New help in understanding the "proper work"
  of PAs

September 2006
Feature Story

Ed Finkel

The steadily emerging professional roles of pathologists’ assistants generally involve facilitating the pathologist’s practice of medicine but not practicing medicine—defined as making diagnoses or determining treatment for patients—themselves.

But precisely where to draw that line is not always clear. The College’s newly revised Policy and Scope of Work documents for pathologists’ assistants, developed with the American Association of Pathologists’ Assistants, represents a renewed attempt to make that line brighter.

The policy says that pathologists’ assistants may not make a diagnosis based on examination and analysis of human tissue, body fluids, or other material. They are qualified to “gather, screen, and prepare materials…pursuant to protocol developed by the pathologist” and “perform other tasks that facilitate the practice of medicine.”

“The gist of the policy is that pathologists’ assistants have been out there for a while, and there’s been a lot of questions from pathologists as to when they’re supposed to be used, what they can do, what they can’t do,” says David N. Henkes, MD, chair of the CAP Professional Affairs Committee. “There’s some [pathologists’ assistants] who are very good, take a lot of interest and have lots of education and do very well. Others don’t have all that background and skills but are still able to be very helpful to the pathologist. This policy was intended to formalize expectations… It lays down the themes very well.”

The scope-of-work statement delves into more detail in terms of surgical pathology and the preparation of cadavers for postmortem examinations. Under the supervision and direction of a pathologist, assistants are qualified to ensure appropriate specimen accessioning, obtain pertinent clinical information and history, describe gross anatomic features of and dissect surgical specimens, obtain and submit biological specimens, prepare and submit tissue for frozen section analysis, photograph pertinent specimens and slides, and assist with administrative duties and laboratory maintenance.

“Even within the protocol, you have to make sure that each person is competent to do each one of those tasks and that the person who’s doing those tasks would understand and realize when they start to reach a level they shouldn’t be,” Dr. Henkes says. “It is important that the pathologist provide oversight to make sure they don’t go past that level.

“It’s also a recognition that, in certain practices, these individuals can be very vital in terms of gathering and organizing the information so a diagnosis can be made more efficiently and more appropriately.”

Dr. Henkes says the revised policy and scope-of-work statement are unlikely to result in radical changes so much as reassure labs that they’re doing the right thing and give them guidance on how to make hiring judgments.

“It’s not going to change a lot,” he says. “But it provides a framework for pathologists to understand what they can expect out of pathology assistants. A lot of practices may get together and say, ‘Do we need a pathologist or do we need a pathologists’ assistant?’ These documents will help people determine what they need.”

The partnership with the American Association of Pathologists’ Assistants began when it approached the College to certify a scope-of-practice statement the AAPA had developed. The College responded that it felt more comfortable with the title “scope-of-work” and made other suggestions, recalls E. Randy Eckert, MD, chair of the CAP Council on Government and Professional Affairs.

“We reviewed it and worked through the process of what we felt needed to be in there and what they felt needed to be in there,” he says. “That scope-of-work statement contains in it things we believe anyone who is hiring a pathologists’ assistant needs to understand [about their] ability based on their education and training. It specifically lays out the fact that, under all circumstances, the things they do are to be under the supervision of a pathologist.”

Dr. Eckert predicts the documents will be evergreen. “I don’t see us changing that scope-of-work statement,” he says. “It clarifies what we believe is the proper work that a pathologists’ assistant should do. What we want to make sure is that they don’t want to practice independently. They continue to state that they don’t, which is great; it’s just one of those things we have to keep a watchful eye on.”

Tom Reilly, chairman of the AAPA board of trustees, says the nearly 1,000-member, 34-year-old association initially created its list of professional responsibilities for pathologists’ assistants in 1993 in part as a tool for its members to use in their job searches and negotiations. The ASCP adopted the list in 1994, and it has been refined in the years since. The profession grew gradually in terms of the numbers of pathologists’ assistants in the field, and the number of training programs grew slowly also, stabilizing at six for a number of years. The AAPA has worked with the National Accrediting Agency for Clinical Laboratory Sciences to develop and maintain minimum standards for training programs.

“When we started all those years ago, few institutions hired program-trained pathologists’ assistants. The more common practice was for a pathologist to train a person from within the pathology department, perhaps a histotech or med tech, according to the specific needs of that job situation,” he says. “These on-the-job trained people in most cases do some of what we are trained to do, but in some cases do all of what we do. But as a rule, their training is limited in comparison to our professional educational training experience.”

The AAPA is the only professional association of pathologists’ assistants in the world, Reilly says, and has always “espoused and placed great value in” educational and professional training as an appropriate background for entry into the profession. “The AAPA does not want to infringe on anyone’s ability to hire whomever they want to do whatever they want them to do. We have never taken the stance that program training is the only avenue to working in this field. On the contrary, we have always accepted on-the-job-trained individuals as members of our association.” A major difference between program-trained pathologists’ assistants and others, “and there are probably more of them out there than there are of us,” Reilly says, “is that we are able to assure a potential hiring pathologist that we are able, by dint of our training, to deal appropriately with whatever types of surgical specimens are received in surgical pathology.”

The list of professional responsibilities is essentially a menu of what a trained pathologists’ assistant can do. “Individuals, of course, bring a variety of additional skills to the table, based upon their personal experience,” he says. Since its incorporation, the AAPA has made it a priority to educate the medical community about the profession and about the association. The effort has paid off in recent years, Reilly says, in terms of greater awareness and recognition within the pathology and medical community.

The professional responsibilities document is what the AAPA brought to the table to begin to “build a relationship” with the CAP over a series of open discussions that led eventually to the CAP issuing its policy and scope-of-work statement, Reilly says. “This was a joint effort between our groups,” he says. “We’re continuing to have collegial informational meetings with the CAP in trying to plot what we’re going to do in the future. The statement-of-practice issue has been the crux of things—it’s been a start. We see this as a very positive place to be with the CAP. We’re looking forward to maintaining and further developing the relationship we have now.”

Before the joint work with the College, AAPA members used the list of professional responsibilities as a conversation starter. “It was something we had put together as an organization for our members,” he says. “It was a tool, something for our members to take with them to educate the pathologist or lab manager who would potentially hire them... We took it to different pathology meetings, handed it out, and mailed it out to our constituents as well as to pathologists and laboratory managers.”

The joint documents validate that approach, Reilly says. “This specific set of responsibilities is the basis for defining the scope of practice for certified pathologists’ assistants,” he says. “It is my understanding that the CAP would also like to see eventually developed a subset of these responsibilities for the on-the-job-trained pathologists’ assistants. How that affects the market down the road, who knows?”

In Dr. Henkes’ own 14-pathologist practice, at Pathology Reference Laboratory and Christus Santa Rosa Hospital in San Antonio, the policy and scope-of-work documents helped determine that the group needed a pathologist on two occasions but pointed them toward hiring a pathologists’ assistant more recently, he says.

“The first couple times we looked at this, it just didn’t fit,” he says. “Now…we know it will fit very well. It’s very easy to sit and say, ‘Do we need a pathologist, or do we need a pathologists’ assistant,’ and go down the wrong track. There may be a tendency to hire a PA expecting to increase throughput but not having the higher cost, but once you sit down and look at the situation, you may find you really need a pathologist.” In other situations, a PA can free up a pathologist to do more diagnostic work. “A pathologist and a PA are not interchangeable,” he says. “They’re not another pathologist. Let’s face it…You can’t just say, ‘Here, go do this,’ and that’s it. You have to make sure you have appropriate oversight and make sure you really understand, as the overseeing physician, you’re the person who’s held accountable for diagnosis and treatment. You have to have the protocols set up.”

The policy and scope-of-work statement serve another, broader purpose: boosting collegiality among those in the laboratory, Dr. Henkes says. “It’s been very important that we establish that these are professional colleagues and people we work with,” he says. “It’s important that we’re now setting collaborative ground rules for what can or can’t be done, and what should or shouldn’t be done, by these individuals.

“The College has been an advocate of recognizing there are pathology aides that have gone through various training and education. Not all persons assisting pathologists are certified or have been through a formal training program. But they are working within an appropriate supervision level by the pathologist and are very vital to the practice.” These people are considered essential to the pathologist’s practice, he says. “They’re not doing all the same tasks as certified pathologist assistants, but they’re doing many things for which they’re capable and competent. We’re not at all trying to discourage these individuals.”