Chasing Mavericks

Chasing Mavericks is a movie about legendary big wave surfer Jay Moriarity. For those who like to see people rocket down ridiculously big waves just for the thrill of it (like me), the movie is a treat. Nevertheless, the critical response to the movie has been uneven. Interestingly, one reviewer pointed out that surfer movies in general are particularly hard to bring to the screen. As an audience we like movies that have a plot that moves from early struggles to a successful climax. There is a beginning, middle and end; however, surfing isn’t like that. Of course surfers are always seeking out that one big wave and that one perfect ride and as soon as they achieve it, they go right back looking for another wave to ride. There is no end to the story, no matter how fantastic any one wave, there is always another one just behind it.

In some ways this also describes cytology, and cytology screening in particular. Perhaps this is why cytology has struggled to advertise itself to the American public. Cytologists screen day in and day out. Everyone is looking for that one great case where they identify a single abnormal cell that makes all the difference in the life of a patient. For the patient, that cell is part of a story that is easy to tell. Everything was fine until crisis struck, and then with the help of a wide variety of health care professionals, the patient successfully overcomes the crisis.

For the cytologist who found that cell, there is of course satisfaction. Perhaps someone in the laboratory may even point out how great a call it was. But more often than not, few people in the laboratory will know what happened, and certainly no one outside the laboratory will think about how lucky that patient was to have that cytologist looking at his or her slides, especially if it was a really great call. Instead, that cytologist will go back to work and start screening more cases. They rode the big one, they did what everyone in the field wants to achieve someday, but the mission doesn’t change. No matter how great the call, there is always another wave coming up right behind it, and that does not fit well on the American movie screen.

But as the surfers in the movie point out, it doesn’t really matter. Sure they want their story on the screen, they want people to understand what they are doing and appreciate it. But at the end of the day all that really matters is that they are doing it, and are going to keep doing it because that is their mission in life. Perhaps we should learn something from these surfers, who are always quick to recognize when one of their own has succeeded, since no one else is likely to recognize us. We in the laboratory should all take a little more time to recognize the individuals who have succeeded in catching that big wave and identified a cell that may change someone’s life. We should acknowledge that it is those who screen who are really the big wave surfers of our world!

Andrew Renshaw, MD
ASC President, 2012-2013

Designing an Anatomic Pathology Practitioner

For several years now there has been a push to revise and update training for cytotechnologists to ensure that they are prepared for the needs of the future. Both the American Society for Clinical Pathology and the College of American Pathologists have submitted letter to the Cytotechnology Program Review Committee (CPRC) detailing specific areas that they would like to see covered in all cytotechnology training programs, and the CPRC has taken these suggestions to heart and is actively engaged in the process of implementing these recommendations as part of the Standards and Guidelines for the Accreditation of Educational Programs in Cytotechnology

As a practicing pathologist and cytologist and as a member of the American Society of Cytopathology, I strongly support these efforts. I look forward to the day when the cytotechnologists in my hospital system can be aiding in the interpretation not only of tests that are traditionally in the area of clinical pathology (FISH, molecular diagnostics, laboratory management) but also in areas that are traditionally the purview of pathologists (special stains, immunohistochemistry, primary sign out of non-gynecologic cytology). I foresee a time when the name “cytotechnologist” may be too restrictive, and titles such as “Anatomic Pathology Practitioner” may be more appropriate.

Nevertheless, while I strongly support these efforts, I do see an area where my vision of the future is slightly different than the one that is described in these letters. In these letters, the rivalry between cytotechnologists and medical technologists/medical technicians (MTs) remains strong today. While MTs are willing to give up very specific and limited areas of their field, they most certainly are hanging on tight to their primary role in the clinical laboratory. This makes sense – like cytotechnologists, MTs are under pressure from management to justify their utility, and I would be hanging on tight if I were in their shoes as well. Since there are many more MTs than cytotechnologists, in any competition between these two specialties, cytotechnologists can not come out ahead. Does this matter for the future of the cytotechnology?

I would say yes. There is an opportunity out there that I have not seen clearly articulated in any of these letters to date. That opportunity is in the very small hospitals (where I spend most of my time), not the academic centers. There are many small hospitals in this country, and there is a real need for assistants to pathologists in this setting. In academic centers, there is enough work to keep an “anatomic pathology practitioner” busy just doing anatomic pathology. In small hospitals there is not. In my hospital there are 1-2 hours of anatomic pathology a day, and in no circumstance would I ever be able to hire an “anatomic pathology practitioner” for this setting. It’s simply not a financially viable arrangement. On the other hand, if I could hire some one who can cut the frozen, examine it at the microscope (with my help via telepathology), do the rest of the AP processing, and then work in the clinical laboratory for the remaining 6 hours of the shift, that would be highly attractive to many pathology groups and hospitals. What I am describing of course is a cytotechnologists/histotechnologist/medical technologist hybrid.

Other specialties have also used these small hospitals to gain acceptance as full -fledged members of their health care teams. While nurse anesthetists work in larger hospitals under the direct supervision of anesthesiologists it is their role in smaller hospitals, where they are often the only person on site, and where the extent of what they can actually do has been demonstrated. The same could happen for cytotechnologists.
But can we actually get to this point? I believe the key step to making this happen is for cytotechnologists to give up – they are never going to win a fight with MTs. Instead they should create a hybrid program that gives them just enough qualification to work in the clinical laboratory, but then focus on developing their anatomic pathology skills. While there are many models that can successfully enlarge the practice sphere of cytotechnologists, if they really want to gain acceptance as full-fledged anatomic pathology specialists, perhaps the easiest route is through smaller hospitals. A license that contains permission to practice in the clinical laboratory is the key to greater responsibility in the anatomic pathology world.

Andrew Renshaw, MD
ASC President, 2012-2013