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February 2009

Residency training in pathology Residency training in pathology

I thank Jared Schwartz, MD, PhD, for leading the CAP with vision, devotion, and passion. I enjoyed reading his January 2009 column, “Winning recipe: minds over matter.” His message has echoed with me so strongly that I am writing to you in the hopes of adding a piece of green to the “stone soup” we are creating.

Last year, Dr. Schwartz visited our institution, Mount Sinai Medical Center in New York, and gave a stimulating presentation to our faculty members in the Department of Pathology. Afterward, I asked him about pathologists performing ultrasound-guided fine-needle aspiration, or USG-FNA. He responded with enthusiasm and excitement and even made a copy of my certificate for performing USG-FNA, issued by the School of Diagnostic Medical Sonography certified by the State of New York.

Before I was trained in advanced sonographic procedures, I performed FNA of palpable masses for 10 years. It is satisfying to see our anxious patients triaged and managed immediately after our on-site FNA diagnosis is made. Many of our clinical colleagues, especially our otolaryngology and head and neck surgery team, understand and appreciate the full benefit of having cytopathologists perform FNA procedures and provide an immediate on-site evaluation and feedback. Many nonpalpable lesions, such as thyroid nodules or any deeply seated lesion, cannot be biopsied by pathologists, which delays patient care and management.

As a group of transformational pathologists, our team decided to expand the horizon of our practice and establish our own USG-FNA service at Mount Sinai, with strong support from the chairmen of our Department of Otolaryngology and Head and Neck Surgery and Department of Pathology. We have been performing USG-FNA at Mount Sinai since July 2008.

With ultrasonographic practice a part of radiology, some may worry about stepping on the toes of our radiology colleagues. At Mount Sinai, the cytopathology USG-FNA service has been complementary to the radiology practice. A patient scheduled for USG-FNA with our radiologists has to wait six to eight weeks; when provided by the cytopathology team, the procedure is same-day service. For patients whose clinical course is likely to be aggressive, the clinicians prefer the cytopathology USG-FNA service.

In the age of personalized medicine, each patient should be cared for with the maximum capacity our health care system can provide. When a radiologist performs USG-FNA, it is often done without an adequacy check or in the presence of the cytopathology team for an adequacy check. In either case, a clinician who referred the patient to radiology would not receive a cytological interpretation in less than two to three days, and often patient care would be delayed for longer than a week because of the difficulty of bringing patients back in a timely fashion.

We are now providing USG-FNA same-day service with immediate on-site evaluation and a preliminary report to patients and clinicians. Mount Sinai patients are evaluated first by clinicians, who call our cytopathology USG-FNA team if the patient is determined to have a mass or lesion (either palpable or indicated by previous ultrasound evaluation). The cytopathology team takes its mobile unit, consisting of a portable ultrasound machine with printer, microscope, and FNA supplies, to wherever the patient is located—cancer center, physician’s office, inpatient bedside, or clinic. We evaluate the patient via ultrasound machine with regard to the nature of the lesion—hyper- or hypoechoic, likely components such as solid or cystic, vascularity, and relationship with the neighboring structures such as carotid artery. This image information is critical, even for a palpable mass which could be aspirated without guidance. With ultrasound guidance, an operator can insert the needle into a more precise target location and avoid bloody or nonrepresentative aspirates. USG-FNA also opens a new door for pathologists—performing FNAs for generally nonpalpable lesions, such as sub-centimeter lesions of the thyroid and breast. Once the target is identified, a plan is made regarding the length of needle to be used, site of entrance, whether local anesthetic is needed, and so on. The rest of the procedure is the same as any conventional FNA. Once air-dried smears have been read on site and a preliminary cytological diagnosis along with ultrasound findings are discussed with the patient and referring physician, the patient is triaged—all during the same visit.

Our pathology colleagues in the New York area have been calling of late to ask how to set up a USG-FNA service. Yesterday, after we finished performing multiple USG-FNAs in our cancer center, the chairman of otolaryngology and head and neck surgery asked me to provide a training course jointly with his team. Does the CAP have a plan to train pathologists to perform USG-FNA? If it does, we would be happy to share our experience and help our pathology colleagues move to the new arena of modern pathology and patient care.

Maoxin Wu, MD, PhD
Director of Cytopathology
Associate Professor
Department of Pathology
Department of Otolaryngology
and Head and Neck Surgery
Mount Sinai Medical Center
New York, NY

 The CAP is developing a certificate program in ultrasound-guided fine-needle aspiration with a focus on thyroid and breast. The program, which will begin this year, will consist of prework requirements and a two-day hands-on, faculty-led workshop that will cover the basic physics of ultrasound imaging, correlating evidence to findings on ultrasound, using ultrasound to guide the needle and perform FNA, using proper technique to create slide smears, and other things. The workshop will conclude with a practical assessment and observation of key skills and techniques practiced throughout the two days. There will also be a cognitive exam.

The program will be offered twice this year: June 9–10 at the CAP and Oct. 9–10 in Washington, DC, before CAP ’09. Participation in these two workshops will be by invitation only. Future workshops will be open enrollment. For more information, send questions to education@cap.org.

—Editor

Point-of-care testing Point-of-care testing

I’ve read CAP TODAY for many years and, in so doing, have read many point-of-care testing articles. I read the most recent such article, “Point of care saga: a tale of three cities” (January 2009), with much amusement. The painfully obvious answer to the POC problem is to place a professional laboratorian at each unit. He or she would not only recognize potential problems but also be able to operate a higher level of bedside testing equipment, thus eliminating some of the problems stemming from the simpler devices. Of course, this would take away from the shrinking staff in the laboratory. The answer to that problem is to graduate more laboratory professionals. Of course, the answer to that problem is to recognize the professionalism of medical technologists. This would mean higher salaries—and that won’t happen.

Barbara Christian Chaviers, BS, MT(ASCP)
Chief Clinical Laboratory Scientist
Stephen F. Austin State
University Health Services
Nacogdoches, Tex.