College of American Pathologists
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  Case numbers: How few are too few? When do you lose skills?


CAP Today




January 2012
Cytopathology And More

Christine Noga Booth, MD

Q. There are regulations regard-ing the maximum number of slides that cytotechnologists can review in a certain period. Are there standards regarding the minimum acceptable number of cases that a pathologist should review in a certain time frame to practice safely?

A. There is no existing literature that addresses pathologist review of too few cases. However, this question does bring to light the need for a robust quality assurance program within the cytopathology laboratory as well as the need for educational activities and proficiency testing. There are no standards regarding a minimum number of required cases to maintain proficiency, and it would be extremely difficult to create a standard that can apply to every type of cytopathology practice.

A good quality assurance program should be able to identify when issues arise and allow for ways to address those issues. Quality control measures, such as cytologic-histologic correlation and peer review, can help to identify quality issues. This information can then be used to develop a plan to ensure quality in the future. For example, if a pathologist encounters a fine-needle aspirate from an unusual site or if there is a low volume of a certain specimen type within the laboratory, there are several ways to handle the situation. The laboratory could create a policy that either requires mandatory review of these low-volume specimens by a second pathologist from within the same laboratory or requires that the case be sent out for a second opinion from a consulting pathologist.

Physicians are required to have a minimum number of continuing medical education hours each year per state regulations to maintain state licensure. For pathologists who result Pap tests (even one per year), there is an annual proficiency testing requirement with a minimum passing score that was first implemented in 2005. This requirement was outlined in the Code of Federal Regulations from CLIA ’88 42 CFR 493.855(a), which says: “The laboratory must ensure that each individual engaged in examination of gynecologic preparations is enrolled in a proficiency testing program approved by the Centers for Medicare and Medicaid Services and is tested annually.” Pathologists who review both histologic and cytologic gynecologic specimens for internal quality control or quality assurance and in which there is a potential for a change in diagnosis as a result of their review must also participate in proficiency testing.

Pathologists who completed their initial American Board of Pathology examination in 2006 or after are additionally required to complete yearly steps for maintenance of certification by successfully completing self-assessment modules as well as recertifying every 10 years. The ABP also offers maintenance of certification to pathologists without a time-limited certificate through the same program on a voluntary basis.

Pathologists can participate in laboratory continuing education activities by being involved in journal clubs, leading a review of cases from educational glass slide programs, and discussing online cytopathology educational cases with cytotechnologist and pathologist colleagues. Though no specific standards are set in regard to a minimum number of cytopathology cases needed to maintain proficiency, we can be creative and innovative in our approach to meet the needs of the patients we serve.

Dr. Booth is a staff pathologist and cytopathology fellowship program director in the Pathology and Laboratory Medicine Institute at the Cleveland Clinic. She is the American Society of Cytopathology liaison to the CAP Cytopathology Committee.

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