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Keywords:

  • medical training in cytopathology;
  • international survey;
  • accreditation;
  • postgraduate training;
  • cytopathology examinations

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References

Anshu, A. Herbert, B. Cochand-Priollet, P. Cross, M. Desai, R. Dina, J. Duskova, A. Evered, A. Farnsworth, W. Gray, S. S. Gupta, K. Kapila, I. Kardum-Skelin, V. Kloboves-Prevodnik, T. K. Kobayashi, H. Koutselini, W. Olszewski, B. Onal, M. B. Pitman, Ž. Marinšek, T. Sauer, U. Schenck, F. Schmitt, I. Shabalova, J. H. F. Smith, E. Tani, L. Vass, P. Vielh and H. Wiener Survey of medical training in cytopathology carried out by the journal Cytopathology

This report of the Editorial Advisory Board of Cytopathology gives the results of a survey of medical practitioners in cytopathology, which aimed to find out their views on the current situation in undergraduate and postgraduate training in their institutions and countries. The results show that training in cytopathology and histopathology are largely carried out at postgraduate level and tend to be organized nationally rather than locally. Histopathology was regarded as essential for training in cytopathology by 89.5% of respondents and was mandatory according to 83.1%. Mandatory cytopathology sections of histopathology were reported by 67.3% and specific examinations in cytopathology by 55.4%. The main deficiencies in training were due to its variability; there were insufficient numbers of pathologists interested in cytology and a consequent lack of training to a high level of competence. Pathologists without specific training in cytopathology signed out cytology reports according to 54.7% of responses, more often in centres where training was 3–6 months or less duration. Although 92.2% of respondents thought that specialist cytology should not be reported by pathologists without experience in general cytopathology, that practice was reported by 30.9%, more often in centres with small workloads. The survey report recommends that 6–12 months should be dedicated to cytopathology during histopathology training, with optional additional training for those wanting to carry out independent practice in cytopathology. Formal accreditation should be mandatory for independent practice in cytopathology. When necessary, temporary placements to centres of good practice should be available for trainees intending to practise independently in cytopathology. There should be adequate numbers of pathologists trained in cytopathology to a high level of competence; some of their time could be released by training cytotechnologists and trainee pathologists to prescreen cytology slides and assess adequacy of fine-needle aspiration samples when immediate diagnosis was not required. The survey demonstrated a clear need for European and international guidelines for training in cytopathology.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References

Members of the Editorial Advisory Board and many of their colleagues were conscious that there might be problems in training pathologists in the clinically diverse speciality of cytopathology at a time when fine-needle aspiration (FNA) cytology should be developing rapidly to support new methods of specimen procurement1 and exfoliative cytology continues to play an important role in patient management and screening.2 In many places with active cervical screening programmes time dedicated to ‘non-gynaecological’ cytopathology may be compromized by increasing demands from workload and quality control in cervical cytology.3 Now that cervical screening is likely to be modified (especially in its volume) by human papillomavirus testing4 and vaccination,5 non-gynaecological cytopathology should flourish, but only if teaching and training are available to a high standard. Our observations take account of the Bologna principles6 for higher education and training and should be considered by the European Union of Medical Specialists (UEMS), with which the European Federation of Cytology Societies (EFCS) and European Society of Pathology have both been working.

The aims of this survey were directed at specialists practising in cytopathology to elicit their views on the current situation in undergraduate and postgraduate teaching and training in cytopathology in their countries and institutions. We aimed to find out what they regarded as the essentials of good training, what were thought to be examples of good practice and what were deficiencies in training. We also aimed to link these training practices to consultant pratice and laboratory workloads in the institutions from which responses were received. Finally, we aimed to publish the results of this survey as an evidence-base for those wanting to improve cytopathology training in Europe and elsewhere in the world. Our aims are consistent with those of the Bologna declaration for higher education and training, recognizing the need for common reforms and coordinated action with comparable and compatible criteria for education and practice.8

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References

A draft questionnaire was discussed and validated at the Cytopathology Editorial Advisory Board meeting in June 2008. It included both closed- and open-ended questions. The survey questionnaire was uploaded onto an online survey site (http://www.surveymonkey.com) and the link was circulated to representatives of cytology societies by email with an appeal to circulate it widely. Among other medical practitioners in cytopathology, survey respondents included members of the Advisory and Management Boards of Cytopathology, representatives of societies affiliated to Cytopathology and officers of member societies of the EFCS. The survey was advertised on the EFCS website (http://www.efcs.eu), which proved to be a useful site for this type of communication.

The survey was divided into five parts: (1) curriculum design, (2) undergraduate training, (3) postgraduate training, (4) assessment of training and (5) consultant workloads and practice in cytopathology. All analyses were calculated for total respondents and countries as a whole and where relevant both analyses are presented.

Chi-square test was used as a test of significance to compare difference between proportions. Statcalc calculator in the EPI INFO 6 software was used for calculation of Chi-square tests.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References

We received responses from 76 individuals from 26 countries including: Australia, Canada, Chile, Croatia, the Czech Republic, Denmark, France, Greece, India, Italy, Kuwait, New Zealand, Norway, Portugal, Romania, Russia, Singapore, Slovenia, Spain, Sudan, Sweden, Switzerland, Turkey, the United Kingdom (UK), Uruguay and the USA (Figure 1). There was a single respondent from each of 15 countries, two from six countries, three from four and seven from one. As it was not mandatory to reveal personal details in the survey questionnaire, 27 respondents did not provide details of position or place of work and not all respondents answered all the questions. Respondents had received training in cytology from 27 different countries, all except one in the country where they practised.

image

Figure 1.  Map showing distribution of respondents across the world.

Download figure to PowerPoint

Curriculum design

Of 69 responses, 46 (66.7%) said that the medical school curriculum was designed at national level. The curriculum was designed at regional level according to nine (13.0%), while according to 14 (20.3%) it was designed at the level of the individual institution, where schools had the freedom to tailor their curriculum according to their needs. Conventional learning was said to be used by 46 (66.7%) medical schools, while 16 (23.2%) followed a horizontally or vertically integrated curriculum. In 15 (21.7%) schools, problem-based learning was used. In six schools there was a combination of conventional and problem-based learning and two had all three forms of curricula.

Undergraduate training

Organization of undergraduate teaching  Nine of 68 (13.2%) respondents said that cytopathology was included as a defined course in the medical curriculum while 59 (86.8%) said it was not a defined course. Of the nine respondents who said that their schools had cytopathology as a defined course, the duration of that course was less than a year in six, 1–2 years in two and more than 2 years in one school. Four respondents who said that cytopathology was not a defined course said that the subject was taught for less than a year. On the other hand, histopathology was included as a defined course in the medical curricula of 53 of 70 (75.7%) respondents’ countries. Of the 53 respondents who said that histopathology was a defined course, 18 (33.9%) said that the modules lasted less than a year. Nineteen (35.8%), six (11.3%) and five (9.4%) respondents said that courses lasted 1 year, 2 years and 3 or more years, respectively, while five of them did not specify the duration of the course. These percentages were similar in replies for 26 named countries as a whole, where cytopathology was not a defined course in their undergraduate curriculum in 21 (80.8%), but histopathology was a defined course in the curriculum in 17 (65.4%). Responses varied among respondents in 11 countries.

Histopathology was included as part of multidisciplinary clinical teaching sessions in 40 (59.7%) of 67 respondents’ medical schools. Of these 40, histopathology was included in the teaching sessions after the third year in 22 (55.0%) of the respondents’ medical schools, in the third year in 13 (32.5%), in the second year in three (7.5%) and in the first year in two (5.0%). Cytopathology was used in the clinical teaching modules in 33 (49.3%) of 67 respondents’ medical schools. Respondents reported including cytopathology training in several other formats at the undergraduate level. Most medical schools included cytopathology in lectures but not in practical training.

Several respondents reported that cytopathology was taught as part of the pathology-histopathology course, eight respondents reported that it was included as part of the gynaecology course and one respondent each reported that it was taught during the medical, surgical and radiation oncology or internal medicine course. In two schools cytopathology was offered as an optional subject or taught only when it came up as part of a systemic course or case discussion.

Postgraduate training

Organization of postgraduate training  Of 63 replies to the question, 76.2% said that postgraduate training was organized at a national level (in four of these it was also regional, institutional or both), 1.6% said it was at a regional level, 20.6% said it was institutional and 1.6% said ‘other’. Cytopathology was integrated into histopathology training according to 50 (79.4%), of whom 58.0% said that exposure was continuous. These percentages were similar in replies for 26 named countries, of which 76.9% said organization was national (four of these recorded institutional organization as well), 69.2% said that cytopathology was integrated into routine histopathology training and 50% of those had continuous exposure.

Time dedicated to cytopathology training  Of 60 replies to this question, 44 (73.3%) said there was a defined time for cytopathology training. Twenty-four (40.0%) said the defined time for cytopathology training was 6–12 months or more, 20 (33.3%) said training lasted for 3–6 months or less while 16 (26.7%) said there was no defined time dedicated to training. Defined time varied when there was more than one response from the same country, probably because trainees in some centres were able to undertake specialist training. Thus, in 26 named countries responses were variable in nine; five said the defined time for cytopathology was 6–12 months or more, five said 3–6 months or less and six reported no defined time. This contrasted with histopathology training, which 70.7% of 58 respondents said was for more than 3 years and 86.2% for at least 2–3 years; in 26 named countries, 69.2% reported histopathology training for more than 3 years and 88.5% for at least 2–3 years. There were 51 individual responses concerning the year of histopathology training during which cytopathology started, but there was either no response or they varied in 12 (46.3%) of 26 countries. Responses were not significantly different between the first year (15, 29.4%), second year (19, 37.3%) and final year (17, 33.3%). Cytopathology training was separate from histopathology training according to 58.9% of 56 replies.

Histopathology as a requirement for cytopathology training  Ten (16.9%) of 59 respondents said that it was possible to train in cytopathology without histopathology while 49 (83.1%) said it was not. Five of those 10 answering ‘yes’ to this question mentioned non-medical degrees as criteria for entry into training. An open question as to whether histopathology training was essential for cytopathology elicited a positive response in 89.5% of 57 replies. Two others said it was essential ‘to a certain level, especially for non-gynaecological cytology’ and one said it was ‘not essential but very, very useful’. Only one response, from a laboratory with non-medical graduates training in cytopathology, said ‘unfortunately, not’. Gynaecologists, haematologists, microbiologists, oncologists and ‘doctors during specialist education’ were able to train in cytopathology according to seven free-text responses. In four of these they also trained in histopathology. According to one response, limited responsibility was given to peumonologists and neurologists to report cytology.

Cytology practice during training  Trainees were more likely to screen unmarked gynaecological (87.7%) or non-gynaecological (85.7%) slides and prepare their own draft reports (89.1%) than they were to attend rapid on-site evaluation of slides (71.7%), carry out their own FNAs (67.9%) or sign out reports at a defined stage of training (36.4%) (Table 1). The trend was more pronounced in responses combined for named countries as a whole. Non-medical cytologists contribute to cytology training of medical trainees in 16 (61.5%) countries.

Table 1.   Trainee practice and examinations in cytopathology
Training practiceAll responses (maximum 77)26 countries (*one no response)
YesNoTotalYesNoYes & no
Response rate 67.5–75.3%
  1. (n) = percentage.

  2. gyn, gynaecology; non-gyn, non-gynaecological; FNA, fine needle aspirate.

Screen unmarked gyn slides50 (87.7)7 (12.3)5722 (84.6)4 (15.4) 
Screen unmarked non-gyn slides48 (85.7)8 (14.3)5619 (73.1)3 (11.5)4 (15.4)
Prepare draft reports49 (89.1)6 (10.9)5521 (80.8)3 (11.5)2 (7.7)
Attend rapid assessment FNAs40 (71.7)16 (28.6)5613 (50.0)9 (34.6)4 (15.4)
Carry out FNAs38 (67.9)18 (32.1)5614 (53.8)9 (34.6)3 (11.5)
Sign out reports at defined time in training*20 (36.4)35 (63.6)555 (19.2)14 (53.8)6 (23.1)

Examples of good practice given as free-text comments focused on (1) additional specialist training (n = 10), (2) good local departments and enthusiasm of cytopathologists (n = 9), (3) formal specialist courses, examinations and accreditation (n = 8), (4) interaction with clinical teams (n = 6), (5) practice and hands-on experience under supervision (n = 5) and (6) training along with histopathology (n = 5). Others (n = 3) said what good training ‘should be’ and one mentioned improvement in gynaecological cytopathology training after a national screening debacle. There were no responses to this question from 30 of 76 respondents. Some respondents mentioned more than one of these features as in the quotation in the text box below. There was no correlation between these broad groups of responses about good practice and size of workload or time dedicated to cytopathology training.

An example of good practice in training

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References
  •  •
    Connection with other clinicians (gynaecologists, haematologists, oncologists)
  •  • active participation in FNA

  •  • direct contact with patients

  •  • participation in treatment planning

  •  • training in histopathology.

All of these are contained in a 3-year programme of independent training (specialisation) in clinical cytology.”

Examples of deficiency in training focused on (1) lack of experienced cytopathologists in many centres (several said that most pathologists were not interested in cytology) and variability of training (n = 9), (2) lack of specific cytopathology training or time for that training (n = 9), (3) lack of equipment, facilities and time for overworked cytopathologists (n = 8), (4) the need for better integration of cytopathology with histopathology (n = 5), (5) lack of training to a high level of competence (n = 4) and (6) neglect of gynaecological cytology (n = 2) or it being not available when cervical cytology was centralized (n = 1). Single respondents mentioned the problem of cytopathology/histopathology subspecialization, the need for standardized terminology, lack of government and clinicians’ awareness of biomedical scientist (cytotechnologist)/pathologist interaction. Four replies made no specific points and 30 of 76 respondents did not answer this question.

Lack of equipment, facilities and time for overworked cytopathologists were related to centres with 6–12 months or more of training in cytopathology (seven of eight responses). Problems with integrating cytopathology into histopathology and lack of training to a high level of competence were related to centres with no defined time or 3–6 months or less dedicated to cytopathology training (four of four and five of five comments in those categories, respectively). There was no correlation between these responses and size of workload.

Examples of deficiencies in training

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References
  •  • “Insufficient time to gain experience

  •  •“Insufficient numbers of pathologists with an interest in cytopathology to provide training

  •  • “It is a ‘desert island’ from where it ought to be easy to go to Europe for homogenous guidelines rather than aiming for local or even national initiatives

Assessment of Training

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References

Mandatory examinations in pathology exist in 45 (81.8%) of 55 respondents’ countries. Cytopathology is a mandatory section of the histopathology postgraduate examination in 35 of 52 (67.3%) of the respondents’ settings. Of 55 respondents, 31 (56.4%) said that there were no separate postgraduate examinations in cytopathology. According to 32 (58.2%) of 55 responses a specialist cytopathology examination was not required for independent practice in cytopathology.

A mandatory pathology qualification (histopathology/cytopathology) exists in 49 (89.1%) of 55 respondents’ countries. These degrees are awarded by national, regional or institution-based agencies. Certain overseas qualifications (such as MRCPath) were not accepted in the work settings of 28 (51.9%) of 54 respondents.

Cytopathology workloads and consultant reporting practice

Cytopathology workloads  The variation in workloads (defined by number of specimens received per year) of gynaecological cytology, FNA and exfoliative cytology handled by 42 and 46 respondents who gave information about their laboratories is shown in Table 2. For purposes of analysis, non-gynaecological cytology workloads have been divided into small (< 1 000 tests per year), medium (1 000–5 000 tests per year) and large (> 5 000 tests per year). For analysis, gynaecology laboratories have been divided into those above and below 10 000 tests per year. Workloads for FNAs and exfoliative cytology varied from below 100 to 25 000 requests per year. Cervical cytology workloads varied from 100–500 to 200 000 requests per year; those defined as ‘large’ processed a range of 13 000–200 000 with an average of 38 000 per year. The balance in terms of large, medium and small laboratories is shown in Table 2.

Table 2.   Workloads reported by respondents
Tests per yearGynaecologyFNAExfoliative cytology
< 1 00021110
1 000–5 00081917
5 000–10 00061415
10 000+2624
Total responses to the question424646

Consultant reporting practice  Of 55 respondents, 87.3% said that cytopathologists attend multidisciplinary meetings and contribute to clinical decisions on patient management. Pathologists without specific training in cytopathology sign out cytopathology reports according to 54.7% of 53 responses. Pathologists report specialized cytology for a particular system without experience in general cytopathology according to 30.9% of 55 responses. Medical practitioners from other specialties report cytopathology according to 15.1% of 53 responses and non-medical cytologists report non-gynaecological cytology according to 16.3% of 49 responses. These percentages are shown in Tables 3–5. According to 48.1% of 54 responses, non-medical staff report cervical cytology.

Table 3.   Consultant reporting practice according to cytopathology time
Consultants signing out cytopathologyCytopathology training timeNo ResponseTotal
Nil, 3-6 months or less6-12 monthsor more
Specialist reporting without experience in general cytopathologyYes106117
No2116138
%‘yes’ response 32.327.3 30.9
Pathologists without specific training in cytopathologyYes225229
No816024
%‘yes’ response 73.323.8 54.7
Medical practitioners from other disciplinesYes5308
No2519145
%‘yes’ response 16.713.6 15.1
Non-medical staff reporting non-gynaecological cytologyYes5308
No2317141
%‘yes’ response 17.915.0 16.3
Table 4.   Consultant reporting practice according to FNA workload
Consultants signing out cytopathologyFNA workloadNo responseTotal
LargeMediumSmall
Specialist reporting without experience in general cytopathologyYes546217
No12155638
%‘yes’ response 29.421.154.5 30.9
Pathologists without specific training in cytopathologyYes8116429
No885324
%‘yes’ response 50.057.954.5 54.7
Medical practitioners from other disciplinesYes23218
No15169545
%‘yes’ response 11.815.818.2 15.1
Non-medical staff reporting non-gynaecological cytologyYes14308
No14147641
%‘yes’ response 6.722.230.0 16.3
Table 5.   Consultant reporting practice according to exfoliative cytology workload
Consultants signing out cytopathologyExfoliative cytology workloadNo responseTotal
LargeMediumSmall
Specialist reporting without experience in general cytopathologyYes546217
No14134738
%‘yes’ response 26.323.560.0 30.9
Pathologists without specific training in cytopathologyYes1087429
No893424
%‘yes’ response 55.647.170.0 54.7
Medical practitioners from other disciplinesYes41218
No15168645
%‘yes’ response 21.15.920.0 15.1
Non-medical staff reporting non- gynaecological cytologyYes32308
No15126641
%‘yes’ response 16.714.333.3 16.3

According to 51 free-text replies, 92.2% thought that experience in general cytopathology was essential for specialist cytopathology reporting while three thought it should be essential and only one thought it should not. According to 61.5% of 53 free-text replies, non-pathologists should not report cytopathology. Nine respondents (17.3%) thought that ‘trained and certified technicians’ could report in areas with many normal cases such as the cervix, sputum and urine. Two (3.8%) gave an unqualified ‘yes’ to this question and four (7.6%) said ‘yes’ if correctly trained and with the supervision of a cytopathologist. Two said that gynaecologists may report cervical cytology. There was little mention of cervical screening cytology in these free-text responses, which did not reflect the widespread practice of non-medical staff reporting and signing out such cytology.

Who should report cytopathology?

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References
  •  • “I personally favour cytopathologists signing out, particularly abnormal gynaecological cytology and general cytology, because there is often ‘value added’ by a clinical perspective on the cellular pattern.

  •  • “Specially trained medical technicians do a very good job as screeners in cytopathology and also relieve the pathologists of a large load of normal/negative smears and reporting.

Correlation between reporting practice, training and workload Tables 3–5 show the reporting practice of (1) specialists with no general cytopathology experience, (2) general pathologists with no specific training in cytopathology, (3) non-pathologist medical practitioners and (4) non-medical staff reporting non-gynaecological cytology. These practices were tabulated against time dedicated to cytopathology training (Table 3), FNA workload (Table 4) and non-gynaecological cytology workload (Table 5). We decided to use total responses rather than those for individual countries because the latter were frequently variable, reflecting practices in different institutions in the same country.

The likelihood of pathologists without specialist cytopathology training reporting cytopathology was related to the time dedicated to cytopathology training. Pathologists without specialist training reported cytopathology in 73.3% centres where 3–6 months or less was dedicated to cytopathology training as against 23.8% of centres where 6–12 months or more were dedicated to cytopathology training (P = 0.0005). There was no association between the relatively small percentages of medical practitioners of other specialities and non-medical staff, respectively, and time dedicated to cytopathology training or workload.

There was a correlation between small workloads for FNA and exfoliative cytology and the likelihood of pathologists without experience in general cytology reporting specialized cytopathology. The percentage answering ‘yes’ to that question represented 25% of those with medium and large workloads of exfoliative and FNA cytology compared with 60% of those with small exfoliative cytology workloads and 54.5% with small workloads of FNA cytology. The difference was significant for exfoliative cytology (P = 0.037) but not for FNA cytology (P = 0.066). There was no correlation between likelihood of gynaecological cytology being reported by non-medical staff and time dedicated to training but there was an association with workload. Among 16 respondents with workloads below 10 000 per year, 31.3% answered ‘yes’ to non-medical staff reporting gynaecological cytology compared with 63.0% of 27 with workloads of 10 000 or more (P = 0.04).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References

This survey showed that the majority of undergraduate and postgraduate training was organized at a national level, suggesting that improvements to training should be focused on governments rather than individual institutions. Perhaps not surprisingly, cytopathology was less likely than histopathology to be a defined undergraduate course (13.2% compared with 75.7%). Histopathology was only included in 59.7% of multidisciplinary clinical sessions and cytopathlogy in 49.3% of these clinical teaching modules, reflecting a relatively low level of exposure to pathology in general. However, in some medical schools cytopathology was taught as part of histopathology, gynaecology, oncology, surgery and internal medicine, demonstrating its wide clinical relevance as a discipline.

As with histopathology, the low level of cytopathology teaching at undergraduate level means that training must almost entirely be carried out at postgraduate level. One of the most consistent findings in this survey was the importance of histopathology as a basis for cytopathology training. Histopathology training was mandatory for training in cytopathology in 83.1% of respondents’ countries and an overwhelming majority of respondents (89.5%) regarded it as essential. Qualifications and examinations for histopathology and cytopathology were usually combined (more than 80%). Although 67.3% of respondents reported mandatory cytopathology sections of examinations, mandatory cytopathology courses and separate examinations were less common, which was identified as a deficiency in training. ‘In Europe, we only know of a postgraduate diploma in France (7) and the Royal College of Pathologists Diploma in Cytopathology, which is available but no longer used in the UK (8).’ The lack of integration of cytopathology into histopathology was also cited as a deficiency. However, the main deficiencies in cytopathology training were the variability of training, the lack of specifically trained cytopathologists in many centres, the lack of training to a high level of competence and the overwork and shortage of training facilities in those centres that did have trained cytopathologists and potentially good training programmes. The over-riding problem is that while histopathology is essential for training in cytopathology, ‘most pathologists have no interest in cytology’.

One of the problems identified in the survey was the lack of training to a level of competence, which must be a serious problem when so many posts include cytopathology in their job description and 87.3% attend multidisciplinary meetings and contribute to decisions on management of patients. Furthermore, cytopathologists in centres of good practice carry out FNAs themselves, provide immediate diagnoses and contribute to image-guided biopsy sessions.

Training in cytopathology was more likely to involve screening slides than gaining hands-on experience with FNA and rapid assessment and less than a third of trainees gained sufficient experience to be allowed to sign out reports. Examples of good practice in cytopathology cited ‘connection with other clinicians (gynaecologists, haematologists, oncologists), active participation in FNA, direct contact with patients, participation in planning of therapeutic approach (along with) training in histopathology’, demonstrating the added clinical perspective that a training in cytopathology requires; it is not a training that should be confined to the examination of slides.

It was unusual for non-medical degrees to be acceptable for entry into cytopathology training and medical graduates from other specialties were usually (but not always) required to train in histopathology as well. Although non-medical staff sign out negative cervical cytology according to 48.1% of responses, particularly in laboratories with larger workloads, they rarely sign out non-gynaecological cytology, except in some instances negative sputum and urine. Nevertheless, non-medical staff contributed to cytopathology training according to more than half of responses, supporting the comment that there are ‘insufficient numbers of pathologists with an interest in cytopathology to provide the training’. In view of the important role that well-trained cytotechnologists play in cervical screening cytology, their role could usefully be expanded by formally training them to pre-screen non-gynaecological cytology specimens and perhaps to assess cytology sample adequacy in situations where a cytopathologist was not needed to provide a diagnosis on site.

The length of time dedicated to training in cytopathology was highly variable and frequently depended on the local enthusiasm of cytopathologists, often with insufficient time and resources. There was at least 6–12 months for cytopathology in 40% of responses compared with at least 2–3 years for histopathology in 88.5%. The brief time dedicated to cytopathology was frequently cited as a deficiency in training. Although this survey provides information about opinion and practice of cytopathology, the importance of who reports what and how much training is required depends on clinical audit, correlation with histopathology and outcome, none of which is available in this survey. However, we thought that variations in reporting practice should be correlated with time dedicated to cytopathology training and workload to see whether any patterns emerged. There was a correlation between training times of 3–6 months or less and likelihood of pathologists without specific training in cytopathology signing out reports, and this practice was reported in 54.7% of responses. Furthermore, there was a correlation between centres where training was 3-6 months or less and respondents saying that there was insufficient integration of cytopathology into histopathology training and a lack of training to a high level of competence. Although 92.2% of respondents thought that specialist cytology should not be reported by pathologists without experience in general cytopathology, that practice was reported in 30.9% of responses and correlated with laboratories with smaller workloads.

We have demonstrated serious deficiencies in cytopathology training as well as insufficiencies in manpower and resources in places with potentially adequate programmes. What is the way forward and what can be gained from this survey? It is clear that cytopathology training is overly dependent on local centres of excellence and that training is variable, often concentrating on microscopy alone rather than the clinical aspects of the speciality. A vicious cycle of inadequate training and insufficient trainers can only be broken by increasing the amount of time dedicated to cytopathology training, if necessary by seconding trainees (as temporary placements) to centres where adequate training is available, and providing mandatory requirements for independent practice. As this is unlikely to be achieved at a local or even national level it should be taken at least to the level of the EFCS and perhaps the European Union, for example through UEMS, so that guidelines can be produced that overcome the unfortunate but unacceptable fact that ‘most pathologists have no interest in cytology’. The overwhelming opinion that (1) a medical qualification and (2) training in histopathology are essential for practice in cytopathology and the growing importance of direct involvement with patient care and attendance at multidisciplinary meetings and biopsy procedures make it necessary to regard cytopathology as a ‘superspeciality’ rather than a ‘subspeciality’ and grant it the level of training it deserves.

Recommendations

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References
  • • 
    6-12 months should be dedicated to cytopathology during histopathology training with optional additional training for those wanting to carry out independent practice in cytopathology.
  • • 
    Formal accreditation (preferably with specialist examinations) in all types of cytopathology should be mandatory for independent practice in cytopathology, including specialist cytopathology.
  • • 
    When necessary, temporary attachments (secondments) to centres of good practice should be available to trainees intending to practise independently in cytopathology.
  • • 
    There should be adequate numbers of pathologists trained in cytopathology to a high level of competence; some of their time could be released by training cytotechnologists and trainee pathologists to pre-screen non-gynaecological cytology slides and assess adequacy of FNAs when immediate diagnosis is not required.
  • • 
    European and international guidelines for training and accreditation in cytopathology should be developed with some urgency.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. An example of good practice in training
  7. Examples of deficiencies in training
  8. Assessment of Training
  9. Who should report cytopathology?
  10. Discussion
  11. Recommendations
  12. References