cytology, and finally my thoughts for the future.
Dr. Papanicolaou was born in Kimi, Greece on May 13, 1883, and his birthday is now celebrated as Cytotechnology Day. He received his medical degree in 1904 but he was not interested in practicing general medicine. He studied a variety of subjects in graduate school including philosophy, anthropology, zoology, and oceanography, and received his doctorate degree from the University of Munich in 1910.1 While serving in the Balkan War, he became interested in moving to America. His first major position was in the Cornell Department of Anatomy in 1914, and his project involved studying the somatic and genetic effects of prolonged alcohol exposure in guinea pigs.1 Dr. Papanicolaou had the opportunity to also continue his studies of sex determination and differentiation in this large animal colony. One of his challenges was how to obtain ova at the correct time. Papanicolaou pondered this problem for some time and awoke one morning with a solution: he surmised that guinea pigs must have a menstrual cycle similar to humans, so he examined the guinea pig females daily for vaginal discharge.1 He determined that guinea pigs have a 15 to 16 day cycle and published his findings with his mentor, Professor Charles Stockard.1
The guinea pig research led to ovulation and hormonal studies in many different species by many laboratories. In 1923, Papanicolaou began his hormonal studies in women and later recorded his first cancer observation. This finding was presented in 1928 at the Third Race Betterment Conference, a gathering of eugenicists, but his report met with indifference and skepticism.1, 2 Papanicolaou temporarily abandoned his cancer studies and returned to his hormonal research. His wife Mary (Andromaque) continued to encourage him in his research and often served as his subject.1 Eventually, he discovered a case of carcinoma in situ of the cervix in 1932 while studying hormonal changes and infertility. A fortunate collaboration with Dr. Herbert Traut, a gynecologist, resulted in grant funding and additional observations on the application of cytology to the detection of cervical cancer. He and Traut published the landmark article “The Diagnostic Value of Vaginal Smears in Carcinoma of the Uterus” in the American Journal of Obstetrics and Gynecology in 1941, followed by the monograph Diagnosis of Uterine Cancer by the Vaginal Smear in 1943.3
Papanicolaou's publications led to confirmatory research by others and a major collaboration with Dr. Charles Cameron, the first Medical and Scientific Director of the American Cancer Society (ACS).4, 5 The ACS put major efforts into promoting widespread cervical cancer screening by the “Pap” test, and sponsored a conference on cervical cancer and cytologic detection in 1948.2 Dr. Papanicolaou advanced to a Professor of Anatomy position at Cornell University and remained in this position until shortly before his death on February 19, 1962.2 Two significant observations from Papanicolaou's story are the often long time-lag between the discovery and acceptance of new scientific observations, and the importance of collaborative efforts.
I will now turn my attention to the current status of cervical cancer screening. The number of Papanicolaou (Pap) tests performed in the U.S. has increased steadily from 1993 to 2003, and a National Health Interview Survey found that over 85% of women born after 1930 had been screened in the previous 3 years.6 Indeed, approximately 65% had been screened in the previous year, and approximately 15% of all Pap tests were vaginal smears status post hysterectomy and most of these vaginal tests were likely unnecessary. By 2010, the projected number of Pap tests performed each year will be 75 million. However, if the 2002 ACS cervical cytology screening guidelines are followed, which include biennial screening in young women, triennial screening in women ages 30 to 70 years, and human papillomavirus (HPV) testing, there should be only 34 million tests performed.6, 7 Increasing use of HPV cotesting as a primary screening test in conjunction with cytology will most likely lead to fewer Pap tests in the future.
The ACS has also published guidelines on the use of the HPV vaccine.8 The vaccine is targeted to girls ages 11 to 12 years and there is no change to the ACS cervical cancer screening recommendations at present because screening does not generally need to begin until age 21 years. However, vaccinated girls without previous HPV exposure will likely have 70% fewer cancers and approximately 40% to 50% fewer high-grade lesions, assuming that there is a long duration of protection by the vaccine.8 The lower risk status of the vaccinated population may lead to a later recommended age to start screening and a longer screening interval. Therefore, even fewer Pap tests will be required in the future.
Given the projected decrease in Pap tests, what is the future of cytopathology? Our goal as a profession is to serve patients, other physicians, and the public by offering the best methods for cancer detection and diagnosis by cytologic and related methods. To remain viable as a profession, we need to remain open to change and adaptation. Pap tests may become a minor part of our work, but we can still offer new diagnostic and screening methods.
What does the public want from us? In my opinion, the public wants accurate diagnoses, timely and economical care, access to new technologies, accountability, and better communication with patient-centered care. They want practitioners to use evidence-based medicine, and increasingly they want medical care provided by specialists who are certified and maintain certification on a regular basis.9
One means of accountability is cytology proficiency testing, which was legislated in 1988 as an effort to protect the public from practitioners with high error rates. However, cytology proficiency testing assesses the 1 type of cytology examination, cervical cytology, that is likely to decrease in the future. Some individuals say that government regulation of our profession is necessary to protect the public as we are not capable of doing so on our own. But how will we be held accountable for other areas of cytology practice? Will we develop individual proficiency tests for each? I certainly hope this is not our future.
Some areas that we can address to remain relevant as a profession are new quality management methods, evidence-based medicine, multidisciplinary approaches to healthcare, and lifelong learning and maintenance of certification. The cytology profession's active participation in the development of consensus guidelines for terminology and management in the areas of cervical, breast, and thyroid cytology are examples of our increasing use of evidence-based medicine. Fine-needle aspiration cytology has encouraged a multidisciplinary approach instead of the silo mentality in healthcare.
In the remainder of my talk, I will discuss maintenance of certification as a means to promote lifelong learning and public accountability. As a disclosure, I am a trustee of the American Board of Pathology (ABP), which administers pathology certification, but my remarks today represent my own opinion.
Cytotechnologists are certified by the American Society for Clinical Pathology (ASCP), which now offers a Certification Maintenance Program (CMP).10 CMP is required for cytotechnologists certified in 2004 or later, and for specialists in cytotechnology certified in 2006 or later. Certificates are valid for 3 years, and the program is optional for those individuals certified earlier. CMP requires 36 points over the 3-year period including 1 point in safety and 2 in the area of the certificate; 10 points in the specialty area are required for the specialist certificate. The points are similar to continuing education units, but may also include coursework, competency assessment by one's employer, publications, thesis work, and serving as a laboratory inspector or an examination committee member.
Maintenance of certification (MOC) is required for all pathologists certified in 2006 or later in both general areas of anatomic and clinical pathology or in the cytopathology subspecialty. The original certificate is good for 10 years if the pathologist participates successfully in MOC. Individuals certified earlier with lifetime certificates are encouraged to participate in either MOC or voluntary recertification, although the original certificate will not be affected.11 All 24 member boards of the American Board of Medical Specialties (ABMS) now have an MOC program, and all have similar general competencies and 4-part MOC structures. The ABP will not require individuals with lifetime certificates to participate in MOC, but it is likely that organizations with a vested interest in maintenance of certification will pressure or require individuals to participate in the future. Examples are state licensing boards, credentialing committees, and third-party payers. In the future, MOC may be linked to maintenance of licensure; this topic is currently being discussed by the Federation of State Licensing Boards. Other ABMS boards are piloting initiatives that would link MOC to pay-for-performance initiatives proposed by the Centers for Medicare and Medicaid Services. There may be other regulatory bodies that also require all physicians to participate in MOC.
Other ABMS board specialties could potentially pressure all board-certified physicians to participate in MOC. Even though the current MOC programs of the ABMS are relatively new, many boards have had time-limited certificates for many years. All individuals certified in family medicine practice with time-limited certificates, and 60% to 75% of physicians with boards in internal medicine, obstetrics and gynecology, surgery, and pediatrics have time-limited certificates. Pathology is in the minority with its small number of practitioners with time-limited certificates. Other specialties in which a majority of physicians currently hold lifetime certificates include radiology, dermatology, and otolaryngology.
Why participate in MOC of CMP? It puts cytologists and pathologists on the same track as other clinicians and is expected by the public. Such programs are prospective and ongoing, and may help prevent more regulatory intrusions by the government. Finally, participation is the right thing to do!
The ABP voluntary recertification is currently a good option for those pathologists with lifetime certificates. This program requires 150 continuing medical education (CME) units over the previous 3 years, with at least 100 being category 1 and at least 80% of the category 1 credits in the individual's practice area.11 Pathologists must also document their practice setting and laboratory accreditation. An optional secure examination will be available for certain circumstances starting in 2008.
The MOC requirements are divided into 4 parts. Part 1 is documentation of professional standing or licensure and practice setting. Part 2 is lifelong learning and self-assessment, and requires an average of 35 category 1 CME units per year with at least 10 in self-assessment modules. Part 3 is a secure examination, and Part 4 includes both peer attestations and practice performance and improvement programs.11 Most pathologists have to document practice setting and CME for licensure, accounting for much of Parts 1 and 2. The CME requirements for licensure vary among states, and self-assessment modules are not generally required for licensure. Laboratory accreditation, interlaboratory comparison programs, and quality management and improvement programs account for most of the Part 4 requirements. Pathologists will need to furnish the names of appropriate individuals for the peer attestation portion of Part 4. Parts 2 and 4 need to be documented every 2 years of the 10-year MOC cycle.11 The Part 3 examination is still under development but is expected to be modular with a variety of practice areas available from which to choose, including breast and gynecologic pathology. To maintain certification in both anatomic and clinical pathology, individuals must choose modules representing each area.
Pathologists have the option of maintaining certification in any or all areas in which they obtained a primary certificate. To increase convenience, the general and specialty examinations may be taken at 1 time. While individuals practicing in only 1 area may initially find it appealing to maintain their certificate in only 1 area, such as cytopathology, this approach could limit future certification options. If certification in an area such as anatomic or clinical pathology is dropped, the pathologist can return the certificate back within 5 years by participating in all MOC areas.11 If the diplomate wishes to regain the certificate after 5 years, the primary certificate examination must be retaken instead. The ABP encourages individuals to maintain their certificates in all areas to preserve the ability to be involved in all areas of pathology practice.11
Participating in certification maintenance programs is 1 way to assure accountability and encourage lifelong learning. Individual proficiency testing in cervical cytology is a bandage approach to regulation for 1 area of our practice. Our educational programs need to stress lifelong learning approaches as well. We cannot teach everything we will ever need to know in undergraduate and graduate education programs, and we cannot test for every cytology technique offered in the future. Our educational approaches need to stress competencies that will allow us to be flexible and adapt to new testing approaches. Interpersonal and communication skills, practice-based learning and improvement, professionalism, and systems-based practice are educational competencies that will allow us to remain relevant in the future. One way that cytologists can demonstrate systems-based practice is to be active in organized medicine and advocate our opinions to regulatory bodies.
Let us soar into a bright future with proven and new diagnostic cytology techniques that will optimize patient care. Promoting lifelong learning competencies and being active in organized medicine are 2 musts for our profession. Thank you again for bestowing the Papanicolaou Award on me.
- 2Dr. Pap's smear: the test & its times. American Medical News. September 3, 2007: 22–23..
- 3The diagnostic value of vaginal smears in carcinoma of the uterus. Am J Obstet Gynecol. 1941; 42: 193–206., .
- 10American Society for Clinical Pathology. Certification Maintenance Program Booklet. Available at: http://www.ascp.org/certification/CMP/ Accessed November 26, 2007.