See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/7972716

What is the best indicator to determine anatomic pathology workload?

Canadian experience

Article  in  American Journal of Clinical Pathology · February 2005

DOI: 10.1309/23NYGNB2HFNNW4V8 · Source: PubMed

CITATIONS READS

28 3,891

1 author:

Raymond Maung
Interior Health Authority
15 PUBLICATIONS   669 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

pathologists' workload and safety View project

All content following this page was uploaded by Raymond Maung on 05 June 2014.

The user has requested enhancement of the downloaded file.

 Anatomic Pathology / ANATOMIC PATHOLOGY WORKLOAD CALCULATION
What Is the Best Indicator to Determine Anatomic
Pathology Workload?
Canadian Experience
Raymond T.A. Maung, FRCP (Canada), MBA
Key Words: Pathology manpower; Anatomic pathology workload
DOI: 10.1309/23NYGNB2HFNNW4V8
Abstract
Health care resources in Canada are limited, and
there is tremendous pressure to reduce laboratory
budgets. It is almost impossible to acquire new
pathologist positions to adequately meet service
demands. There is a need to determine objectively the
appropriate pathologist workload. I looked at multiple
indicators (total accessioned cases, number of
specimens, slides, blocks, Royal College of Pathologists
[London, England] model, population served, and level
4 equivalent [L4E]) that might reflect the pathologist’s
work and determine which indicators are the best. L4E
is a calculated weighted value based on complexity
levels of individual anatomic pathology consultation.
Of all indicators analyzed, L4E is the best reflection of
a pathologist’s anatomic pathology work because it has
the best statistical values, is a direct output
measurement of pathologist consultations, and uses
data routinely collected in many North American
laboratories.
© American Society for Clinical Pathology
There are few guidelines as to how professional human
resource requirements for an individual pathology department
should be calculated. Some are based on raw numbers of sur-
gical pathology (SP) cases, cytologic examinations, and
autopsies done1,2 and the population of the community served
during the year.3 (Note that the term center is used in this arti-
cle to describe the institution—laboratory, hospital, or organi-
zation with many facilities—that serves the population.) I
looked at various routinely obtained indicators in anatomic
pathology (AP), including input (cases, specimens, blocks,
and slides) and output (reports, but not the number of words
or lines transcribed in the reports4), to determine which most
accurately reflect the work done by pathologists.
Materials and Methods
Data were collected in 2 interdependent surveys.
Although data were collected, information excluded in the
present discussion includes clinical pathology (CP) consulta-
tive activities, administration (eg, quality assurance and con-
trol activities, running Papanicolaou (Pap) smear programs),
and academic activities (research and teaching, education of
technologists, education of physicians in the proper use of lab-
oratory resources, and participation in various educational and
interdepartmental rounds).
The first survey, directed to all practicing pathologists in
Canada, obtained the opinions of the working pathologists in
an attempt to categorize their activities and obtain a general
view of the workload. The survey was sent to all department
heads based on the Canadian Association of Pathologists data-
base with a request that copies of the survey be distributed to
Am J Clin Pathol 2005;123:45-55 45
45 DOI: 10.1309/23NYGNB2HFNNW4V8 45
Maung / ANATOMIC PATHOLOGY WORKLOAD CALCULATION

all members of the department. The survey indicated that the
work done by pathologists can be best categorized as consul-
tation, administration, and professional development activi-
ties. The 2004 User’s Guide for Pathology Practice Activity
and Staffing Program from the College of American
Pathologists (PathFocus)5 categorized pathologists’ activities
into AP, CP, administration and management, scholarly pur-
suit, other/miscellaneous activities, and teaching and educa-
tion. This is similar to the 3 major categories indicated in the
present survey (ie, consultation includes AP and CP; adminis-
tration includes administration and management and some
activities in the other/miscellaneous category; academic and
professional development includes the scholarly pursuit and
teaching and education categories). The purpose of PathFocus
is stated as “PathFocus is designed to assist pathology prac-
tices in objectively assessing their group’s activities and
staffing needs related to other groups of similar complexity.”5
Thus, PathFocus compares one group’s staffing level with the
staffing level of similar groups, but it does not indicate the
appropriate level of staffing for a certain level of total output
for the group. As such, the focus of this study is not the same
as that of PathFocus.
Consultation includes all activities that pathologists per-
form that have direct patient care consequences.
Documentation is relatively easy for AP because all activities
performed are documented in consultation reports. In British
Columbia,6 Alberta,7 and Ontario8 models and in the Current
Procedural Terminology (CPT)9 for SP in the United States,
SP cases are classified into 6 billing levels. Except for the
Ontario model, the 3 other systems reviewed are similar in the
separation of different types of specimens into different levels
and serve as a basis for this analysis. Although the Ontario
model has 6 levels like the others, it is quite different in how
each specimen is categorized in the different levels. It is
preferable to have more levels (details) of SP cases, but the
division of SP cases into 6 levels is well established, and data
are obtained routinely and can be used as the basis for the cal-
culation of AP workload. More levels will allow more detailed
analysis but will be less practical.
I assumed that the amount billed for each level reflected
the value of each level in relation to other levels. Level 4,
which is most classification, includes the majority of consul-
tations performed in AP, eg, examination of surgical biopsy
specimens of prostate, breast, and gastrointestinal tract, and is
considered 1 unit (level 4 equivalent [L4E]), and the other lev-
els and activities (eg, autopsies, cytologic examinations, intra-
operative consultations) are weighed in comparison with level
4 ❚Table 1❚. Level 4 is equivalent to CPT code 88305.
Intradepartmental and external consultative activities
are of tremendous importance in patient care, and a system
to record these activities is required urgently. Recommended
situations include highly critical or significant cases,10 prob-
lem-prone specimens,11,12 and patients referred from one
institution to another. The internal and external reviews
improve patient care by reducing diagnostic errors.13-16
Because intradepartmental and external consultative activi-
ties are not recorded in a systematic manner nationally, they
are not included in the present analysis. These activities con-
stitute a minor portion of the total AP consultations done in
most institutions (except in Cancer Centers, which are not
represented in this study), and the impact of this on the
analysis will be minimal. This may change in the future if

❚Table 1❚
Anatomic Pathology Consultative Activities and Their Proposed Weighted Values

Level Individual Consultative Procedures Relative Weighting*

1 Gross only examination (If pathologist deems that microscopic examination required, 14%
the specimen is not classified here.)
2 Confirmation of normality by gross and microscopic examination of small specimens 32%
3 Confirmation of common degenerative, inflammatory, and common benign conditions 49%
4 Small specimens for diagnosis, including all endoscopic biopsy specimens and small organs 100%
removed for benign conditions
5 Complex biopsy specimens or small whole organs, including specimens from specialized 172%
biopsies and excisions
6 Large complex organ requiring extensive gross dissection and microscopic assessment 253%
— Screening cytology (sputum and urine cytology, pathologist review of marked Papanicolaou 49% (ie, same as level 3)
smears)
— Diagnostic cytology (FNA, fluids) 100%
— Intraoperative consultations (with and without frozen sections) 150%
— Autopsy (full, uncomplicated) 800%
— Intradepartmental consultation† 25% of level of specimen reviewed
— Consultation, review (eg, cancer clinic reviews, for studies)† 66% of level of specimen reviewed
— Consultation, complicated (for difficult cases, external)† 150% of level of specimen reviewed
— Other procedures (eg, FNA, bone marrow biopsy with or without aspiration)† As per other specialties or 100% of level 4

FNA, fine-needle aspirate.

* Percentages are of level 4 unless otherwise stated.
† Proposed; not included in the present analysis.

46 Am J Clin Pathol 2005;123:45-55 © American Society for Clinical Pathology

46 DOI: 10.1309/23NYGNB2HFNNW4V8
 Anatomic Pathology / ORIGINAL ARTICLE

protocols and standards of practice demand more routine sec-
ond consultations for predefined specimens.
The survey also asked how specimens should be counted.
A large majority held the view that when multiple specimens
are received and are accessioned under a single number, they
should be counted according to the uniqueness of each speci-
men. For example, 2 skin biopsy specimens, one from the face
and one from the leg, are, in most situations, unrelated to each
other and should be counted as 2 specimens. Each diagnosis
also is associated with unique medical and legal importance
and responsibility.
In the second survey, which was based on the data from the
first survey, more detailed practice information was obtained.
The survey was directed to the department heads and chiefs
(hereafter referred to as department heads). The following infor-
mation was requested: (1) practice demographics, eg, popula-
tion, full-time equivalents (FTEs) of professionals; (2) AP data
for a 1-year period, ie, accessioned SP cases, cytologic speci-
mens, autopsies, and intraoperative consultations, and acces-
sioned cases in 1 month (maximum, 1,000 cases) with more
detailed information about the cases (eg, number accessioned,
type of specimens, diagnoses) so that specimens could be
counted and categorized in a standardized manner; monthly
data prorated according to the annual data; (3) annual number
of blocks, slides, and specimens; (4) non–gynecologic cytology
divided into 2 levels: screening cytology, including sputum and
urine specimens and Pap smears reviewed by the pathologist
and equated to level 3 SP (7% of Pap smears are considered to
be reviewed by the pathologist, based on the percent of Pap
smears reviewed by the British Columbia Cancer Agency,
which does all the Pap smears for all of British Columbia); and
diagnostic cytology, including the rest (fine-needle aspirations,
fluids, washes, and brushes) and equated to level 4 SP; (5) in
addition to the current medical professional (AP, hematopathol-
ogy and transfusion medicine, microbiology, chemistry, and
administration) FTEs in each subsection, the optimal profes-
sional FTEs needed to perform the duties adequately.
By using the optimal number of pathologists given by the
department heads as a base, descriptive statistics for the sam-
ple data were computed. In addition, regression analysis was
performed studying the relationship between the workload
indicators and optimal FTEs. The data analysis routines in
Microsoft Excel XP (Microsoft, Redmond, WA) were used.
Results
First Survey
The first survey (43 respondents of 247; 17.4% response
rate) obtained opinions of pathologists about what services
they perform that are of value and should be included in the
calculation of the pathologist’s workload. The services were
categorized into consultation, administration, and academic
and professional development activities. Although the survey
obtained opinions about how to capture consultative activities
in CP, administration, and academic and professional develop-
ment activities, the rest of this article is limited to consultative
activities in AP. According to the preferences of 29 of 43
respondents, the relative weights of the different levels of SP
cases were calculated ❚Table 2❚.
Second Survey
Of 240 mailed surveys, there were 31 responses but only
27 respondents submitted complete data sets sufficient for
analysis. Although the response rate was low (11.3%), the
respondents’ centers ranged from tertiary centers with medical
school affiliations and resident training to small centers with
only a few pathologists, and the statistical analysis showed
that the results were significant.
The practice demographics ❚Table 3❚ show that the respond-
ing centers varied from large to small centers serving popula-
tions of more than 1 million to 12,000. By using the optimal
FTEs suggested by the department head as the denominator,

❚Table 2❚
Calculated Weights for Different Systems of Surgical Pathology Levels According to Opinions of 29 of 43 Survey Respondents

Suggested Weight by Individual Respondents (n = 4)*

CPT9 Codes
BC6 Ontario7 Study Proposal Weighted for Similar
Level (n = 9)* (n = 5)* (n = 11)* 1 2 3 4 Average (%)† Specimen Type‡

1 0.13 0.27 0.08 0.1 0.25 0.1 0.1 0.14 0.21

2 0.42 0.35 0.2 0.4 0.42 0.4 0.2 0.32 0.41
3 0.54 0.67 0.33 0.5 0.67 0.6 0.6 0.49 0.63
4 1.0 1.0 1.0 1.0 1.0 1.0 1.0 1.00 1.00
5 1.4 1.6 2.0 1.8 2.0 1.4 2.0 1.72 1.84
6 2.83 2.0 2.5 2.5 2.5 2.8 2.5 2.53 2.53

BC, British Columbia; CPT, Current Procedural Terminology.

* Number of respondents who preferred the system. Level 4 has a weighted value of 1 because it is the standard against which other levels are weighted.
† Weighted average for each surgical level = [9 (BC) + 5 (Ontario) + 11 (Author) + 1 (Respondent 1) +1 (Respondent 2) + 1 (Respondent 3) + 1 (Respondent 4)]/29
‡ Weights are for comparison.

© American Society for Clinical Pathology Am J Clin Pathol 2005;123:45-55 47

47 DOI: 10.1309/23NYGNB2HFNNW4V8 47
Maung / ANATOMIC PATHOLOGY WORKLOAD CALCULATION

❚Table 3❚
Practice Demographics of the Centers*

AP FTEs

Current
Level 4 Population Compared With
Center SP Cases Specimens Equivalents Blocks Slides Served Current Optimal Optimal (%)†

1 15,283 22,304 23,828 37,500 45,360 150,941 4.23 6.00 –29.44

2 8,890 10,940 12,127 17,565 33,047 93,488 2.67 4.00 –33.33
3 100,253 145,117 163,514 280,372 565,042 110,3221 41.05 50.00 –17.90
4 15,196 23,565 27,564 50,456 127,886 226,553 5.75 7.00 –17.86
5 111,513 160,413 186,629 311,827 628,434 1,201,631 34.15 53.00 –35.57
6 6,869 9,032 8,649 13,008 21,810 134,122 1.33 3.00 –55.56
7 6,595 6,595 7,596 12,773 30,571 79,102 0.67 2.00 –66.67
8 1,828 4,081 3,916 3,900 4,945 35,091 0.67 1.00 –33.33
9 34,015 42,275 46,195 84,228 183,478 400,000 8.8 11.00 –20.00
10 5,240 6,983 7,553 17,083 21,786 50,000 1.9 1.90 0.00
11 9,577 11,895 13,478 24,744 58,291 150,000 4.5 4.50 0.00
12 6,500 7,015 7,366 9,682 11,602 50,000 1 2.00 –50.00
13 12,500 16,245 17,008 41,600 95,680 225,000 4.5 5.00 –10.00
14 4,000 5,436 5,106 6,000 10,000 12,000 1 1.90 –47.37
15 8,714 8,714 8,084 Not given 25,949 80,000 1 2.00 –50.00
16 5,084 5,854 5,738 9,354 19,655 63,000 2 2.25 –11.11
17 8,137 9,624 11,434 15,646 20,944 90,000 3 4.00 –25.00
18 15,319 20,032 21,617 41,908 72,878 200,000 4.5 4.50 0.00
19 20,000 24,639 26,350 67,023 110,510 480,000 7 8.00 –12.50
20 20,000 26,482 26,770 59,507 90,322 250,000 5.8 6.25 –7.20
21 7,130 8,845 7,650 13,525 21,101 76,500 2.5 2.50 0.00
22 12,284 17,770 18,982 30,000 40,000 160,000 4 4.50 –11.11
23 12,832 15,929 15,721 40,938 71,815 400,000 3.75 3.75 0.00
24 4,600 5,564 5,701 8,232 14,064 42,500 2 2.00 0.00
25 8,937 11,569 13,095 26,800 33,500 140,000 3 4.50 –33.33
26 10,500 17,347 17,967 39,000 50,000 123,500 3 4.00 –25.00
27 10,342 12,570 11,829 25,000 40,000 140,000 2.7 2.70 0.00

AP, anatomic pathology; FTE, full-time equivalent; SP, surgical pathology.

* The numbers of SP cases, specimens, level 4 equivalents, blocks, and slides are for 1 calendar year. Optimal FTEs were given by department heads.
† Current Compared With Optimal FTE = (Current FTE – Optimal FTE)/Optimal FTE.

the optimal work for each pathologist (indicator units per
pathologist) in that center was calculated using various indica-
tors (total units for indicator/optimal FTEs; for example, for
center 1, 15,283 SP cases divided by 6 = 2,547 [results are
rounded to whole numbers]). The results are given in ❚Table 4❚,
which is based on the opinions of the department head about the
appropriate FTEs for the department and, thus, the average
workload for a pathologist. Although the FTEs were given intu-
itively, they are relatively consistent and accurate. This is evi-
dent because the optimal workload measured by several of the
indicators is relatively similar between centers. This is high-
lighted in ❚Figure 1❚ by the relative flatness of graph lines for a
few of the indicators. In most cases, the optimal FTEs given by
the respondents were in whole numbers; only some were given
to half or quarter FTEs (usually in situations when there were
sufficient FTEs in the department), in contrast with the calculat-
ed FTEs, which are given to the second decimal value.
The data in Figure 1 and Table 4 show that the numbers of
L4Es, specimens, and SP cases were least variable between the
centers and, thus, most accurately reflect the impression of
pathologists about their workloads across the different centers.
L4E has the lowest SD and the lowest variability.
❚Table 5❚ and ❚Figure 2❚ show the calculated FTEs in AP
for various indicators. In the first set of columns, the required
AP FTEs were calculated by using the following formula:
Required AP FTEs = Total Units of Indicator Annually
(from Table 3)/Average Units of Indicator (from Table 4)
To determine how the calculated number of FTEs varies
from the optimal FTEs (as indicated by the department head),
the following formula was used:
Difference of Calculated FTEs Requirement From
Optimal FTEs (%) = (Calculated FTEs for Indicator –
Optimal FTEs)/Optimal FTEs
Positive percentages indicate that the calculated value
overestimated the FTEs needed, and negative percentages
indicate underestimation. The second set of columns in Table
5 show that the L4E calculation in most cases overestimated
needed FTEs by 2% (average, 0%). The variation in the differ-
ence from optimal FTE was low (SD 17.3%). The variation in
individual calculation is probably high, as the optimal FTE
given by the department head is usually in round numbers or
a quarter to half increments. Because of the low denominators
involved, a slight difference of the calculated and optimal
FTEs makes a huge difference in percentage (eg, center 1, a

48 Am J Clin Pathol 2005;123:45-55 © American Society for Clinical Pathology

48 DOI: 10.1309/23NYGNB2HFNNW4V8
 Anatomic Pathology / ORIGINAL ARTICLE

❚Table 4❚
Optimal Pathologist Workload per Year*
Center Surgical Pathology Cases Specimens Level 4 Equivalent Blocks Slides Population

1 2,547 3,717 3,971 6,250 7,560 25,157

2 2,223 2,735 3,032 4,391 8,262 23,372
3 2,005 2,902 3,270 5,607 11,301 22,064
4 2,171 3,366 3,938 7,208 18,269 32,365
5 2,104 3,027 3,521 5,884 11,857 22,672
6 2,290 3,011 2,883 4,336 7,270 44,707
7 3,298 3,298 3,798 6,387 15,286 39,551
8 1,828 4,081 3,916 3,900 4,945 35,091
9 3,092 3,843 4,200 7,657 16,680 36,364
10 2,758 3,675 3,975 8,991 11,466 26,316
11 2,128 2,643 2,995 5,499 12,954 33,333
12 3,250 3,507 3,683 4,841 5,801 25,000
13 2,500 3,249 3,402 8,320 19,136 45,000
14 2,105 2,861 2,687 3,158 5,263 6,316
15 4,357 4,357 4,042 Not given 12,975 40,000
16 2,260 2,602 2,550 4,157 8,736 28,000
17 2,034 2,406 2,858 3,912 5,236 22,500
18 3,404 4,451 4,804 9,313 16,195 44,444
19 2,500 3,080 3,294 8,378 13,814 60,000
20 3,200 4,237 4,283 9,521 14,452 40,000
21 2,852 3,538 3,060 5,410 8,440 30,600
22 2,730 3,949 4,218 6,667 8,889 35,556
23 3,422 4,248 4,192 10,917 19,151 106,667
24 2,300 2,782 2,850 4,116 7,032 21,250
25 1,986 2,571 2,910 5,956 7,444 31,111
26 2,625 4,337 4,492 9,750 12,500 30,875
27 3,830 4,655 4,381 9,259 14,815 51,852
Average 2,659 3,449 3,600 6,530 11,323 35,562
Median 2,500 3,366 3,683 6,103 11,466 32,365
SD 634 670 633 2,200 4,443 17,972
SD as percentage 23.84 19.43 17.58 33.69 39.24 50.54
of average
Maximum 4,357 4,655 4,804 10,917 19,151 106,667
Minimum 1,828 2,406 2,550 3,158 4,945 6,316
* Data are numbers determined by dividing the indicator, eg, number of surgical pathology cases, by the optimal number of full-time equivalents identified by the department head
(Table 3). Results are rounded to whole numbers.

25,000 120,000
Category 4 equivalent per pathologist (optimal) Specimens per pathologist (optimal)
Blocks per pathologist (optimal) Slides per pathologist (optimal)
Surgical pathology cases per pathologist (optimal) Population per FTE (optimal)
100,000
20,000

80,000
15,000

60,000

10,000
40,000

5,000
20,000

0 0
r 1 r 2 r 3 r 4 r 5 r 6 r 7 r 8 r 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
n te nte nte nte nte nte nte nte nte ter ter ter ter ter ter ter ter ter ter ter ter ter ter ter ter ter ter
Ce Ce Ce Ce Ce Ce Ce Ce Ce Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen Cen

❚Figure 1❚ Units per FTE for anatomic pathology if at optimal staffing (based on Table 4 data). FTE, full-time equivalent.

© American Society for Clinical Pathology Am J Clin Pathol 2005;123:45-55 49

49 DOI: 10.1309/23NYGNB2HFNNW4V8 49
Maung / ANATOMIC PATHOLOGY WORKLOAD CALCULATION

❚Table 5❚
FTE for Anatomic Pathologists Calculated Using Various Indicators

FTE Requirements in Each Center* Difference of Calculated FTE Requirement From Optimal FTE†

Center Optimal L4E Spec Blk Slide Pop SP UK L4E Spec Blk Slide Pop SP UK

1 6.00 6.62 4.43 5.74 4.01 5.94 4.10 4.70 10 –26 –4 –33 –1 –32 –22
2 4.00 3.37 2.58 2.69 2.92 3.68 2.38 2.87 –16 –36 –33 –27 –8 –40 –28
3 50.00 45.42 29.07 42.94 49.90 43.43 26.87 32.33 –9 –42 –14 0 –13 –46 –35
4 7.00 7.66 4.41 7.73 11.29 8.92 4.07 4.86 9 –37 10 61 27 –42 –31
5 53.00 51.84 32.33 47.75 55.50 47.31 29.89 37.53 –2 –39 –10 5 –11 –44 –29
6 3.00 2.40 1.99 1.99 1.93 5.28 1.84 1.76 –20 –34 –34 –36 76 –39 –41
7 2.00 2.11 1.91 1.96 2.70 3.11 1.77 2.10 5 –4 –2 35 56 –12 5
8 1.00 1.09 0.53 0.60 0.44 1.38 0.49 0.47 9 –47 –40 –56 38 –51 –53
9 11.00 12.83 9.86 12.90 16.20 15.75 9.12 9.80 17 –10 17 47 43 –17 –11
10 1.90 2.10 1.52 2.62 1.92 1.97 1.40 1.52 10 –20 38 1 4 –26 –20
11 4.50 3.74 2.78 3.79 5.15 5.91 2.57 2.80 –17 –38 –16 14 31 –43 –38
12 2.00 2.05 1.88 1.48 1.02 1.97 1.74 1.89 2 –6 –26 –49 –2 –13 –6
13 5.00 4.72 3.62 6.37 8.45 8.86 3.35 3.64 –6 –28 27 69 77 –33 –27
14 1.90 1.42 1.16 0.92 0.88 0.47 1.07 1.14 –25 –39 –52 –54 –75 –44 –40
15 2.00 2.25 2.53 0.00 2.29 3.15 2.34 2.70 12 26 –100 15 57 17 35
16 2.25 1.59 1.47 1.43 1.74 2.48 1.36 1.61 –29 –34 –36 –23 10 –39 –29
17 4.00 3.18 2.36 2.40 1.85 3.54 2.18 2.81 –21 –41 –40 –54 –11 –45 –30
18 4.50 6.00 4.44 6.42 6.44 7.87 4.11 4.44 33 –1 43 43 75 –9 –1
19 8.00 7.32 5.80 10.26 9.76 18.90 5.36 5.91 –9 –28 28 22 136 –33 –26
20 6.25 7.44 5.80 9.11 7.98 9.84 5.36 5.63 19 –7 46 28 57 –14 –10
21 2.50 2.12 2.07 2.07 1.86 3.01 1.91 2.03 –15 –17 –17 –25 20 –24 –19
22 4.50 5.27 3.56 4.59 3.53 6.30 3.29 3.68 17 –21 2 –21 40 –27 –18
23 3.75 4.37 3.72 6.27 6.34 15.75 3.44 3.65 16 –1 67 69 320 –8 –3
24 2.00 1.58 1.33 1.26 1.24 1.67 1.23 1.27 –21 –33 –37 –38 –16 –38 –36
25 4.50 3.64 2.59 4.10 2.96 5.51 2.40 3.06 –19 –42 –9 –34 22 –47 –32
26 4.00 4.99 3.04 5.97 4.42 4.86 2.81 3.24 25 –24 49 10 22 –30 –19
27 2.70 3.29 3.00 3.83 3.53 5.51 2.77 2.78 22 11 42 31 104 3 3
Average — — — — — — — — 0 –23 –4 0 40 –29 –21
Median — — — — — — — — 2 –28 –9 1 27 –33 –26
SD — — — — — — — — 17.3 18.0 37.5 38.5 69.4 16.7 17.9
Maximum — — — — — — — — 33.4 26.3 67.2 69.1 319.9 16.8 34.9
Minimum — — — — — — — — –29.2 –47.0 –100.0 –56.3 –75.1 –51.0 –53.5

Blk, No. of blocks; FTE, full-time equivalent; L4E, level 4 equivalent; Pop, population (Royal College of Physicians and Surgeons of Canada [Ottawa] model); Slide, No. of
slides; Spec, No. of specimens; SP, total accessioned surgical pathology cases; UK, Royal College of Pathologists (London, England) model.
* Required AP FTEs = Total Units of Indicator Annually (from Table 3)/Average Units of Indicator (from Table 4).
† Difference of Calculated FTEs Requirement From Optimal FTEs (%) = (Calculated FTEs for Indicator – Optimal FTEs)/Optimal FTEs. Positive percentages indicate that the

calculated value overestimated the FTEs needed, and negative percentages indicate underestimation.

difference of 0.62, has a 26% difference). With slides as the FTEs = Intercept + Coefficient × Annual Units of
indicator, in most situations it overestimates by only 1% (aver- Indicator
age, 0%), but there is marked variation with the SD at 38.5%. For example, if the annual L4E for a department is
These results show that in most cases, calculation of FTEs 40,000,
needed using L4E will be on target with the least variation. FTEs = Intercept + Coefficient × annual L4E
Using slides as the indicator, although accurate, has signifi- FTEs = (–0.285) + 0.000292 × 40,000
cant variation (more than twice that of L4E). The other indi- FTEs = 11.41
cators are imprecise and will overestimate or underestimate by The regression was repeated forcing the intercept to be
a significant margin. zero. The R2 for L4E was the same, and the P value was even
Regression analysis was performed between the optimal more significant. The advantage of forcing the intercept to be
FTEs and each of the indicators to determine how much of the zero is the ability to calculate the needed FTEs more easily
FTEs needed can be explained by the indicator in question and the ability to show number of units (of indicator) per
❚Table 6❚. The R2 value of 1 indicates that the indicator in ques- pathologist in a linear manner.
tion can explain 100% of the variability in the determination of FTEs = Intercept + Coefficient × Annual Units of
needed FTEs. The R2 for L4E was highest, with a value of Indicator
0.994, indicating that it can explain 99.4% of the variability of For example, for L4E,
the needed FTEs in a department. The P value was the lowest, 1 FTE = 0 + 0.000289 × Annual Units of L4E
at 2.7 × 10–29, which statistically is extremely significant. The Annual Units of L4E (for 1 FTE) = 1 FTE/0.000289
needed FTEs can be calculated by using the following formula: = 3,455

50 Am J Clin Pathol 2005;123:45-55 © American Society for Clinical Pathology

50 DOI: 10.1309/23NYGNB2HFNNW4V8
 Anatomic Pathology / ORIGINAL ARTICLE

350%

300%

FTE as per L4E FTE as per specimen

FTE as per blocks FTE as per slides
FTE as per population FTE as per surgical 250%
FTE as per raw surgical pathology cases
number UK
200%

150%

100%

50%

0%

–50%

–100%

–150%
er
1
er
3 5
er
7
er
9 11 13 15 17 19 21 23 25 27
er er er er er er er er er er
nt nt nt nt nt n t n t t n t n t n t t t t
Ce Ce Ce Ce Ce Ce Ce Ce
n
Ce Ce Ce Ce
n
Ce
n
Ce
n

❚Figure 2❚ Difference between optimal and calculated FTEs (in percentages) (based on Table 5 data). FTE, full-time equivalent;
UK, Royal College of Pathologists (London, England) model.

❚Table 6❚
Regression Analysis of Various Indicators for Determining Full-Time Equivalents

Regression R2 SE Intercept Coefficients SE t P

Regular
Level 4 0.994 1.017 –0.285 0.000292 4.54584E-06 64.32 2.71259E-29
Specimens 0.993 1.096 –0.675 0.000337 5.65221E-06 59.65 1.76053E-28
SP cases 0.989 1.405 –1.184 0.000488 1.05041E-05 46.45 8.68984E-26
Blocks 0.982 1.766 –0.626 0.000171 4.64152E-06 36.83 2.63667E-23
Slides 0.981 1.812 –0.085 0.000084 2.34011E-06 35.87 5.06235E-23
Population 0.918 3.755 –2.135 0.000042 2.53031E-06 16.75 4.24832E-15
Forced zero intercept
Level 4 0.994 1.028 0 0.000289 3.9018E-06 74.174 8.56584E-32
Specimens 0.991 1.220 0 0.000329 5.26775E-06 62.437 7.36702E-30
SP cases 0.983 1.697 0 0.000466 1.04269E-05 44.724 3.98689E-26
Blocks 0.980 1.812 0 0.000167 3.99116E-06 41.857 2.18154E-25
Slides 0.981 1.779 0 0.000084 1.96197E-06 42.653 1.34543E-25
Population 0.901 4.056 0 0.000039 2.1357E-06 18.135 2.814E-16

© American Society for Clinical Pathology Am J Clin Pathol 2005;123:45-55 51

51 DOI: 10.1309/23NYGNB2HFNNW4V8 51
Maung / ANATOMIC PATHOLOGY WORKLOAD CALCULATION
Therefore, the appropriate workload for a pathologist in
L4E is 3,455 (using regression analysis), which is similar to
the average workload of a pathologist in L4E in Table 4 of
3,600 (the average value).
The average workload per pathologist can be calculated
in the same manner as follows: for specimens, 3,040; for SP
cases, 2,144; for blocks, 5,986; for slides, 11,950; and for pop-
ulation, 25,819. (This value is similar to the recommendations
of the College of Physicians and Surgeons of Canada,3 which
is 24,500 per anatomic pathologist.)
Discussion
Pathology is unique because the workload of each pathol-
ogist is determined mainly by other physicians and users of
laboratory services, and there is no inherent limiting factor for
individual pathologist workload. For most physicians, time is
the limiting factor, for example, availability of operating room
time for surgeons, physician’s office hours, and the operating
time for magnetic resonance imaging machines. In specialties
with inadequate human resources, there are long waiting peri-
ods, which is quite common in Canada.
For pathologists, there is no equivalent time-limiting factor,
and all specimens submitted to the department are processed
and pathologists are expected to read, interpret, and report all
specimens assigned to them (usually distributed according to
the duty roster by a technologist) in a timely manner. This usu-
ally means, in inadequately funded departments (ie, with insuf-
ficient FTEs), pathologists are at their microscopes for long
stretches with the inherent danger of making mistakes.17,18 In
this age of limited resources, it is an uphill and usually losing
battle in many departments to convince administrators to fund
extra positions to bring the number of professionals to an appro-
priately safe level. This is evident in the second survey results in
which there is understaffing of pathologists in 20 of 27 centers
(Table 3). This is made worse because the public usually does
not know what a pathologist does, and because pathologists
make the utmost effort to achieve a reasonable turnaround time,
the public is not aware of the situation. A recent W5 program
from CTV highlighted this issue19 and the dire patient conse-
quences of mistakes that can be made by overworked patholo-
gists. If a patient had to wait weeks to months for the results of
a prostate or breast biopsy, the public would soon become aware
of pathologists’ contributions to their care.
If pathology was funded in a manner similar to that for
other physicians, ie, on the number of consultations done, this
would not be an issue, because as the volume rises, the profes-
sional funding levels would rise and, as a result, so would the
number of pathologist FTEs to perform duties adequately.
Most pathologists in Canada are funded on a global basis, by
salary or individual contracts. However, this does not take into
52 Am J Clin Pathol 2005;123:45-55
52 DOI: 10.1309/23NYGNB2HFNNW4V8
account many changes and innovations being introduced into
pathology that increase the workload of pathologists, such as
those discussed in the following paragraphs.
Increased Diagnostic and Reporting Complexities for
Most AP Specimens
During the past decade, AP has evolved from providing
just a diagnosis to additional information related to prognosis
and therapy and management.20,21 Even the diagnosis is more
detailed because of advances in knowledge and special stud-
ies such as immunologic, molecular, and other techniques.
Most organ resections now demand many blocks to meet the
needs of the clinicians; a good example is the mastectomy and
lumpectomy, which now routinely demand more than 25
blocks, and, in many institutions, estrogen receptor, proges-
terone receptor, and HER-2/neu status are required routinely.
For prostatectomy specimens, many institutions submit the
whole specimen to be able to determine volume of the tumor,
the margin status, and involvement of the prostate capsule,
which are important prognostically.
New Techniques for Obtaining Specimens
Various endoscopies and direct and radiographically
directed core and fine-needle biopsies have permitted clinicians
to obtain tissue from superficial and most deep organs. The
resultant specimens are small and demand more routine levels
(sections and slides from a block) and detailed study by the
pathologist to provide the necessary information, eg, p63 and
smooth muscle myosin heavy chain22 stains in breast biopsy
specimens and high-molecular-weight cytokeratin stains, p63,
and α-methylacyl coenzyme A23 in prostate biopsy specimens
to distinguish invasive carcinoma from other look-alikes. The
literature also suggests that detailed information is essential for
management planning and prognosis. This is expanding consis-
tently. For example in prostate biopsy specimens, the number of
cores involved by carcinoma, percentage involved, total length
of carcinoma present in the core, and perineural invasion of a
certain size seem to predict stage and extracapsular involvement
by carcinoma.24 The same is true for other organs.25,26
Checklists, Second Opinions, Quality Assurance
Activities, and Continuing Medical Education
The almost mandatory use of checklists27,28 for most
malignant neoplasms has created more labor-intensive infor-
mation gathering by pathologists. The American College of
Surgeons Commission on Cancer mandated that starting
January 1, 2004, pathologists must provide all scientifically
validated or regularly used data elements of the checklists in
their reports for each site and specimen.29
The increasing pressure to have second opinions on many
specimens such as first-diagnosed malignant neoplasms has
increased the number of interdepartmental and intradepartmental
© American Society for Clinical Pathology

consultations.10-16 At present, this activity is not fully document-
ed and not widely appreciated by the medical community, includ-
ing pathologists. Quality assurance, quality control, and quality
improvement activities are now mandated by various accredita-
tion agencies, also increasing demands on pathologists’ time.
Determining FTEs
There are various recommendations about the average FTEs
for anatomic pathologists and their workload but few recommen-
dations for the appropriate workload for clinical pathologists. The
recommendation from the Royal College of Physicians and
Surgeons of Canada, Ottawa, is based on the population served.3
Other recommendations are based on the raw number of SP
cases, cytologic examinations, and autopsies done.1,2
Recommendations based on population served have some
obvious deficiencies. They do not take into account the referral
pattern and patient mobility between geographic centers or the
demographics of the population, eg, age, sex, race, and income
(in the Royal College of Physicians and Surgeons of Canada
Model). Population-based recommendations are indirect indi-
cators of a pathologist’s workload and do not actually measure
the output of the pathologist. The present study confirms this
because the SD was 50.54%when using population as the indi-
cator for calculating AP FTEs (Table 4), and Table 5 shows sig-
nificant variability from the optimal FTEs from 320% overes-
timation to 56% underestimation. It is also very difficult to esti-
mate the population served, especially in areas that are served
by more than 1 laboratory center. Although the laboratory may
be located in a particular location (for CP), it may serve a larg-
er area for AP, as small centers do not have AP on site. It also
does not take into account the referral of cases. It underesti-
mates the population served for many tertiary referral centers.
Various input indicators such as numbers of technical
work units, slides, and blocks are indirect indicators of
pathologist workload and are not optimal. Technical units
also were considered flawed by Suvarna and Kay30 when
used to measure histopathology laboratory workload calcu-
lations. As for blocks and slides, there is marked variation
between centers and laboratories and even between individ-
ual pathologists about how many blocks are taken from each
specimen type and the number of routine slides and stains
for each block. There are no firm guidelines as to how many
blocks should be taken in a particular specimen, and most
pathologists have a unique way of taking gross specimens
and blocks based on past experience, personal interest, and
literature. The number of routine slides for prostate and
breast core biopsy specimens varies from 1 to 4 for each
block and for sentinel nodes varies from 1 H&E level in
some centers to 2 H&E levels plus 3 cytokeratin stains in
others.31 In addition, technical work units, at present, are not
collected consistently throughout Canada and are not stan-
dardized between countries. Statistics from the present study
© American Society for Clinical Pathology
Anatomic Pathology / ORIGINAL ARTICLE
indicated that using numbers of specimens, blocks, or slides
as the indicator are less reliable than using L4E.
Other examples of input measurements for pathologist
workload are the Royal College of Pathologists (London,
England)1 and Kaiser Permanente2 models, which depend on
raw numbers of accessioned cases and samples (eg, SP cases,
cytologic samples, autopsies). Raw numbers roughly reflect
the amount of work done by pathologists but lack detail to
account for the variations and complexity of work between the
centers. Raw numbers of accessioned cases and samples fail to
account for the work involved for each accessioned case. Not
all specimens are alike, and they vary in the amount of work
needed to complete the case and issue a consultation report; in
other words, different specimens have different output values
(eg, confirming the presence of vas deferens in cases of steril-
ization vs examining a radical mastectomy specimen).
The type of specimens that are discarded in the operating
room and not submitted to (processed by) the laboratory
(because of being listed on an exclusion list) varies. Some
departments have no exclusion lists, but others have extensive
lists. Specimens included in the exclusion list usually are deter-
mined by mutual agreement of clinicians and pathologists. A
department with an extensive exclusion list will have, on aver-
age, more complex specimens because the specimens in the
exclusion lists usually are level 1 or 2 and are discarded before
reaching the department. One department has a relatively exten-
sive exclusion list (eg, nasal cartilage, hernia sacs, arthroscopic
debris, uncomplicated hemorrhoids), and this accounts for
approximately 7,000 to 8,000 accession numbers annually and
could make approximately 20% to 25% of the total accessioned
cases. In the UK model, the excluded cases could justify 2 FTEs
in a community laboratory (1 FTE per 4,000 SP cases) and 4
FTEs in an academic laboratory (1 FTE per 2,000 SP cases).
Depending on the expertise and variety of clinical special-
ists (eg, gastroenterologists, chest surgeons, nephrologists,
neurosurgeons, pediatric surgeons, oncologists) available in the
institution, the complexities of specimens will vary. Also rele-
vant is the expertise of the pathologists in the center, eg, renal
pathology and pediatric pathology demand special expertise of
the pathologist and require substantial time and resource com-
mitment by the department to serve these areas adequately.
Finally, the number of specimens in an accessioned case
might vary from 1 to 10 or more. This, together with the vari-
ation in the rules of assigning accession numbers in different
departments (eg, 3 consecutive daily sputum specimens are
counted as 1 in some departments and 3 in others), makes the
number of specimens in each accessioned case vary widely.
For these reasons, raw numbers of accessioned cases do not
take into account the degree of complexity of the specimens
processed by the department and do not reflect the true work
done by pathologists. Statistics in the present study support
this because the UK model has more variability than L4E.
Am J Clin Pathol 2005;123:45-55 53
53 DOI: 10.1309/23NYGNB2HFNNW4V8 53
Maung / ANATOMIC PATHOLOGY WORKLOAD CALCULATION
In most departments, there is routine collection of the
type and number of specimens under an accession number and
diagnosis and billing codes (based on various provincial codes
and in the United States, CPT codes). If not collected formal-
ly, the aforementioned information can be extracted easily
from surgical, cytology, and autopsy reports. By using these
data, a more detailed collection of work output (output meas-
urement) by the AP pathologist is possible and serves as the
basis for the calculation of appropriate workload for average
anatomic pathologists (1 FTE).
A method of measuring a more detailed histopatholo-
gist’s workload was suggested by Suvarna and Kay30 using
Kim Unit activity based on the weighting of dissection,
microscopy, and reporting of each type of specimen. The pres-
ent article also tries to weight the different specimens based on
their output value, but unlike the Kim Unit, is based on infor-
mation that already is collected in many centers (at least in
North America) or easily extracted from reports generated.
Tomaszewski et al4 showed that the time it takes to com-
plete cases correlates best with total number of slides, fol-
lowed by total lines of diagnoses, templates, and notes, and
number of H&E-stained slides. They found that CPT codes
and numbers of specimens were poor correlates. As noted by
the authors, their data may not be applicable to other institu-
tions. Depending on the protocols and traditions of different
departments, there is marked variation in the number of blocks
taken for particular types of specimens and in the routine
number of H&E-stained and specially stained slides taken
from some specimens. The same can be said regarding total
lines of diagnoses. Some pathologists’ diagnosis lines include
only the diagnosis, but some include the checklist and other
relevant information in the diagnosis box. These variations
also are noted between individuals in a department. Therefore,
the number of slides and total lines of diagnoses might be use-
ful to determine prospectively the changing workload in a par-
ticular department, but comparison between departments
should be done with care.
In the present study, I used a different approach. I request-
ed the optimal FTEs that would, in the opinion of the depart-
ment head, be adequate to perform the duties in the depart-
ment and calculated which of the indicators, output and input,
would be best able to predict the optimal FTEs needed in the
department. I looked at the routinely collected data, thus easi-
ly available in most institutions—number of accessioned
cases, number of specimens, billing codes of specimens, num-
ber of blocks, number of slides, and population served—and
did several statistical computations using Excel XP.
In the first set of statistical analyses (Table 4), the aver-
age and median workloads for 1 AP FTE are 3,600 (mean)
and 3,683 (median) for L4E with an SD of 633, which is
17.58% of the average. The SDs in ascending order after
L4E are numbers of specimens, SP cases, blocks, and slides
54 Am J Clin Pathol 2005;123:45-55
54 DOI: 10.1309/23NYGNB2HFNNW4V8
and population. These results indicate that the distributions of
these latter indicators are much more variable.
The accuracy of the calculated AP FTEs using the various
indicators of the optimal FTE as indicated by the department
head (Table 5) shows that only the calculations based on L4E
and slides were accurate to 1% to 2%, with the other indica-
tors overestimating or underestimating by 27% to –33%.
These results suggest that calculations based on numbers of
specimens, blocks, and SP cases and population and the UK
model are too inaccurate (imprecise) to be used to determine
the needed AP FTEs in a department. Of the numbers of L4E
cases and slides, the calculation using slides as the indicator
has an SD (variability) that is more than twice that of the cal-
culation using L4E. This is borne out by the minimum and
maximum values for each indicator.
The regression analysis data in Table 6 show that L4E has
the highest R2 value (0.994), which indicates that it can
explain 99.4% of the variables to determine the needed AP
FTEs and also has the lowest P value (2.7 × 10–29), which sug-
gests that it also is the most statistically significant of the indi-
cators analyzed.
The recommended L4E value of 3,455 can be translated
to work relative value units (RVUs). The total RVU for an L4E
(ie, CPT code 88305) is 2.58 (professional component, 1.12 +
technical component, 1.46).32 Thus, the equivalent RVUs for
a pathologist performing AP consultative work would be
8,914 (professional component, 3,870 + technical component,
5,044). In the present survey, the majority of respondents in
nonacademic settings indicated that they spend 15% of their
time in academic and professional development activities
(data not shown). If this percentage is factored in, the work of
average pathologists doing only AP consultative activities
would be 10,487 RVUs (professional component, 4,553 +
technical component, 5,934). The Medical Group
Management Association data for mean production per AP
FTE give an RVU of 3,964,33 which is similar to the calculat-
ed professional component RVUs of the recommended AP
pathologist workload for L4E of 3,455.
I believe that AP consultative activities are best expressed as
L4E. Although not ideal, this would meet many of the require-
ments of a good indicator for measuring AP workload. L4E rep-
resents a direct output indicator, which measures the value of AP
consultations. With proper weighting to reflect the complexity
and value of each consultation, one can include all consultative
activities (eg, SP cases, cytologic examinations, autopsies, inter-
nal and external consultations). This proposal uses routinely col-
lected data, which makes the system easy to implement and
compare. Finally, the analysis of L4E shows very solid statistical
values and has the best results of all the indicators analyzed.
From the Department of Pathology, Royal Inland Hospital,
Kamloops, Canada.
© American Society for Clinical Pathology

Address reprint requests to Dr Maung: Dept of Pathology,
Royal Inland Hospital, 311 Columbia St, Kamloops, BC, Canada
V2C 2T1.
Acknowledgments: I thank the pathologists Valerie Boras,
MD, Erik Larsen, MD, Rick Berendt, MD, Murray Treloar, MD,
and Nicholas van der Westhuizen, MD, for their suggestions and
comments during the different phases of the project. Special thanks
to Chris Janssen, PhD, professor of Business Statistics, without
whose advice on statistical analysis this article would not have
been possible.
References
1. Royal College of Pathologists. Medical and Scientific Staffing
of National Health Service Pathology Departments. London,
England: Royal College of Pathologists; 1999:19-22. Available
at: http://rcpath.org. Accessed May 20, 2003.
2. Haber SL. Kaiser Permanente: an insider’s view of the practice
of pathology in an HMO hospital-based multispecialty group.
Arch Pathol Lab Med. 1995;119:646-649.
3. Royal College of Physicians and Surgeons of Canada
(RCPSC). National Specialty Physician Review. Ottawa, Canada:
Royal College of Physicians and Surgeons of Canada; 1988:14.
4. Tomaszewski JE, Abraham S, Bell K, et al. The measurement
of complexity in surgical pathology. Am J Clin Pathol.
1996;106(4 suppl 1):S65-S69.
5. PathFocus. 2004 User’s Guide. Available at:
http://www.cap.org/apps/docs/path_focus/2004PathFocusUser
Guide.pdf. Accessed June 24, 2004.
6. Anatomic pathology fee guideline. In: British Columbia Medical
Association Guide to Fees. Vancouver, Canada: British
Columbia Medical Association; 2002:AE43-AE47.
7. Alberta Health and Wellness. Anatomic Pathology
Procedures: Common Laboratory Procedure List (Alberta).
Edmonton, Canada: Alberta Health and Wellness; Revised
March 15, 1996:4-12.
8. Diagnostic and Therapeutic Procedures. Published 1 July.
2003. page J34-35. Available at: http://www.health.gov.on.ca/
english/providers/program/ohip/sob/physserv/J_diagth.pdf.
Accessed May 20, 2003.
9. Kirschner CG, Jacobson CA, Reyes D, et al, eds. Surgical
pathology, CPT 88300 to 88309 and Appendix A, modifiers
21 and 52. In: Current Procedural Terminology: (CPT) 1999,
Standard Edition. Chicago, IL: American Medical Association;
1998:335-339, 387-388.
10. Tomaszewski JE, Bear HD, Connally JA, et al. Consensus
conference on second opinions in diagnostic anatomic
pathology: who, what, and when. Am J Clin Pathol.
2000;114:329-335.
11. Troxel DB, Sabella JD. Problem areas in pathology practice:
uncovered by a review of malpractice claims. Am J Surg Pathol.
1994;18:821-831.
12. Titus K. No rights, no wrongs in second opinions. CAP Today.
July 2001. Available at: http://www.cap.org/apps/docs/
cap_today/cover_stories/cov_0701.html. Accessed September
24, 2004.
13. Renshaw AA, Pinnar NE, Jiroutek MR, et al. Quantifying the
value of in-house consultation in surgical pathology. Am J Clin
Pathol. 2002;117:751-754.
14. Kronz JD, Westra WH, Epstein JI. Mandatory second opinion
surgical pathology at a large referral hospital. Cancer.
1999;86:2426-2435.
© American Society for Clinical Pathology
View publication stats
Anatomic Pathology / ORIGINAL ARTICLE
15. Abt AB, Abt LG, Olt GJ. The effect of interinstitution
anatomic pathology consultation on patient care. Arch Pathol
Lab Med. 1995;119:514-517.
16. Lind AC, Bewtra C, Healy JC, et al. Prospective peer review
in surgical pathology. Am J Clin Pathol. 1995;104:560-566.
17. Reason J. Human error: models and management. BMJ.
2000;320:768-770.
18. Leape LL, Berwick DM. Safe health care: are we up to it? BMJ.
2000;320:725-726.
19. Favaro A. Deadly diagnosis [transcript]. “W5” CTV
Television, January 18, 2000.
20. Parham DM. The hidden increase in histopathologists’
workload. J Clin Pathol. 1996;49:689-690.
21. Cross SS, Bull AD. Is the informational content of histopatho-
logical reports increasing? J Clin Pathol. 1992;45:179-180.
22. Lerwill M. Current practical application of diagnostic
immunohistochemistry in breast pathology. Am J Surg Pathol.
2004;127:1076-1091.
23. Sanderson SO, Sebo TJ, Murphy LM, et al. An analysis of the
p63/α-methylacyl coenzyme A racemase
immunohistochemical cocktail stain in prostate needle biopsy
specimens and tissue microarrays. Am J Clin Pathol.
2004;121:220-225.
24. Haese A, Chaudhari M, Miller MC, et al. Quantitative biopsy
pathology for the prediction of pathologically organ-confined
prostate carcinoma: a multiinstitutional validation study.
Cancer. 2003;97:969-978.
25. Harris GC, Denley HE, Pinder SE, et al. Correlation of
histologic prognostic factors in core biopsies and therapeutic
excisions of invasive breast carcinoma. Am J Surg Pathol.
2003;27:11-15.
26. Sharifi S, Peterson MK, Baum JK, et al. Assessment of
pathologic prognostic factors in breast core needle biopsies.
Mod Pathol. 1999;12:941-945.
27. Kempson RL. The time is now: checklists for surgical
pathology reports [editorial]. Arch Pathol Lab Med.
1992;116:1107-1108.
28. Rosai J, Bonfiglio TA, Corson JM, et al. Standardization of the
surgical pathology report. Mod Pathol. 1992;5:197-199.
29. Required data elements from CAP cancer checklists,
mandated for use by the American College of Surgeons
Commission on Cancer, effective January 1, 2004. Available
at: http://www.cap.org/apps/docs/cancer_protocols/
protocols_intro.html#1. Accessed September 24, 2004.
30. Suvarna SK, Kay MS. KU activity: a method for calculating
histopathologists’ workloads. J Clin Pathol. 1998;51:530-534.
31. Pargaonkar AS, Beissner RS, Snyder S, et al. Evaluation of
immunohistochemistry and multiple-level sectioning in
sentinel lymph nodes from patients with breast cancer. Arch
Pathol Lab Med. 2003;127:710-705.
32. Year 2002 Medicare Relative Values for Pathology Services.
Available at: http://www.cap.org/apps/docs/medicare/
beneficiary_notices/2002rvs.html. Accessed September 24,
2004.
33. Pathologists lean toward equal shares: production and “X, Y,
Z” systems also used. Physician Compensation Report. August
23, 2000. Available at: http://articles.findarticles.com/p/
articles/mi_m0FBW/is_13_1/ai_64777379. Accessed June 24,
2004.
Am J Clin Pathol 2005;123:45-55 55
55 DOI: 10.1309/23NYGNB2HFNNW4V8 55