Voices from the Field
Car models change each year, computer software changes at least that often, even postage rates increase more rapidly than before, and no one seems to be able to keep up with change in the stock market. But change in the field of medicine in general comes relatively slowly. And that is the way most of us like it. We expect procedures and practices to be researched, evaluated, scrutinized and only when confidently deemed beneficial, put into effect.
Possibly the slowest branch of medicine to institute change is pathology, including cytopathology. After all, how much can tissues and cells change? Yes, clinical laboratories have been modified considerably over time, with new subspecialties emerging and with many, if not most, procedures being mechanized or automated. Cytopathology, on the other hand, has moseyed along looking at exfoliated cells, energized only fairly recently by the increased evaluation of fine needle aspirate specimens. In the last three or four years, however, the pace of change has picked up, fueled by the introduction of mechanization in specimen processing, automation in specimen evaluation and restructuring in laboratory organization and administration.
Fifteen years ago a survey was done to evaluate attitudes of cytotechnologists who had been in the field 25 years or more. The outpouring of enthusiasm for the discipline was so great that the results were published in three installments.1 Sure, there were some complaints of stress, lack of recognition of the value of the field and low salaries. But the majority of responses indicated high satisfaction of the present and anticipation of positive changes in the future.
Change has definitely occurred. But has it been positive? A recent, small survey of attitudes of experienced cytotechnologists revealed responses that could be called "mixed" at best. Asked if they would become a cytotechnologist again, given the chance, most answered "yes." Would they recommend the field to others? Even numbers said yes and no, with some answering "it depends." However, most of those who said they would do it all over again were emphatic in their choice, while others less sure varied from "probably" to "maybe" to "not sure." Still, a much different response from 15 years ago.
What made the difference? Elements mentioned by the current respondents, in no particular order, were: emphasis on zero error rate in diagnosis; workload quotas; threat of (or actual) litigation; negative publicity; increase in large private laboratories (instead of moderate-sized hospital laboratories) and related "commercialization"; increase in regulations and resultant paperwork. What follows are questions asked in the non-scientific survey and how those who participated responded.
What do you like about being a cytotechnologist?
Contributing to the reduction in cancer mortality, the actual saving of lives was very important to many who participated in the survey. Another frequently mentioned aspect of the field was the challenge of the detective looking for clues, putting the evidence together to make the diagnosis, hunting for the rare event of cancer.
"I like finding the isolated cell that tells me the problem," said a cytotechnologist from the northwest. "[I like] the challenge of diagnosing and being accurate," said another.
Many were attracted by the detailed microscopy, the variation in the cells, the anticipation of something new in the next slide, and the beauty and colors of the cells. Often appreciated was the sense of independent decision-making: "I like the uniqueness of our profession. I am proud of the expertise required and the responsibility we hold," stated a teaching supervisor from upstate New York.
A synthesis of the strong positive feelings coming through about this field would be: the enjoyment of working independently yet with the option of consulting with others; on interesting ever-new material, with the possibility of something diagnostically significant just ahead; and being depended upon for observational ability and interpretive skills that lead quite directly to the saving of lives. What could go wrong?
What do you dislike about being a cytotechnologist?
No hesitation here. The top dislike is the over-concern for productivity. This is often expressed as having to meet a quota or pressure to read slides faster than is comfortable with accuracy. This factor derives from two sources. First, is the increase in the number of private, often commercially oriented, cytology laboratories competing for business with, and the resultant decline of, hospital-based laboratories. Second, curiously, is the attempt to limit the extremely high number of slides some cytotechnologists had been encouraged to read. This excessive number was thought to lead to diagnostic errors, so CLIA '88 set a maximum of 100 slides a day (eight-hour period) that a cytotechnologist may read. The legislation further mandated that each cytotechnologist's workload be individually tailored to his/her abilities and skills, and re-evaluated every six months. From the comments in this survey, it would seem either that the legislative rules are not being followed, or that they are unrealistic.
The second most frequently, and often vehemently, mentioned dislike was the threat of litigation. Usually hailed as part of the most successful screening program for early cancer detection in medical history, cervical cytology is now being held to 100 percent sensitivity as well as specificity. This, as statisticians and epidemiologists will testify, is a contradiction. Cervical cytology is but one element in the screening program, and all elements--patient, clinician, laboratory, etc., must function optimally to achieve the desired goal. But changing attitudes in our culture have resulted in an increase in litigation in medicine as a whole, and in cytology in particular. This change has led to such ominous comments about alleged cervical cytology error as, "It has tremendous jury appeal,"2 spoken apparently approvingly by an attorney. No wonder a cytotechnologist with more than 40 years experience commented, "I have a severe case of displeasure when it comes to the threat of possible litigation that haunts every one of us who is presently using a microscope to try to better women's health!"
Another dislike was "sitting all day long with an aching neck, back, arms and knees." This New England supervisor-teacher would like "an ergonomic desk, chair, microscope and computer outfit that will prevent, or at least minimize, the risk of repetitive motion injuries."
Low salaries, especially compared with those in fields requiring comparable education, were mentioned by several respondents. Bad publicity, the need for paper trails of documentation and increased paperwork in general, virtually nonexistent funding for continuing education, and being undervalued were other negative aspects. A cytotechnologist from the northwest summed it up this way: "We are not machines, and this is not a mechanical science. We are highly trained and the addition of the demands have added such tension and production orientation that there is little time for enjoyment of the practice left."
If the above questions had been asked of you some time ago, would your answer have been different? Why or why not?
We were attempting with this question to determine whether the respondents' attitudes had changed over time. About one-third said they would have answered the same either time. They were enthusiastic about the field then, and are excited about the new technologies now. Others said their "likes" were the same, but "dislikes" increased in quantity and quality. Some negative aspects, such as sitting in one position all day, have not changed. Others, such as the threat of litigation, low relative salaries, work quotas and reduced budgets were recent.
Several people mentioned institutional mergers or corporate takeovers as a current source of concern. These business moves often result in the push for profits that eliminates time for discussion of interesting cases, as well as money for continuing education.
"The job used to be fun; now it is pretty intimidating," is how one cytotechnologist put it. Another commented, "You can't turn back the clock, but sometimes I'd really like to return to the halcyon days at ____ Hospital in the 70s. It was interesting and varied, and we did a good job not because we had regulators breathing down our neck, but because we were committed to doing a good job for the patients."
What, if anything, would you want to see changed in the field of cytology?
All of the respondents, whether they liked the field now as well as in the past or not, would like to see some changes. Pay commensurate with the responsibilities of the job, and recognition of the error rate inherent in human activity topped the list of changes wanted.
Although this group of cytotechnologists acknowledges that with their experience and longevity in the field they were reasonably well reimbursed, attracting new employees with current pay levels is difficult. Sign-on bonuses of as much as $7,500 offered by large laboratory corporations, and one editor's comment that "college-educated cytotechnologists aren't getting paid much more than deli meat slicers"3 seem to bear this out.
A New York teaching cytotechnologist asks for recognition that "since we're not perfect, the Pap smear is not a perfect test, and a person or laboratory that misses a difficult case is competent if following well-defined procedures for quality control and assurance." (It should be noted that a cervical cancer screening program includes repeat evaluations and follow-up, and is not dependent upon a single observation.)
Another long-time cytotechnologist from Indiana broadens the discussion by asking for "Safe Harbor" laws to protect cytology laboratories from litigation when they are following the CLIA regulations. He and others point out that educating the public, especially the legal profession, about the value and realistic expectations of the Pap smear would go a long way to reducing the threat of litigation.
Considering the list of dislikes, changes in salary (increase) and required workload (decrease, or at least de-emphasis) could be expected to be requested. Several wishes for more opportunities for continuing education were expressed, with the strategic observation that better educated cytotechnologists have been shown to make fewer errors. The need to widen the expertise and scope of responsibility for cytotechnologists to include molecular biology, flow cytometry and perhaps histology was suggested by one supervisor in the northeast.
Would you recommend the field of cytology to others as a promising profession today?
"Absolutely! One of the best times to consider this profession is right now!"
Given all of the previous discussion, it might seem surprising that as many as 40 percent of those surveyed say they would recommend the field to others. But the above response, from the east, is challenged by another from the Midwest, saying, "No. The future is not bright." In between is a reply from the northwest, "I am less likely to recommend the profession than I was perhaps 15 years ago."
Those who would encourage others to apply often mention the need for replacing retiring technologists and report on their own recruitment activities in schools and in the community at large. Naysayers point to advances in automation, which may reduce the number of people needed. Several mentioned the need for people entering the field now to be more versatile, developing additional laboratory skills such as those involved with performing HPV testing or special stains. As one cytotechnologist put it, "The world under a 10X objective is too small a place to spend the better part of your waking hours."
If you had it to do over, would you become a cytotechnologist again?
Responses ranged from "yes," and "absolutely" to "probably," "not sure," "probably not" and "no, I'd probably be an engineer."
Although very few would most definitely not try again, almost half of those responding modified their enthusiasm for the field in some way. Those strongly in favor of becoming a cytotechnologist again mentioned growth in knowledge and professional stature, increase in reimbursement and contributing to the health of many people as plus factors.
"I still feel that there is nothing more important than the work we do," said one respondent.
Some would consider additional studies. "I would become a cytotechnologist again," a manager from Arizona remarked, "unless I was more serious and studious and became a physician."
A resounding "Yes, I would do it again without a moment's hesitation," from a teacher/manager with 42 years in the field was qualified by her next statement: "However, I would not wish to continue clinical practice under the circumstances that are frequently found in mega-labs where the goal is monetary, not truly medical!"
The strong positive feelings that most of these cytotechnologists with long experience in the field continue to hold for their chosen field is striking, as are the serious doubts and misgivings also voiced. Which will prevail to become the influence that will shape cytology in the years to come?
The care for the future of cytology of those cytotechnologists contacted in this survey is clearly evident, along with concern for the problems, as exemplified in this final quote from a cytotechnologist on the east coast. "I would like to see a garden of cytology, both vegetable and flower. The vegetable garden to nurture and sustain us (good, objective, state-of-the-art science with well-paid, dependable, licensed and certified cytotechnologists, who are respected and recognized [by all components of health care as well as general society] members of the health care team), and flowers that show others the beauty we bring to science and the well being of our patients (through education and technical enhancement that bring efficiency to the process of saving lives)."
1. Goodell, R.M. 25 years of cytology. ASCT News 1986; 7(1),7(5),7(7).
2. Kellar, D. How to defuse compliance time bombs. Part 2. MLO 1999;31(6):56-66.
3. Berger, D. Show them the money. MLO 2000;32(8):6.
Caskey, C. Laboratory ergonomics. The answer to CTD prevention. ADVANCE for Lab Med Prof, 2000;12(6):5.
Klipp, J. Who wants to work in a lab? MLO 2000; 32(8):25-29.
Foubister, V. Bench press. The technologist/technician shortfall is putting the squeeze on laboratories nationwide. CAP TODAY, 2000;14(9):84-90.
Roberta M. Goodell is an assistant editor of Acta Cytologica, on the editorial staff of Cytopaths and currently co-editing the revised edition of the Quality Assurance Guide of the American Society for Cytotechnology. She would like to thank everyone who participated in the survey.
Demographics of Survey Respondents
Years in Profession
Diagnostic cytotechnologist: majority
Supervisor/manager (incl. Asst.): 1/2
Other: section head anatomic
pathology; senior science advisor
(Respondents occupied more
than one category)
Private laboratory: 53%
Hospital laboratory: 33%
Cytology industry laboratory: 7%
Other: state laboratory: 7%
figures/courtesy Roberta Goodell, CT(ASCP), CFIAC