From Histology to ROSE

As a Senior Biomedical Scientist (BMS) with the entirety of my scientific career based in Histopathology and Molecular Biology, the prospect of becoming competent in the provision of a ROSE service for diagnostic cytology was somewhat daunting and if I am honest I was probably somewhat naïve as to the complexity and volume of information which I was about to embark on. Besides a very basic introduction to cytology preparation procedures during a brief rotation through the discipline during my state registration to become a BMS, I had no real knowledge of diagnostic cytology or what could possibly be involved with rapid onsite evaluation (ROSE).

Initially I would be required to assist with the provision of the ROSE service for the lung cancer diagnostic pathway. After some very serious conversations regarding what is involved in ROSE, I was taken to observe an Endobronchial Ultrasound Bronchoscopy (EBUS) clinic. This was not only to show me the process of what I was required to do in clinic, but to see if I was able to handle the intense clinic situation. Whilst I was fully aware that there was a patient at the end of every Histology specimen I had ever been involved with and understood the importance of sample integrity, the realisation of the process of obtaining the specimen hit home as the procedures were invasive and uncomfortable for the patient. I was soon to realise the intensity of the atmosphere in the room and sensed a great deal of pressure on the scientists performing ROSE. This was something I was not used to and would need to adapt to very quickly. Determined to rise to the challenge, I agreed that I was happy to join the EBUS team and was eager to get started.

Initially we began with weekly slide sessions however this alone came with anxieties as these were group sessions which were already running for existing, established ROSE Cytologists who had been training for over a year and performing ROSE on their own. To sit there and expose how little I knew and my level of incompetence was really out of my comfort zone and a feeling I didn’t enjoy. I was also not entirely sure how the members of the Cytology department felt about a Histologist joining their team. By taking comprehensive notes and frequent review and repetition, my confidence in these situations gradually grew until I was on a level with them. On the odd occasion my knowledge exceeded theirs, I was filled with pride, motivating me to continue gaining knowledge.

As my knowledge increased and I began to gain confidence, I was soon to realise that there was a lot more to this than just being able to recognise all of the different cell types, determine the benign cells masquerading as diagnostic cells, and the pressure of exposing my incompetence to the rest of the department. I was then to face the realisation that I had never prepped a cytology spread in my life. This was something very alien to my set of skills and something I needed much guidance in. To prepare myself for the clinic situation, simulated FNAs were created using chicken kidneys contained in disposable gloves to replicated abnormally oversized lymph nodes. I could practice creating direct spreads by FNAing the “chicken nodes”. I was soon to realise that this was not a true representation of how this would feel in clinic. A calm, unpressured, air conditioned environment with no consequence to a poor prep was not what I was about to experience in clinic.

To begin with, I observed the ROSE expert in the whole clinical procedure, a kind of fly on the wall experience. This I felt comfortable with. There was no pressure on me and I was able to follow the procedure, pre-empting the next stage in my head until I learned the process. It was then my turn to have a go! The process was broken down into stages. I would get used to handling the needle, performing the direct spread, drying the slides, and finally staining them (a process I was very comfortable with due to my Histology background, finally something I knew!). This was enough for now. My accompanying ROSE expert would be responsible for screening the slides and communicating with the clinicians. I would listen for her every word, trying to memorise her sentences to ensure that I was aware of the correct phraseology so not to give the incorrect message across, something I was very wary of doing. Communicating with the clinicians in the intense clinical environment is something no one can prepare you for. Each consultant is different, every clinic is different and every sample unique. Once the pressure was off and the results had been communicated, I was then able to screen the slides in my own time. As the weeks went on and my clinic experience grew, I began to pre-screen the slides prior to the experience ROSE checking my opinion and began to feed back to the consultant. The weekly case reviews continued alongside my continuing clinic exposure helping to solidify my knowledge and increase my confidence. Continual assessment by my ROSE trainer meant that the training was tailored to me and my abilities, however this felt very fast and at times I felt her confidence in me was far greater than my confidence in myself. Soon I was performing the whole procedure but with her in the room, my comfort blanket in case I needed her. Once she was happy, I underwent my competency assessment to allow me to perform EBUS alone. I still knew she would always be at the end of the phone, I was not happy to put down my blanket yet! I was aware of the limits of my knowledge.

In addition to the weekly slide sessions, I began to attend the relevant Multidisciplinary team meetings (MDTs) where past and potential ROSE patients were discussed with the clinical background information. The first time I set foot in the meeting I felt incredibly out of my depth, and maybe a little conspicuous, assuming that people would be looking at me thinking who was I and why was I even there. I was swiftly introduced to the team, and instantly felt welcome and there was no question as to why I was in attendance. In fact, this led to the invitation of all EBUS ROSE providers to the meeting. What I was about to be part of was incredibly fascinating, with scans and clinical imaging of the various patients, something I had never had the opportunity to see before, especially in the context of an upcoming laboratory specimen. This alone was vast and a huge amount of information to learn to understand and take in. With comprehensive explanations of what I was seeing, I gradually began to understand the information being presented. This is now an invaluable part of the preparation for every patient, helping to visualise what we are expecting to see in clinic and aids with the slide assessment process no end.

Over the next twelve months my experience and confidence grew exponentially with the increased exposure to clinics and the consolidation of knowledge via the continuation of the weekly case reviews around the multiheader microscope. My thirst for reassurance, however, continued and I still ask the ROSE expert for confirmation that I made the correct choices in clinic frequently following a tricky case. The field of ROSE is vast and I am still aware that my experience is limited to the EBUS cases I have dealt with so far. There are still many improvements which can be made to my technical skills and knowledge, however as I have developed I am now able to give advice to consultants to improve sample quality as and when required, something which felt a very distant possibility at the start. I am aware that there is still a lot to learn, with the odd, interesting complex case knocking my confidence, however I am now confident in my ability to know what to do in every scenario.

Being one of the first Histology trained BMS to become competent in the provision of ROSE for EBUS has been an absolute privilege to be an established part of the team and I look forward to the next chapter in my ROSE career. With the ability to open ROSE out to other pathology disciplines, the potential for ROSE provision becomes incredible, with invaluable benefits to both the patient and the laboratory. I am now in the process of developing my ROSE provision to include Head and Neck Cytology. Here I go again……….