Editor's note: This is the second part of a 2-part series. View the first part here.
Some managerial efforts to meet regulation requirements in surgical pathology grossing are directed to on-the-job (OJT) trained workers. This group deserves a closer look.
A Look Back
OJT is a remnant of "the good old days" when pathologists grossed by themselves and were assisted by histotechnicians. Histotechnicans were recruited from the laboratory or morgue aids. Many of them became proficient in the artisan histotechnology and in grossing assistance.
Employment of OJT histology technicians with or without certification is at the discretion of local management without any regulation. ASCP certification is often used to justify an increase in histology technicians' wages. Some states, like Florida and New York, require histotech licensing.
Times have changed. Many histotechnology programs, though now shrinking and insufficient for the laboratories' demand, produce educated histology technicians. The old timers were grandfathered. They will eventually leave the professional scene. However, now OJT histology technicians are entering also the histology laboratory workforce. These questions are presented in detail by René J. Buesa in comprehensive articles about histology laboratories staffing.1,2
Sometimes, OJT is a name for grossing justification by trained pathologists who do not have a U.S. license. They need only adjustment of their training to different conditions in the practice. In rare occasions, pathology residents who haven't yet passed the board exam work at the grossing positions.
The entire concept of OJT without a theoretical background, in my opinion, is questionable as far as grossing in surgical pathology is concerned; I feel it devaluates the seemingly simple grossing procedure.
Opinion on Optional Learning Technique
There are certain grossing techniques that can be taught only at the grossing table, but apprenticeship is not an optimal option to learn grossing, in my opinion. Basic knowledge of surgical pathology is a prerequisite for professional grossing. Only in this situation one can recognize a grossing problem or ask for help to solve it. The less knowledge, the less doubts. The grossing person, for example, encounters question about inking (when and how), cutting (when and how) and other situations that can help or hinder the diagnosis making process. The grossing person ought to envision the sample under the pathologist's microscope. Pathology residents with good tutoring on basic grossing techniques quickly become proficient in grossing, owing to their theoretical surgical pathology background.
OJT cannot be completely dismissed, but it should be the exception, not the norm, in my opinion. In reality, though, OJT is the rule for histotechnologists.
Grossing Histotechnologist as a Solution
| A precise diagnostic section of a skin lesion during grossing.
The current increase of amount and variety of specimens and the detachment of the pathologist and grossing person make the situation first and foremost dangerous for irreplaceable material as biopsies. Pathologists cannot control many grossing outcomes. There is an urgency to find a pragmatic solution for current state of affairs in grossing biopsies and small specimens.
Pathologists' assistants would be the optimal variant. Although states with stringent license policies might try limit grossing only to pathologists, pathology residents and ASCP-certified PAs, it is unattainable around the country.
As well, there are parallel problems. Trained pathologists' assistants are reluctant to work only on biopsies grossing, and managers are reluctant to hire certified pathologists' assistants for a job that does not require such workers.
A grossing histotechnologist would be an appropriate position for a worker who does grossing biopsies and small specimens in surgical pathology. Histotechnologists are the natural pool for this task. Having experience in embedding and microtomy, histotechnologists can visualize and predict the small sample's behavior after grossing to assure that the most diagnostically valuable part of the sample appears on the slide under the pathologist's microscope.
Grossing histotechnologists also can be effective in assurance of completeness of submission of the specimen by understanding how it can be lost during processing and microtomy. Grossing technology of biopsies and small specimens is different from grossing large specimens, though general principles apply to all of them.3
Some histotechnologists may want to pursue grossing as a career for many reasons. Among them: the desire to go out from a monotonous physically demanding microtomy work and an increase in wages. Safety requirements in the gross room are, however, the most stringent in the laboratory, for good reason; the worker encounters many chemical and biohazards.
There is an experience abroad by involving histotech in grossing, especially in biopsies and small specimens. In Australia, the Royal College of Pathologists has guidelines for biomedical scientists who are doing macroscopy (specimen dissection, cut-up, dictation and block selection). This practice is wide spread in Britain and Canada.
| Sawing a small bone fragment.
A grossing histotechnologist position can make a difference if it meets certain conditions, including:
1. a theoretical course in surgical pathology at one of the histotechnology programs. It might be also offered by a pathologists' assistant program. This is the main requirement.
2. a course of internship as a part of the theoretical course. Otherwise, the theoretical background will evaporate.
3. an optimal educational level of eligibility for HT or HTL(ASCP) certification.
ASCP certification should be the final stage of training and eligibility for grossing histotechnologists. ASCP has a well-established system of certifications. The pathologists' assistants' ASCP certification would not be difficult to transform in grossing histotechnologist certification.
Dr. Dimenstein has retired from the Pathology Department, Loyola University Chicago Medical Center. He runs a website on the topics in this article and more at www.grossing-technology.com. The author thanks René J. Buesa B.Sc., HTL(ASCP) for valuable advice in the preparation of this article.
1. Buesa RJ: Salaries in histology. Annals of Diagnostic Pathology.; 12: 122-127, 2008.
2. Buesa RJ: Histology aging force and what to do about it. Annals of Diagnostic Pathology 13 (3): 176-184, 2009.
3. Dimenstein IB: Grossing biopsies: an introduction to general principles and techniques. Annals of Diagnostic Pathology 13: 106-113, 2009.