Authors: Sara E. Monaco MD1, Haiyan Liu MD2

Affiliations:

  1. Cytopathology Fellowship Program Director, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA
  2. Cytopathology Fellowship Program Director, Geisinger Medical Center (GMC), Danville, PA

The cytopathology fellowship training programs in the United States have been experiencing new and unexpected challenges in the past couple of weeks due to the arrival of the coronavirus disease 2019 (COVID-19). The new measures to contain the SARS-CoV-2 virus, including social distancing and use of personal protective equipment (PPE), have impacted every aspect of our personal and professional lives as learners and educators.[1]. For cytopathology fellowship programs in particular, the COVID-19 outbreak has created an onslaught of new issues and opportunities that programs and hospitals have had to deal with. Some of the issues are discussed as follows:

  1. Cytology Case Sign-out: Given the emphasis on social distancing measures to contain the spread of the virus, most institutions have eliminated double scoping, and opted for more independent sequential slide review by the fellow and then the attending pathologist. This sequential slide review model is most likely an issue for inexperienced trainees, such as first or second year residents (PGY1 and 2), who typically need more guidance with double scoping in order to recognize diagnostic cellular features. For the fellows, this sequential sign out may pose more of an issue on challenging cases and on cases where they are uncertain of the diagnosis. Thus, there is a real need for closing the loop and returning challenging cases to the fellow with an explanatory note or comment about the final report details or cytological findings, therefore providing valuable feedback. On follow-up review, the fellow or resident has the opportunity to revisit the case and spend as much time as they need to understand the cytological features that were missed or misinterpreted. Furthermore, reading the final signed out report allows the learner to understand the verbiage and formatting of the results that the attending pathologist used, and provides additional feedback.
  1. Self-directed online learning: Most hospitals have cancelled large group gatherings, including most educational conferences, such as grand rounds, journal clubs, didactics and other meetings. As an alternative to cancelling, some institutions have moved these educational sessions to online meetings or other remote conferencing modalities. The advantages of distant e-learning are that the fellows can target those online resources that cover areas of their own interest or areas of weakness, and can find materials that match their learning style (e.g. podcasts, live webinars, and online interactive slide sessions). Some of the online resources covering a variety of cytopathology, pathology and other medicine related topics are summarized in Table 1. [TABLE 1] This distant learning experience also allows fellows to gain familiarity with the variety of online resources available, and may lead to an increase in trainees becoming members in professional societies, as they realize the hard work by various pathology societies in providing these educational resources and the fact that some of the valuable resources are only available to members. This type of learning often provides CME or SAM credits, which are advantageous for the American Board of Pathology (ABPath) Maintenance of Certification (MOC) requirements. Some cytology practices are also incorporating mini-assignments for reading or self-assessment questions to supplement service work during this time of distant learning.
  1. Case volume & Service responsibilities: Most hospital cytology laboratories rely heavily on outpatient elective procedures for case volume; however, during this viral outbreak, there has been a reduction or elimination of elective procedures given the need to allocate healthcare resources to critically ill patients with the SARS2-CoV-2 virus. This allows cytopathology fellows the time to focus on learning from other educational resources or slide study sets, opposed to the routine busy service work. In addition, the shortening of their work schedule allows them to have more time for responsibilities at home or in their personal lives. Some institutions have also allowed fellows or other trainees the option to swap service weeks for an educational elective from home, if they need to be home for personal reasons or for self-quarantine after travel or exposure to the virus. The educational resources in Table 1 can provide hours of online learning that a trainee could use to substantiate a home or off-site educational elective.[TABLE 1]. Another opportunity that has come up for trainees is the ability to volunteer for alternative services that may need help or coverage during this time, including clinical pathology rotations, filling hospital needs in viral testing or clinical services that are seeing an increased demand.
  1. Pathologist performed Fine Needle Aspiration (FNA) and FNA Clinic Services: Cytopathology laboratories have varying practices for FNAs performed by pathologists, even during this time. During this pandemic, some institutions may suspend the activity of a pathologist-run FNA clinic, while others may be doing procedures on a limited or case-by-case basis; however, either way, the availability of performing pathologist-performed FNA biopsy procedures is likely limited at this time. For those that perform FNAs in small clinic rooms, there may be a limitation for the number of staff members to be present during the biopsy procedure, which could potentially exclude a trainee from being present, or the attending cytopathologist may designate the cytotechnologist or fellow to be present at different parts of the procedure. Some of the reasoning behind suspending or limiting FNA clinic procedures are to limit the unnecessary use of masks or other PPE, to reduce the risk of exposure to potential COVID-19 carriers, and to practice social distancing to flatten the epidemiological curve of the pandemic by postponing unnecessary procedures that could be performed at a later time when stay at home orders are lifted.
  1. Rapid On-site Evaluation (ROSE): Clinical judgement should be used to determine if ROSE is absolutely necessary for the success of the biopsy procedure and to determine which members of the cytology team should be present. With the shortage of PPE nationwide, many hospitals are trying to limit the number of individuals present during procedures; therefore, the cytopathology fellow or cytotechnologist may have to decide who will go on-site for slide preparation, staining, and triage. In addition, the fellow should be aware of any changes in the specimen handling instructions during the pandemic (see item #6), before going on a ROSE procedure alone, given that some institutions are limiting the preparation of smears, limiting air-dried specimens, or utilizing alternative rapid stains on alcohol fixed slides (see #6 on specimen processing). For ROSE in high-risk settings with the potential for aerosolization of droplets (e.g. bronchoscopy suite), N95 masks, eye protection, and face shields, in addition to other PPE, are highly recommended; the operating room or bronchoscopy suite staff should provide the same PPE that its operators and assistants are wearing to the cytology personnel. In addition, the staff or electronic medical record should have a way of indicating if a patient is a person under investigation (PUI) for COVID-19 or if they tested positive, and in these situations, there should be institutional guidelines established for specimen handling. If there are multiple procedures in one day, limiting the involved cytology personnel to one individual can be helpful, so that the same PPE can be used for multiple procedures.
  1. Specimen Processing: The virus can be inactivated by 10% formalin or >70% alcohol, but the effectiveness of virus inactivation in other cytology fixatives, such as CytoLyt, SurePath fixative, and Diff-Quik fixative is unknown.[1] Therefore, some institutions are utilizing alternative rapid stains on alcohol fixed slides for ROSE, such as toluidine blue, alcohol-fixed Diff-Quik stain, ultrafast Papanicolaou stain, or rapid h.ematoxylin and eosin stain. Many cytology specimens, such as FNA biopsies, are received as unfixed fresh cellular material that is potentially infectious and could get aerosolized during manipulation and expulsion of the material. Therefore, special specimen processing precautions should be created and adhered to. Cytology trainees should be aware of these guidelines on the CDC website, in addition to institutional guidelines.
  1. Laboratory policies: Although there are emergency preparation plans for most laboratories and hospitals, this global pandemic event is unprecedented and therefore, revisions and changes in policies are inevitable. Keeping staff aware of the changes and the policies is crucial, and can be done via email, telephone conference calls, or online video conferencing. This pandemic provides a unique opportunity for fellows to see how hospitals and pathology laboratories adapt to unforeseen issues, and to understand some of the management issues such as those related to staffing changes as people get sick or quarantined, schedule changes to accommodate personnel that are at high risk (e.g. elderly, immunocompromised), and schedule modifications to allow staff to work remotely from home (see item #8).
  1. Telepathology: When available, telepathology can be very helpful in removing the fellow or attending from the workplace or the actual procedure, allowing them to social distance by providing services from home or from their office. In cytopathology, telecytology has been a valuable tool for ROSE procedures, in which the fellow and/or pathologist can provide adequacy and preliminary diagnoses remotely from their office or home without the need for PPE. Furthermore, digital slide scanning also allows trainees and pathologists to review slides remotely to triage cases and review immunohistochemical studies. During this pandemic, there has been an increased demand for telepathology services, and fellows should be aware of the changing regulatory guidelines that can result in revised protocols or SOPs to allow for remote microscopy or digital slide review at an off-site location.
  2. Research and Academic Productivity: Although things may slow down on-service, this opens more time for fellows to work on research papers and other writing. Given that social distancing and decreased service demands due to the pandemic have come at the final third of the fellowship year, fellows likely have quality assurance or research projects that they may want to complete prior to the end of their fellowship year and most fellowship programs have time allocated for elective and/or research time that can be utilized during the pandemic.
  3. Wellness: This pandemic has impacted trainees in all aspects of their lives, including food, housing, childcare, safety, and mental health. Obtaining food is anxiety-producing given that grocery shopping carries risks of being infected and also given the limitations on what is available. Furthermore, restaurants and other food service relied on during working hours may be closed or be limited in availability. Some institutions have reached out to local grocery stores to provide special curbside pick-up of online orders or dedicated shopping hours for healthcare workers. Housing is another issue given that some trainees are concerned about exposure to family members or roommates, so some institutions are offering expanded temporary housing options in hotels or college dormitories. Some trainees may have family members in different parts of the country affected by the virus or elderly family members who may no longer be able to assist with childcare given the elevated risk of fatal complications from the virus in this population. The trainees with young children may need to find in-home childcare support given that most daycares and schools are now closed due to state mandated closures to prevent further spread of the virus. Some hospitals have internal resources to help with childcare, such as daycares designated for first responders that can stay open and thereby designated as “essential”. College students and medical students who are home for distant learning, are also offering services in some localities to help with childcare. Another resource is care.com, which is offering a free one-month premium membership to healthcare workers in need of child or senior care (see http://frontlines.care.com/). Program directors should be prepared to provide a signed letter stating that the trainee is an essential health care provider, in order for trainees to get some of these resources and to provide documentation to authorities if questioned during the “Stay at Home Order” mandates in some states. In addition, there are emotional and psychological consequences related to the fear of getting exposed or infected with the virus at work or in one’s personal life that could result in illness or quarantine. In some ways, people are at the mercy of the news, online resources, or social media for regular updates about the virus, and this can create or exacerbate anxiety and depression. Given recent wellness initiatives prompted by the ACGME, most institutions now have resources available for trainees to help with any factors affecting the emotional, physical, and other aspects of the trainee’s well-being, and these are crucial during this viral outbreak so that everyone can function optimally given the added stress at a time like this. Additional external resources include free guided meditation apps (e.g. Headspace and Ten Percent Happier) available for healthcare workers in response to the COVID-19 pandemic.

Hopefully, all of the changes related to the COVID-19 pandemic will have some positive impact in creating new opportunities for cytopathology fellows, and in preparing them well for dealing with emergent and life-changing issues in the future. For most cytopathology fellowship directors and attending pathologists, finding ways to train fellows and residents in accordance with social distancing has been a challenge and has changed the way we approach teaching and education in the past few weeks. Thus, it is important to realize that we are all in this together, learning and navigating through this unprecedented time.

Click below for the summary:

TABLE 1 Summary of Online Educational Resources in Cytopathology and Other Areas of Pathology and Medicine

Reference:

  1. Pambuccian S. The COVID-19 Pandemic: Implications for the cytology laboratory. Journal of the American Society of Cytopathology