Margaret L. Compton and Kim A. Ely

The interesting case conference (ICC) has previously been described as an activity that provides a valuable educational experience for trainees. [1] At Vanderbilt University Medical Center, we hold a weekly cytology interesting case conference for both residents and cytotechnologists. This in-person conference, which is led by the cytopathology fellow, is an opportunity to review classic cytologic findings, discuss ancillary testing, and talk about new developments in cytology such as important journal articles or updates to classification systems. It is also a designated time for the cytotechnologists to review cases that they found challenging, or cases where there was a discrepancy between rapid on-site examination and final diagnosis.

However, while attendance at the in-person ICC is required for residents on the cytology service, it can sometimes be difficult for residents who are rotating on other services to attend. Because of the different schedules for each rotation, residents may be occupied triaging cases for immunohistochemical studies, participating in multidisciplinary tumor boards, or other service-related activities. Furthermore, since Vanderbilt residents rotate at clinical sites in four different locations, many of the residents are not even physically present in the main hospital at the time of the conference. In addition to the logistical barriers to attendance posed by the geographic and scheduling constraints, there is a potential psychological barrier that may be experienced by junior residents who have not yet rotated in cytology and therefore do not feel like they have the prerequisite knowledge to effectively participate in the conference.

Given the potential challenges to resident attendance at in-person cytology ICCs, we sought to expand resident access to the educational content of the ICC by developing an alternative educational resource for residents that would allow for more learner flexibility. The use of online learning provides an opportunity for improved educational outreach, since learners can access educational material on their own schedule and from a convenient location. E-learning has already been implemented by many pathology educators and professional organizations, with a diverse range of delivery platforms including webinars such as ASC’s Cyto-eConference, Twitter educational hashtags and “Tweetorials,” and even video game based instruction. [2][3][4]  In light of the successes demonstrated by other e-learning platforms, we decided to implement an online “Weekly Questions” series about cytology for the pathology residents at our program.

Every Friday, an email containing several questions about cytology is sent to the AP and AP/CP residents. Some of the clinical fellows in other subspecialties, such as surgical pathology, have also opted in to receive the Weekly Questions. Each email contains at least one image-based question in which the resident must free-text their answer, and 2-3 multiple choice style questions. For the free-text question, the resident can ask for additional ancillary studies such as immunohistochemistry or special stains. An example of this type of question would be as follows:

Question stem: “A 45 year old man with a history of heroin abuse presents with shortness of breath. The attached image (pap stain) is from his BAL. What is your diagnosis?” (Attached image: Papanicolaou stained slide demonstrating foamy casts.)

The resident then may reply and ask for a GMS stain, at which point they will be sent an image of the GMS stain showing Pneumocystis jirovecii. In the event that the resident asks for a stain that was not performed, they will be told either that it was not performed and either a.) would not be contributory to the diagnosis or b.) what the presumptive stain result would be, if performing the study would have been appropriate for the morphologic differential diagnosis.

The topics of the multiple choice questions may either be related to the image based question such as asking about immunohistochemistry or molecular pathology topics within the same organ system, or may cover unrelated topics such as laboratory management, technical aspects of specimen handling, and regulatory issues. We have found that, when the questions are based around a particular theme, it helps avoid frustration if each question can be answered independently and doesn’t require getting the first question correct. The residents are given a week to email their answers to the cytology fellow. After a week, the correct answers are sent out, including a short explanation and a link to the relevant literature, where appropriate.

The fellow chooses cases for the Weekly Questions from interesting slides encountered during signout or from the study sets available in the cytopathology sign-out area. As the popularity of the cytopathology questions series has grown, residents who wish to contribute also have started to bring cases to the attention of the fellow. Because of the e-learning format, the process of obtaining slide photomicrographs can be batched, so that the fellow can create a queue of interesting case images, and the case slides can then be quickly returned to the files. Although preparing the electronic Weekly Questions series does require a small time commitment on behalf of the cytopathology fellow, there are multiple benefits to conference preparation. The image-based format allows the fellow to accrue an image bank of classic findings and unusual entities that they can later incorporate into presentations or publications. Furthermore, the fellow gains experience in writing multiple choice boards/CME style questions. Their own learning is also enhanced, as preparation of the questions and the explanations requires a solid knowledge base.

We have found that the Weekly Question series has been well-received by residents. Not only does it allow for a flexible learning schedule, but it also ensures that residents are exposed to the field of cytology throughout the entire course of their residency training, rather than being limited to the few months that they are scheduled to rotate with the cytology service. In addition to benefiting resident education, the fellow who prepares the Weekly Questions also receives a substantial educational benefit, as well as experience with teaching and question writing.

Although not anticipated at the time of the Weekly Question series inception in July 2019, events of recent months have demonstrated an additional unexpected benefit to electronic learning formats. Due to restrictions related to the COVID-19 outbreak, our institution has had to cancel all in-person educational conferences. We have attempted to adapt by using video conferencing solutions for didactic activities, but during this time of transition it has been helpful to have have pre-existing electronic educational resources for residents.

[1] VandenBussche, Christopher. Innovative Practices in Cytopathology Education: The Johns Hopkins Interesting Case Conference Cytopathology Fellowship Communicator July 2019

[2] Cyto-eConference Series. https://cytopathology.org/page/Cytoeconference Accessed March 17, 2020.

[3] Jiang XS, Madrigal E, Roy-Chowdhuri S. A Twitter primer: Dos and don’ts for cytopathologists. Diagn Cytopathol. 2017 Jul;45(7):577-579.

[4] Gnarpe J and Schubert M. Education for the Gamer Generation. The Pathologist. https://thepathologist.com/inside-the-lab/education-for-the-gamer-generation October 26, 2015. Accessed March 17, 2020.