Dear Editor,
We read this article with great interest and would like to share our
own similar experiences in support of this growing evidence base. Our
department has the added complexity of being one of the UK ST1 training
schools, with between ten and fifteen ST1 - ST5 trainees per year. We
have trained and developed a senior Biomedical Scientist (BMS) in all
specimen dissections who has gained the RCPath Diploma of Expert Practice
in Histological Dissection and been appointed as an Advanced Practitioner
(AP). This post covers all surgical specialties, and the AP currently
dissects the majority of specimens, both simple and complex, as and when
appropriate knowledge and experience has been gained. In terms of
colorectal specimens, all types are dissected by the AP, including
Extralevator Abdomino-Perineal Excision (ELAPE) specimens where the
levator ani and/or coccyx are also resected.
Macroscopy
In terms of macroscopic assessment we follow a similar defined
protocol to that of Sanders et al, with triage of each colorectal cancer
specimen before dissection. Included in this discussion is most
appropriate block selection. This process occurs for both the AP and the
trainees, with the AP following the same pathway as that of the trainees.
The AP and trainee take similar numbers of blocks, as appropriate to the
case, in keeping with the departmental protocol (at least four blocks
required). A macroscopic proforma is used to record data items during
dissection. This is used by all staff, regardless of grade, and is seen
as a method of ensuring that the minimum data items are recorded.
Evidence has shown there to be more chance of identifying extramural
vascular invasion (EVI) where additional tumour blocks are sampled [1].
In the study by Sanders et al it would be interesting to know how often
EVI was identified where additional tumour blocks were taken by the BMS,
as this may not be an appropriate criticism of practice.
Audit
We recently performed an audit to assess lymph node harvesting. This
showed the average lymph node harvest of the AP was twenty-five percent
higher that that of her histopathologist colleagues (consultant and
trainee) (20 vs 15). All staff groups achieve the RCPath requirement of a
harvest of twelve lymph nodes per case [2]. These findings were
statistically significant (p=<0.001) and were presented at a national
meeting [3]. The AP was less likely to perform resampling for additional
lymph nodes (8.1% vs 16.6%). This was attributed to the level of training
and experience of the AP in comparison to some trainee pathologists. In
Sanders et al study the mean numbers of lymph nodes harvested by medical
staff are similar to our own, but those harvested by the BMS are lower.
This may be related to the experience of the BMS, as a similar decrease is
seen with the least experienced trainees in our laboratory. Time spent on
dissection may be a factor as our AP takes on average forty-five to sixty
minutes per case.
Microscopy
As part of the Histopathology team our AP routinely reviews the
slides generated from her colorectal cancer dissections. Reports are
generated using a microscopic minimum dataset proforma and a paper copy of
this is initially completed by the AP for joint review with the consultant
before generation of the final report and authorisation by the consultant.
This pathway is identical to that of the trainees within our department.
Development of scientific staff
Our AP has a specific interest in gastrointestinal pathology and is
currently leading a research study around colorectal cancer diagnostics as
part of a Professional Doctorate in Biomedical Science. This follows the
Modernising Scientific Careers (MSC) programme which aims to provide the
most appropriate developmental opportunities to high achieving scientists
in their field [4]. Achieving the RCPath Specialist Diploma in lower
gastrointestinal histopathology is also a current aim for our AP. To
improve the knowledge base surrounding colorectal cancer management, she
also regularly attends the local colorectal cancer multidisciplinary team
meeting with one of the specialist consultants. This has the additional
benefits in that it publicises the role of the AP within the team, and
also provides an essential feedback mechanism on her performance. We feel
that the performance of the AP is similar to that of an experienced
registrar, and that she should be treated in the same way.
Benefits
The benefits to us are multiple. Consultant histopathologists
benefit from more time to perform other important duties and the ability
to delegate dissection training where appropriate. We would argue that in
many cases reporting is quicker with the AP than with a trainee, as
specimens are less likely to require resampling. Trainee
histopathologists benefit from the additional dissection training,
supervision and an additional source of advice. Due to the protocol
driven nature of the AP's practice, she is able to provide the trainees
with examples of agreed best practice within the department. APs benefit
from career development which was previously unavailable, with the
potential of eventual consultant healthcare scientist status when at
doctoral level and with appropriate experience [4]. Patients benefit from
the knowledge that dissection practice is standardised and that they are
receiving the correct treatment based on appropriate staging.
In conclusion, we feel that there is an important clinical role for
scientists within the histopathology team. Rather than simply working on
the laboratory based aspects of the service, high achievers within this
staff group should be utilised more appropriately. This may be in
specimen dissection and microscopy, but could equally be within
immunohistochemistry or molecular pathology. We agree that the evidence
base needs to be improved in order to support further development within
this area.
Conflict of Interest:
None declared
Dear Editor,
We read this article with great interest and would like to share our own similar experiences in support of this growing evidence base. Our department has the added complexity of being one of the UK ST1 training schools, with between ten and fifteen ST1 - ST5 trainees per year. We have trained and developed a senior Biomedical Scientist (BMS) in all specimen dissections who has gained the RCPath Diploma of Expert Practice in Histological Dissection and been appointed as an Advanced Practitioner (AP). This post covers all surgical specialties, and the AP currently dissects the majority of specimens, both simple and complex, as and when appropriate knowledge and experience has been gained. In terms of colorectal specimens, all types are dissected by the AP, including Extralevator Abdomino-Perineal Excision (ELAPE) specimens where the levator ani and/or coccyx are also resected.
Macroscopy
In terms of macroscopic assessment we follow a similar defined protocol to that of Sanders et al, with triage of each colorectal cancer specimen before dissection. Included in this discussion is most appropriate block selection. This process occurs for both the AP and the trainees, with the AP following the same pathway as that of the trainees. The AP and trainee take similar numbers of blocks, as appropriate to the case, in keeping with the departmental protocol (at least four blocks required). A macroscopic proforma is used to record data items during dissection. This is used by all staff, regardless of grade, and is seen as a method of ensuring that the minimum data items are recorded. Evidence has shown there to be more chance of identifying extramural vascular invasion (EVI) where additional tumour blocks are sampled [1]. In the study by Sanders et al it would be interesting to know how often EVI was identified where additional tumour blocks were taken by the BMS, as this may not be an appropriate criticism of practice.
Audit
We recently performed an audit to assess lymph node harvesting. This showed the average lymph node harvest of the AP was twenty-five percent higher that that of her histopathologist colleagues (consultant and trainee) (20 vs 15). All staff groups achieve the RCPath requirement of a harvest of twelve lymph nodes per case [2]. These findings were statistically significant (p=<0.001) and were presented at a national meeting [3]. The AP was less likely to perform resampling for additional lymph nodes (8.1% vs 16.6%). This was attributed to the level of training and experience of the AP in comparison to some trainee pathologists. In Sanders et al study the mean numbers of lymph nodes harvested by medical staff are similar to our own, but those harvested by the BMS are lower. This may be related to the experience of the BMS, as a similar decrease is seen with the least experienced trainees in our laboratory. Time spent on dissection may be a factor as our AP takes on average forty-five to sixty minutes per case.
Microscopy
As part of the Histopathology team our AP routinely reviews the slides generated from her colorectal cancer dissections. Reports are generated using a microscopic minimum dataset proforma and a paper copy of this is initially completed by the AP for joint review with the consultant before generation of the final report and authorisation by the consultant. This pathway is identical to that of the trainees within our department.
Development of scientific staff
Our AP has a specific interest in gastrointestinal pathology and is currently leading a research study around colorectal cancer diagnostics as part of a Professional Doctorate in Biomedical Science. This follows the Modernising Scientific Careers (MSC) programme which aims to provide the most appropriate developmental opportunities to high achieving scientists in their field [4]. Achieving the RCPath Specialist Diploma in lower gastrointestinal histopathology is also a current aim for our AP. To improve the knowledge base surrounding colorectal cancer management, she also regularly attends the local colorectal cancer multidisciplinary team meeting with one of the specialist consultants. This has the additional benefits in that it publicises the role of the AP within the team, and also provides an essential feedback mechanism on her performance. We feel that the performance of the AP is similar to that of an experienced registrar, and that she should be treated in the same way.
Benefits
The benefits to us are multiple. Consultant histopathologists benefit from more time to perform other important duties and the ability to delegate dissection training where appropriate. We would argue that in many cases reporting is quicker with the AP than with a trainee, as specimens are less likely to require resampling. Trainee histopathologists benefit from the additional dissection training, supervision and an additional source of advice. Due to the protocol driven nature of the AP's practice, she is able to provide the trainees with examples of agreed best practice within the department. APs benefit from career development which was previously unavailable, with the potential of eventual consultant healthcare scientist status when at doctoral level and with appropriate experience [4]. Patients benefit from the knowledge that dissection practice is standardised and that they are receiving the correct treatment based on appropriate staging.
In conclusion, we feel that there is an important clinical role for scientists within the histopathology team. Rather than simply working on the laboratory based aspects of the service, high achievers within this staff group should be utilised more appropriately. This may be in specimen dissection and microscopy, but could equally be within immunohistochemistry or molecular pathology. We agree that the evidence base needs to be improved in order to support further development within this area.
Conflict of Interest:
None declared