Survey of medical training in cytopathology carried out by the journal Cytopathology

ORIGINAL ARTICLE DOI:10.1111/j.1365-2303.2010.00761.x

Survey of medical training in cytopathology carried out by thejournal Cytopathology

Anshu1, A. Herbert2, B. Cochand-Priollet3, P. Cross4, M. Desai5, R. Dina6, J. Duskova7,

A. Evered8, A. Farnsworth9, W. Gray10, S. S. Gupta11, K. Kapila12, I. Kardum-Skelin13,

V. Kloboves-Prevodnik14, T. K. Kobayashi15, H. Koutselini16, W. Olszewski17, B. Onal18,

M. B. Pitman19, Z. Marinsek20, T. Sauer21, U. Schenck22, F. Schmitt23, I. Shabalova24,

J. H. F. Smith25, E. Tani26, L. Vass27, P. Vielh28 and H. Wiener29

1Mahatma Gandhi Institute of Medical Sciences, Sevagram, India, 2Department of Cellular Pathology, Guy�s & St Thomas NHS

Foundation Trust, St Thomas� Hospital, London, UK, 3Service d�Anatomie et Cytologie Pathologiques, Hopital Lariboisiere, Paris,

France, 4Department of Pathology, Queen Elizabeth Hospital, Gateshead, UK, 5Manchester Cytology Centre, Manchester Royal

Infirmary, Manchester, UK, 6Histopathology Department, Imperial College NHS Trust, Hammersmith Hospital, London, UK,7Institute of Pathology, 1st Faculty of Medicine, Charles University, Prague, Czech Republic, 8Cervical Screening Wales and

University of Wales Institute, Cardiff, Wales, 9Douglass Hanly Moir Pathology Cytology, Macquarie Park, New South Wales,

Australia, 10John Radcliffe Hospital, Oxford, England, 11Department of Community Medicine, Mahatma Gandhi Institute of

Medical Sciences, Sewagram, India, 12Cytopathology Unit, Department of Pathology, Faculty of Medicine, Kuwait University,

Kuwait, 13Laboratory for Cytology and Haematology, Merkur University Hospital, Zagreb, Croatia, 14Department of

Cytopathology, Institute of Oncology, Ljubljana, Slovenia, 15Pathology Department, Saiseikai Shiga Hospital, Imperial Gift

Foundation Inc, Shiga, Japan, 16Department of Cytopathology, Aretaieion University Hospital, University of Athens Medical

School, Athens, Greece, 17Department of Pathology, Institute of Oncology, Warsaw, Poland, 18Department of Cytology

&Pathology, Ankara Diskapi Training & Research Hospital, Ankara, Turkey, 19Department of Pathology, Massachusetts General

Hospital, Harvard Medical School, Boston, Massachusetts, USA, 20Department of Cytopathology, Institute of Oncology,

Ljubljana, Slovenia, 21Department of Pathology, Ulleval University Hospital, Oslo, Norway, 22Institute of Pathology, Technical

University of Munich, Germany, 23IPATIMUP and Medical Faculty of Porto University, Porto, Portugal, 24General Institute of

Advanced Medical Studies, Moscow, Russia, 25Department of Histopathology & Cytology, Royal Hallamshire Hospital, Sheffield,

UK, 26Department of Pathology and Cytology, Karolinska University Hospital, Solna, Stockholm, Sweden, 27Department of

Pathology ⁄ Cytopathology, Flor F. University Hospital of Pest County, Kistarcsa, Hungary, 28Department of Pathology, Institut

Gustave Roussy, Villejuif, France and 29Clinical Department of Pathology, Medical Unversity Vienna, Vienna, Austria

Accepted for publication 26 February 2010

Anshu, A. Herbert, B. Cochand-Priollet, P. Cross, M. Desai, R. Dina, J. Duskova, A. Evered, A. Farnsworth,

W. Gray, S. S. Gupta, K. Kapila, I. Kardum-Skelin, V. Kloboves-Prevodnik, T. K. Kobayashi,

H. Koutselini, W. Olszewski, B. Onal, M. B. Pitman, Z. Marinsek, T. Sauer, U. Schenck, F. Schmitt,

I. Shabalova, J. H. F. Smith, E. Tani, L. Vass, P. Vielh and H. Wiener

Survey of medical training in cytopathology carried out by the journal Cytopathology

This report of the Editorial Advisory Board of Cytopathology gives the results of a survey of medical practitioners

in cytopathology, which aimed to find out their views on the current situation in undergraduate and

postgraduate training in their institutions and countries. The results show that training in cytopathology and

histopathology are largely carried out at postgraduate level and tend to be organized nationally rather than

locally. Histopathology was regarded as essential for training in cytopathology by 89.5% of respondents and was

Correspondence:

Dr A. Herbert, Department of Cellular Pathology, Second

Floor North Wing, St Thomas� Hospital, London, UK

Tel: +44(0)20 7188 2926; Fax: +44(0)20 7401 3661;

E-mail: [email protected]

Cytopathology 2010, 21, 147–156 ª 2010 Blackwell Publishing Ltd 147

mandatory according to 83.1%. Mandatory cytopathology sections of histopathology were reported by 67.3%

and specific examinations in cytopathology by 55.4%. The main deficiencies in training were due to its

variability; there were insufficient numbers of pathologists interested in cytology and a consequent lack of

training to a high level of competence. Pathologists without specific training in cytopathology signed out cytology

reports according to 54.7% of responses, more often in centres where training was 3–6 months or less duration.

Although 92.2% of respondents thought that specialist cytology should not be reported by pathologists without

experience in general cytopathology, that practice was reported by 30.9%, more often in centres with small

workloads. The survey report recommends that 6–12 months should be dedicated to cytopathology during

histopathology training, with optional additional training for those wanting to carry out independent practice in

cytopathology. Formal accreditation should be mandatory for independent practice in cytopathology. When

necessary, temporary placements to centres of good practice should be available for trainees intending to practise

independently in cytopathology. There should be adequate numbers of pathologists trained in cytopathology to a

high level of competence; some of their time could be released by training cytotechnologists and trainee

pathologists to prescreen cytology slides and assess adequacy of fine-needle aspiration samples when immediate

diagnosis was not required. The survey demonstrated a clear need for European and international guidelines for

training in cytopathology.

Keywords: medical training in cytopathology, international survey, accreditation, postgraduate training,

cytopathology examinations

Introduction

Members of the Editorial Advisory Board and many

of their colleagues were conscious that there might be

problems in training pathologists in the clinically

diverse speciality of cytopathology at a time when

fine-needle aspiration (FNA) cytology should be

developing rapidly to support new methods of spec-

imen procurement1 and exfoliative cytology contin-

ues to play an important role in patient management

and screening.2 In many places with active cervical

screening programmes time dedicated to �non-gynae-

cological� cytopathology may be compromized by

increasing demands from workload and quality con-

trol in cervical cytology.3 Now that cervical screening

is likely to be modified (especially in its volume) by

human papillomavirus testing4 and vaccination,5

non-gynaecological cytopathology should flourish,

but only if teaching and training are available to a

high standard. Our observations take account of the

Bologna principles6 for higher education and training

and should be considered by the European Union of

Medical Specialists (UEMS), with which the Euro-

pean Federation of Cytology Societies (EFCS) and

European Society of Pathology have both been

working.

The aims of this survey were directed at specialists

practising in cytopathology to elicit their views

on the current situation in undergraduate and

postgraduate teaching and training in cytopathology

in their countries and institutions. We aimed to find

out what they regarded as the essentials of good

training, what were thought to be examples of good

practice and what were deficiencies in training. We

also aimed to link these training practices to con-

sultant pratice and laboratory workloads in the insti-

tutions from which responses were received. Finally,

we aimed to publish the results of this survey as an

evidence-base for those wanting to improve cytopa-

thology training in Europe and elsewhere in the

world. Our aims are consistent with those of the

Bologna declaration for higher education and train-

ing, recognizing the need for common reforms and

coordinated action with comparable and compatible

criteria for education and practice.8

Methods

A draft questionnaire was discussed and validated at

the Cytopathology Editorial Advisory Board meeting

in June 2008. It included both closed- and open-

ended questions. The survey questionnaire was

uploaded onto an online survey site (http://www.

surveymonkey.com) and the link was circulated to

representatives of cytology societies by email with

an appeal to circulate it widely. Among other

medical practitioners in cytopathology, survey

respondents included members of the Advisory and

Anshu et al.148

Cytopathology 2010, 21, 147–156 ª 2010 Blackwell Publishing Ltd

Management Boards of Cytopathology, representatives

of societies affiliated to Cytopathology and officers of

member societies of the EFCS. The survey was

advertised on the EFCS website (http://www.

efcs.eu), which proved to be a useful site for this

type of communication.

The survey was divided into five parts: (1) curric-

ulum design, (2) undergraduate training, (3) post-

graduate training, (4) assessment of training and

(5) consultant workloads and practice in cytopathol-

ogy. All analyses were calculated for total respondents

and countries as a whole and where relevant both

analyses are presented.

Chi-square test was used as a test of significance

to compare difference between proportions. Statcalc

calculator in the EPI INFO 6 software was used for

calculation of Chi-square tests.

Results

We received responses from 76 individuals from 26

countries including: Australia, Canada, Chile, Croatia,

the Czech Republic, Denmark, France, Greece, India,

Italy, Kuwait, New Zealand, Norway, Portugal, Roma-

nia, Russia, Singapore, Slovenia, Spain, Sudan,

Sweden, Switzerland, Turkey, the United Kingdom

(UK), Uruguay and the USA (Figure 1). There was a

single respondent from each of 15 countries, two from

six countries, three from four and seven from one. As it

was not mandatory to reveal personal details in the

survey questionnaire, 27 respondents did not provide

details of position or place of work and not all

respondents answered all the questions. Respondents

had received training in cytology from 27 different

countries, all except one in the country where they

practised.

Curriculum design

Of 69 responses, 46 (66.7%) said that the medical

school curriculum was designed at national level. The

curriculum was designed at regional level according to

nine (13.0%), while according to 14 (20.3%) it was

designed at the level of the individual institution,

where schools had the freedom to tailor their curric-

ulum according to their needs. Conventional learning

was said to be used by 46 (66.7%) medical schools,

while 16 (23.2%) followed a horizontally or vertically

integrated curriculum. In 15 (21.7%) schools, prob-

lem-based learning was used. In six schools there was

a combination of conventional and problem-based

learning and two had all three forms of curricula.

Undergraduate training

Organization of undergraduate teaching Nine of 68

(13.2%) respondents said that cytopathology was

included as a defined course in the medical curricu-

lum while 59 (86.8%) said it was not a defined course.

Of the nine respondents who said that their schools

had cytopathology as a defined course, the duration of

that course was less than a year in six, 1–2 years in

two and more than 2 years in one school. Four

respondents who said that cytopathology was not a

defined course said that the subject was taught for less

than a year. On the other hand, histopathology was

included as a defined course in the medical curricula

of 53 of 70 (75.7%) respondents� countries. Of the 53

respondents who said that histopathology was a

defined course, 18 (33.9%) said that the modules

lasted less than a year. Nineteen (35.8%), six

(11.3%) and five (9.4%) respondents said that

courses lasted 1 year, 2 years and 3 or more years,

respectively, while five of them did not specify the

duration of the course. These percentages were

similar in replies for 26 named countries as a whole,

where cytopathology was not a defined course in

their undergraduate curriculum in 21 (80.8%), but

histopathology was a defined course in the curricu-

lum in 17 (65.4%). Responses varied among respon-

dents in 11 countries.

Histopathology was included as part of multi-

disciplinary clinical teaching sessions in 40 (59.7%)

of 67 respondents� medical schools. Of these 40,

histopathology was included in the teaching sessions

Figure 1. Map showing distribution of respondents across

the world.

Survey of medical training in cytopathology 149


after the third year in 22 (55.0%) of the respon-

dents� medical schools, in the third year in 13

(32.5%), in the second year in three (7.5%) and in

the first year in two (5.0%). Cytopathology was

used in the clinical teaching modules in 33 (49.3%)

of 67 respondents� medical schools. Respondents

reported including cytopathology training in several

other formats at the undergraduate level. Most

medical schools included cytopathology in lectures

but not in practical training.

Several respondents reported that cytopathology

was taught as part of the pathology-histopathology

course, eight respondents reported that it was

included as part of the gynaecology course and one

respondent each reported that it was taught during

the medical, surgical and radiation oncology or inter-

nal medicine course. In two schools cytopathology

was offered as an optional subject or taught only

when it came up as part of a systemic course or case

discussion.

Postgraduate training

Organization of postgraduate training Of 63 replies to

the question, 76.2% said that postgraduate training

was organized at a national level (in four of these it

was also regional, institutional or both), 1.6% said it

was at a regional level, 20.6% said it was institutional

and 1.6% said �other�. Cytopathology was integrated

into histopathology training according to 50 (79.4%),

of whom 58.0% said that exposure was continuous.

These percentages were similar in replies for 26

named countries, of which 76.9% said organization

was national (four of these recorded institutional

organization as well), 69.2% said that cytopathology

was integrated into routine histopathology training

and 50% of those had continuous exposure.

Time dedicated to cytopathology training Of 60 replies to

this question, 44 (73.3%) said there was a defined

time for cytopathology training. Twenty-four (40.0%)

said the defined time for cytopathology training was

6–12 months or more, 20 (33.3%) said training lasted

for 3–6 months or less while 16 (26.7%) said there

was no defined time dedicated to training. Defined

time varied when there was more than one response

from the same country, probably because trainees in

some centres were able to undertake specialist train-

ing. Thus, in 26 named countries responses were

variable in nine; five said the defined time for

cytopathology was 6–12 months or more, five said

3–6 months or less and six reported no defined time.

This contrasted with histopathology training, which

70.7% of 58 respondents said was for more than

3 years and 86.2% for at least 2–3 years; in 26 named

countries, 69.2% reported histopathology training for

more than 3 years and 88.5% for at least 2–3 years.

There were 51 individual responses concerning the

year of histopathology training during which cytopa-

thology started, but there was either no response or

they varied in 12 (46.3%) of 26 countries. Responses

were not significantly different between the first year

(15, 29.4%), second year (19, 37.3%) and final year

(17, 33.3%). Cytopathology training was separate

from histopathology training according to 58.9% of 56

replies.

Histopathology as a requirement for cytopathology

training Ten (16.9%) of 59 respondents said that it

was possible to train in cytopathology without histo-

pathology while 49 (83.1%) said it was not. Five of

those 10 answering �yes� to this question mentioned

non-medical degrees as criteria for entry into training.

An open question as to whether histopathology

training was essential for cytopathology elicited a

positive response in 89.5% of 57 replies. Two others

said it was essential �to a certain level, especially for

non-gynaecological cytology� and one said it was

�not essential but very, very useful�. Only one

response, from a laboratory with non-medical gradu-

ates training in cytopathology, said �unfortunately,

not�. Gynaecologists, haematologists, microbiologists,

oncologists and �doctors during specialist education�were able to train in cytopathology according to seven

free-text responses. In four of these they also trained

in histopathology. According to one response, limited

responsibility was given to peumonologists and

neurologists to report cytology.

Cytology practice during training Trainees were more

likely to screen unmarked gynaecological (87.7%) or

non-gynaecological (85.7%) slides and prepare their

own draft reports (89.1%) than they were to attend

rapid on-site evaluation of slides (71.7%), carry out

their own FNAs (67.9%) or sign out reports at a

defined stage of training (36.4%) (Table 1). The

trend was more pronounced in responses combined

for named countries as a whole. Non-medical cytol-

ogists contribute to cytology training of medical

trainees in 16 (61.5%) countries.

Examples of good practice given as free-text com-

ments focused on (1) additional specialist training

Anshu et al.150


(n = 10), (2) good local departments and enthusiasm

of cytopathologists (n = 9), (3) formal specialist

courses, examinations and accreditation (n = 8), (4)

interaction with clinical teams (n = 6), (5) practice

and hands-on experience under supervision (n = 5)

and (6) training along with histopathology (n = 5).

Others (n = 3) said what good training �should be� and

one mentioned improvement in gynaecological cyto-

pathology training after a national screening debacle.

There were no responses to this question from 30 of

76 respondents. Some respondents mentioned more

than one of these features as in the quotation in the

text box below. There was no correlation between

these broad groups of responses about good practice

and size of workload or time dedicated to cytopathol-

ogy training.

An example of good practice in training

• ‘‘Connection with other clinicians

(gynaecologists, haematologists, oncologists)

• active participation in FNA

• direct contact with patients

• participation in treatment planning

• training in histopathology.

All of these are contained in a 3-year programme

of independent training (specialisation) in clinical

cytology.’’

Examples of deficiency in training focused on (1)

lack of experienced cytopathologists in many centres

(several said that most pathologists were not inter-

ested in cytology) and variability of training (n = 9),

(2) lack of specific cytopathology training or time for

that training (n = 9), (3) lack of equipment, facilities

and time for overworked cytopathologists (n = 8), (4)

the need for better integration of cytopathology with

histopathology (n = 5), (5) lack of training to a high

level of competence (n = 4) and (6) neglect of gynae-

cological cytology (n = 2) or it being not available

when cervical cytology was centralized (n = 1). Single

respondents mentioned the problem of cyto-

pathology ⁄ histopathology subspecialization, the need

for standardized terminology, lack of government and

clinicians� awareness of biomedical scientist (cytotech-

nologist) ⁄ pathologist interaction. Four replies made

no specific points and 30 of 76 respondents did not

answer this question.

Lack of equipment, facilities and time for over-

worked cytopathologists were related to centres with

6–12 months or more of training in cytopathology

(seven of eight responses). Problems with integrating

cytopathology into histopathology and lack of training

to a high level of competence were related to centres

with no defined time or 3–6 months or less dedicated

to cytopathology training (four of four and five of five

comments in those categories, respectively). There

was no correlation between these responses and size

of workload.

Examples of deficiencies in training

• ‘‘Insufficient time to gain experience’’

• ‘‘Insufficient numbers of pathologists with an

interest in cytopathology to provide training’’

• ‘‘It is a �desert island� from where it ought to be

easy to go to Europe for homogenous

guidelines rather than aiming for local or even

national initiatives’’

Table 1. Trainee practice and examinations in cytopathology

Training practice

All responses

(maximum 77)

26 countries

(*one no response)

Yes No

Total Yes No Yes & noResponse rate 67.5–75.3%

Screen unmarked gyn slides 50 (87.7) 7 (12.3) 57 22 (84.6) 4 (15.4)

Screen unmarked non-gyn slides 48 (85.7) 8 (14.3) 56 19 (73.1) 3 (11.5) 4 (15.4)

Prepare draft reports 49 (89.1) 6 (10.9) 55 21 (80.8) 3 (11.5) 2 (7.7)

Attend rapid assessment FNAs 40 (71.7) 16 (28.6) 56 13 (50.0) 9 (34.6) 4 (15.4)

Carry out FNAs 38 (67.9) 18 (32.1) 56 14 (53.8) 9 (34.6) 3 (11.5)

Sign out reports at defined time

in training*

20 (36.4) 35 (63.6) 55 5 (19.2) 14 (53.8) 6 (23.1)

(n) = percentage.

gyn, gynaecology; non-gyn, non-gynaecological; FNA, fine needle aspirate.



Assessment of Training

Mandatory examinations in pathology exist in 45

(81.8%) of 55 respondents� countries. Cytopathology

is a mandatory section of the histopathology post-

graduate examination in 35 of 52 (67.3%) of the

respondents� settings. Of 55 respondents, 31 (56.4%)

said that there were no separate postgraduate examin-

ations in cytopathology. According to 32 (58.2%) of 55

responses a specialist cytopathology examination was

not required for independent practice in cytopathology.

A mandatory pathology qualification (histopathol-

ogy ⁄ cytopathology) exists in 49 (89.1%) of 55

respondents� countries. These degrees are awarded

by national, regional or institution-based agencies.

Certain overseas qualifications (such as MRCPath)

were not accepted in the work settings of 28 (51.9%)

of 54 respondents.

Cytopathology workloads and consultant reporting practice

Cytopathology workloads The variation in workloads

(defined by number of specimens received per year) of

gynaecological cytology, FNA and exfoliative cytology

handled by 42 and 46 respondents who gave infor-

mation about their laboratories is shown in Table 2.

For purposes of analysis, non-gynaecological cytology

workloads have been divided into small (< 1 000 tests

per year), medium (1 000–5 000 tests per year) and

large (> 5 000 tests per year). For analysis, gynaecol-

ogy laboratories have been divided into those above

and below 10 000 tests per year. Workloads for FNAs

and exfoliative cytology varied from below 100 to

25 000 requests per year. Cervical cytology workloads

varied from 100–500 to 200 000 requests per year;

those defined as �large� processed a range of 13 000–

200 000 with an average of 38 000 per year. The

balance in terms of large, medium and small labora-

tories is shown in Table 2.

Consultant reporting practice Of 55 respondents, 87.3%

said that cytopathologists attend multidisciplinary

meetings and contribute to clinical decisions on

patient management. Pathologists without specific

training in cytopathology sign out cytopathology

reports according to 54.7% of 53 responses. Patholo-

gists report specialized cytology for a particular system

without experience in general cytopathology accord-

ing to 30.9% of 55 responses. Medical practitioners

from other specialties report cytopathology according

to 15.1% of 53 responses and non-medical cytologists

report non-gynaecological cytology according to

16.3% of 49 responses. These percentages are shown

in Tables 3–5. According to 48.1% of 54 responses,

non-medical staff report cervical cytology.

According to 51 free-text replies, 92.2% thought

that experience in general cytopathology was essential

for specialist cytopathology reporting while three

thought it should be essential and only one thought

it should not. According to 61.5% of 53 free-text

replies, non-pathologists should not report cytopa-

thology. Nine respondents (17.3%) thought that

�trained and certified technicians� could report in areas

with many normal cases such as the cervix, sputum

and urine. Two (3.8%) gave an unqualified �yes� to

this question and four (7.6%) said �yes� if correctly

trained and with the supervision of a cytopathologist.

Two said that gynaecologists may report cervical

cytology. There was little mention of cervical screen-

ing cytology in these free-text responses, which did

not reflect the widespread practice of non-medical

staff reporting and signing out such cytology.

Who should report cytopathology?

• ‘‘I personally favour cytopathologists signing out,

particularly abnormal gynaecological cytology

and general cytology, because there is often

�value added� by a clinical perspective on the

cellular pattern.’’

• ‘‘Specially trained medical technicians do a very

good job as screeners in cytopathology and also

relieve the pathologists of a large load of

normal ⁄ negative smears and reporting.’’

Correlation between reporting practice, training and

workload Tables 3–5 show the reporting practice of

(1) specialists with no general cytopathology experi-

ence, (2) general pathologists with no specific training

in cytopathology, (3) non-pathologist medical practi-

Table 2. Workloads reported by respondents

Tests per year Gynaecology FNA

Exfoliative

cytology

< 1 000 2 11 10

1 000–5 000 8 19 17

5 000–10 000 6 14 15

10 000+ 26 2 4

Total responses to

the question

42 46 46

Anshu et al.152


tioners and (4) non-medical staff reporting non-

gynaecological cytology. These practices were tabu-

lated against time dedicated to cytopathology training

(Table 3), FNA workload (Table 4) and non-gynaeco-

logical cytology workload (Table 5). We decided to

use total responses rather than those for individual

countries because the latter were frequently variable,

reflecting practices in different institutions in the same

country.

The likelihood of pathologists without specialist

cytopathology training reporting cytopathology was

related to the time dedicated to cytopathology training.

Pathologists without specialist training reported cyto-

pathology in 73.3% centres where 3–6 months or less

was dedicated to cytopathology training as against

23.8% of centres where 6–12 months or more were

dedicated to cytopathology training (P = 0.0005).

There was no association between the relatively small

percentages of medical practitioners of other specialities

and non-medical staff, respectively, and time dedicated

to cytopathology training or workload.

There was a correlation between small workloads

for FNA and exfoliative cytology and the likelihood of

pathologists without experience in general cytology

Table 4. Consultant reporting practice according to FNA workload

Consultants signing

out cytopathology

FNA workloadNo

response TotalLarge Medium Small

Specialist reporting without experience in

general cytopathology

Yes 5 4 6 2 17

No 12 15 5 6 38

% �yes� response 29.4 21.1 54.5 30.9

Pathologists without specific training

in cytopathology

Yes 8 11 6 4 29

No 8 8 5 3 24

% �yes� response 50.0 57.9 54.5 54.7

Medical practitioners from other disciplines Yes 2 3 2 1 8

No 15 16 9 5 45

% �yes� response 11.8 15.8 18.2 15.1

Non-medical staff reporting non-gynaecological

cytology

Yes 1 4 3 0 8

No 14 14 7 6 41

% �yes� response 6.7 22.2 30.0 16.3

Table 3. Consultant reporting practice according to cytopathology time

Consultants signing

out cytopathology

Cytopathology training time

No

Response Total

Nil, 3-6 months

or less

6-12 months

or more

Specialist reporting without experience

in general cytopathology

Yes 10 6 1 17

No 21 16 1 38

% �yes� response 32.3 27.3 30.9

Pathologists without specific training

in cytopathology

Yes 22 5 2 29

No 8 16 0 24

% �yes� response 73.3 23.8 54.7

Medical practitioners from other disciplines Yes 5 3 0 8

No 25 19 1 45

% �yes� response 16.7 13.6 15.1

Non-medical staff reporting non-gynaecological

cytology

Yes 5 3 0 8

No 23 17 1 41

% �yes� response 17.9 15.0 16.3



reporting specialized cytopathology. The percentage

answering �yes� to that question represented 25% of

those with medium and large workloads of exfoliative

and FNA cytology compared with 60% of those

with small exfoliative cytology workloads and

54.5% with small workloads of FNA cytology. The

difference was significant for exfoliative cytology

(P = 0.037) but not for FNA cytology (P = 0.066).

There was no correlation between likelihood of

gynaecological cytology being reported by non-med-

ical staff and time dedicated to training but there was

an association with workload. Among 16 respondents

with workloads below 10 000 per year, 31.3%

answered �yes� to non-medical staff reporting gynae-

cological cytology compared with 63.0% of 27 with

workloads of 10 000 or more (P = 0.04).

Discussion

This survey showed that the majority of undergrad-

uate and postgraduate training was organized at a

national level, suggesting that improvements to

training should be focused on governments rather

than individual institutions. Perhaps not surprisingly,

cytopathology was less likely than histopathology to

be a defined undergraduate course (13.2% compared

with 75.7%). Histopathology was only included in

59.7% of multidisciplinary clinical sessions and cyto-

pathlogy in 49.3% of these clinical teaching modules,

reflecting a relatively low level of exposure to

pathology in general. However, in some medical

schools cytopathology was taught as part of histopa-

thology, gynaecology, oncology, surgery and internal

medicine, demonstrating its wide clinical relevance as

a discipline.

As with histopathology, the low level of cytopathol-

ogy teaching at undergraduate level means that

training must almost entirely be carried out at

postgraduate level. One of the most consistent findings

in this survey was the importance of histopathology as

a basis for cytopathology training. Histopathology

training was mandatory for training in cytopathology

in 83.1% of respondents� countries and an over-

whelming majority of respondents (89.5%) regarded

it as essential. Qualifications and examinations

for histopathology and cytopathology were usually

combined (more than 80%). Although 67.3% of

respondents reported mandatory cytopathology

sections of examinations, mandatory cytopathology

courses and separate examinations were less common,

which was identified as a deficiency in training. �InEurope, we only know of a postgraduate diploma in

France (7) and the Royal College of Pathologists

Diploma in Cytopathology, which is available but no

Table 5. Consultant reporting practice according to exfoliative cytology workload

Consultants signing

out cytopathology

Exfoliative cytology

workloadNo

response TotalLarge Medium Small

Specialist reporting

without experience in

general cytopathology

Yes 5 4 6 2 17

No 14 13 4 7 38

% �yes� response 26.3 23.5 60.0 30.9

Pathologists without

specific training

in cytopathology

Yes 10 8 7 4 29

No 8 9 3 4 24

% �yes� response 55.6 47.1 70.0 54.7

Medical practitioners

from other disciplines

Yes 4 1 2 1 8

No 15 16 8 6 45

% �yes� response 21.1 5.9 20.0 15.1

Non-medical staff

reporting non-

gynaecological

cytology

Yes 3 2 3 0 8

No 15 12 6 6 41

% �yes� response 16.7 14.3 33.3 16.3

Anshu et al.154


longer used in the UK (8).� The lack of integration of

cytopathology into histopathology was also cited as

a deficiency. However, the main deficiencies in cyto-

pathology training were the variability of training,

the lack of specifically trained cytopathologists in

many centres, the lack of training to a high level of

competence and the overwork and shortage of training

facilities in those centres that did have trained cytop-

athologists and potentially good training programmes.

The over-riding problem is that while histopathology is

essential for training in cytopathology, �most pathol-

ogists have no interest in cytology�.One of the problems identified in the survey was

the lack of training to a level of competence, which

must be a serious problem when so many posts

include cytopathology in their job description and

87.3% attend multidisciplinary meetings and con-

tribute to decisions on management of patients.

Furthermore, cytopathologists in centres of good

practice carry out FNAs themselves, provide imme-

diate diagnoses and contribute to image-guided

biopsy sessions.

Training in cytopathology was more likely to

involve screening slides than gaining hands-on expe-

rience with FNA and rapid assessment and less than a

third of trainees gained sufficient experience to be

allowed to sign out reports. Examples of good practice

in cytopathology cited �connection with other clini-

cians (gynaecologists, haematologists, oncologists),

active participation in FNA, direct contact with

patients, participation in planning of therapeutic

approach (along with) training in histopathology�,demonstrating the added clinical perspective that a

training in cytopathology requires; it is not a training

that should be confined to the examination of slides.

It was unusual for non-medical degrees to be

acceptable for entry into cytopathology training and

medical graduates from other specialties were usually

(but not always) required to train in histopathology as

well. Although non-medical staff sign out negative

cervical cytology according to 48.1% of responses,

particularly in laboratories with larger workloads,

they rarely sign out non-gynaecological cytology,

except in some instances negative sputum and urine.

Nevertheless, non-medical staff contributed to cyto-

pathology training according to more than half of

responses, supporting the comment that there are

�insufficient numbers of pathologists with an interest

in cytopathology to provide the training�. In view of

the important role that well-trained cytotechnologists

play in cervical screening cytology, their role could

usefully be expanded by formally training them to

pre-screen non-gynaecological cytology specimens

and perhaps to assess cytology sample adequacy in

situations where a cytopathologist was not needed to

provide a diagnosis on site.

The length of time dedicated to training in cytopa-

thology was highly variable and frequently depended

on the local enthusiasm of cytopathologists, often

with insufficient time and resources. There was at

least 6–12 months for cytopathology in 40% of

responses compared with at least 2–3 years for histo-

pathology in 88.5%. The brief time dedicated to

cytopathology was frequently cited as a deficiency in

training. Although this survey provides information

about opinion and practice of cytopathology, the

importance of who reports what and how much

training is required depends on clinical audit, corre-

lation with histopathology and outcome, none of

which is available in this survey. However, we

thought that variations in reporting practice should

be correlated with time dedicated to cytopathology

training and workload to see whether any patterns

emerged. There was a correlation between training

times of 3–6 months or less and likelihood of pathol-

ogists without specific training in cytopathology sign-

ing out reports, and this practice was reported in

54.7% of responses. Furthermore, there was a

correlation between centres where training was 3-6

months or less and respondents saying that there was

insufficient integration of cytopathology into histo-

pathology training and a lack of training to a high

level of competence. Although 92.2% of respondents

thought that specialist cytology should not be reported

by pathologists without experience in general cytopa-

thology, that practice was reported in 30.9% of

responses and correlated with laboratories with

smaller workloads.

We have demonstrated serious deficiencies in cyto-

pathology training as well as insufficiencies in man-

power and resources in places with potentially

adequate programmes. What is the way forward and

what can be gained from this survey? It is clear that

cytopathology training is overly dependent on local

centres of excellence and that training is variable,

often concentrating on microscopy alone rather than

the clinical aspects of the speciality. A vicious cycle of

inadequate training and insufficient trainers can only

be broken by increasing the amount of time dedicated

to cytopathology training, if necessary by seconding

trainees (as temporary placements) to centres

where adequate training is available, and providing



mandatory requirements for independent practice. As

this is unlikely to be achieved at a local or even

national level it should be taken at least to the level of

the EFCS and perhaps the European Union, for

example through UEMS, so that guidelines can be

produced that overcome the unfortunate but unac-

ceptable fact that �most pathologists have no interest

in cytology�. The overwhelming opinion that (1) a

medical qualification and (2) training in histopathol-

ogy are essential for practice in cytopathology and the

growing importance of direct involvement with

patient care and attendance at multidisciplinary

meetings and biopsy procedures make it necessary to

regard cytopathology as a �superspeciality� rather than

a �subspeciality� and grant it the level of training it

deserves.

Recommendations

• 6-12 months should be dedicated to cytopathol-

ogy during histopathology training with optional

additional training for those wanting to carry out

independent practice in cytopathology.

• Formal accreditation (preferably with specialist

examinations) in all types of cytopathology should

be mandatory for independent practice in cytopa-

thology, including specialist cytopathology.

• When necessary, temporary attachments (sec-

ondments) to centres of good practice should be

available to trainees intending to practise inde-

pendently in cytopathology.

• There should be adequate numbers of patholo-

gists trained in cytopathology to a high level of

competence; some of their time could be released

by training cytotechnologists and trainee pathol-

ogists to pre-screen non-gynaecological cytology

slides and assess adequacy of FNAs when imme-

diate diagnosis is not required.

• European and international guidelines for train-

ing and accreditation in cytopathology should be

developed with some urgency.

References

1. Kocjan G, Chandra A, Cross P et al. BSCC Code of Practice –

fine needle aspiration cytology. Cytopathology 2009;20:283–

96.

2. Chandra A, Cross P, Denton K et al. The BSCC code of

practice – exfoliative cytopathology (excluding gynae-

cological cytopathology). Cytopathology 2009;20:211–23.

3. Wiener HG, Klinkhamer P, Schenck U et al. European

guidelines for quality assurance in cervical cancer screen-

ing: recommendations for cytology laboratories. Cytopa-

thology 2007;18:67–78.

4. Gray W, Bayer-Pietsch E, Chieco P et al. The future of

cytopathology in Europe. Will the wider use of HPV

testing have an impact on the provision of cervical

screening?. Cytopathology 2007;18:278–82.

5. Lynge E, Antilla A, Arbyn M, Segnan N, Ronco G. What�snext? Perspectives and future needs of cervical screening

in Europe in the era of molecular testing and vaccination.

Eur J Cancer. 2009 Oct;45:2714.

6. Confederation of EU Rectors� Conferences and the Associ-

ation of European Universities (CRE). The Bologna decla-

ration on the European space for higher education: and

explanation. Available at http://ec.europa.eu/education/

policies/educ/bologna.pdf (accessed 29 January 2010).

7. Cochand-Priollet B, Vincent S, Vielh P. Cytopathology in

France. Cytopathology 2004;15:163–6.

8. College examinations for fellowship and diplomas. Regula-

tions and guidelines for 2009. Available at http://www.

rcpath.org/resource/pdf/regs_and_guide_2009.pdf (accessed

25 March 2010).

Anshu et al.156


Documents

Survey of medical training in cytopathology carried out by the journal Cytopathology