Updated November 4, 2013
The Performance Improvement Program in Surgical Pathology (PIP) is designed
by pathologists for pathologists. This program provides a practical approach
to continuing education in surgical pathology, and gives pathologists
a method of assessing their diagnostic skills and comparing their performance
with that of their peers. The program is designated for 40 Continuing
Medical Education (CME) category 1 credit, for each participating pathologist
completing the entire program year.
Ten unknown cases with patient histories are mailed four times
per year. The participant selects the appropriate diagnosis from a master list
of diagnoses provided with each case and is asked to return the completed
questionnaire to the CAP within 60 days. A report tabulated for peer
group response will be available online and the slides become the property of
the PIP subscriber.
PIP cases represent a variety of neoplastic and non-neoplastic lesions,
including inflammatory and infectious diseases, and encompass essentially
all organ sites.
PIP began in 1977, under the direction of Donald Penner, MD, as a Slide
Exchange Program, similar to the current Interlaboratory Comparison Program
in Cervicovaginal Cytology (PAP). In 1989, the format changed to the one
currently used, which allows participants to keep the glass slides. Participants
receive 40 cases each year, 10 each quarter, which include glass slides
and appropriate histories with accompanying questions. This is followed
by critiques which include the diagnosis, pertinent histological findings,
a discussion of the differential diagnosis and other significant clinical
and/or biological information.
The format has proved very popular, the program growing from 809 laboratories
in 1989 to over 2000 laboratories (6,000 participating pathologists) currently
enrolled. The PIP Program is the single largest activity of the Surgical
Pathology Committee, which is responsible for case selection, critique
and question writing, and ongoing program evaluation. The program is also
the most common reason for communication between the committee and CAP
membership. Questions related to the PIP program are welcome and can be
directed to the CAP staff.
Surgical Pathology Committee
Attention: Penny Eagle
325 Waukegan Road
Northfield, IL 60093-2750
The CAP Surgical Pathology Committee encourages your assistance in providing
case material for future mailings of PIP. The program has a wish
list of the kinds of specimens that are desirable, but any surgical
pathology diagnosis for which sufficient material is available is suitable
for inclusion in PIP.
The success of the program is also the source of a potential weakness.
Approximately 30-40 blocks of tissue are required to produce the number
of slides needed for each case, and slides from different blocks may not
contain exactly the same diagnostic information. Although great efforts
are made to maximize uniformity of material sent to participants, it is
not possible to produce 2,150 identical slides from different blocks.
For instance, one may receive a slide showing only adenocarcinoma when
the remaining blocks show adenosquamous carcinoma. Moreover, it is sometimes
necessary to combine material from several patients to have sufficient
numbers of blocks. Because of this heterogeneity, a participant may occasionally
question whether the target diagnosis is correct. Target diagnoses are
approved by the committee after the members review slides from all blocks,
often in conjunction with clinical information and immunohistochemical
data that may not be included in the initial mailing. In addition, the
critique writer reviews every 20th slide to ensure that the diagnostic
features are present.
The committee attempts to include a spectrum of surgical pathology cases
such as well-defined entities, uncommon presentations of common lesions,
and rare lesions or ones that pose diagnostic problems. The number of
blocks needed for each case tends to skew case selection towards large
specimens, often tumor specimens. While these tissue requirements preclude
the use of small specimens such as needle biopsies or endoscopic biopsies,
those subjects are included in the program by using photomicrographs.
The most important factor in case selection is tissue availability, but
other factors include perceptions of the subject as one of current interest
to pathologists and inclusion of cases that pose difficult diagnostic
The committee strives for excellent histology in every case. Nevertheless,
less than optimal slides are occasionally used. Participants are asked
to grade the quality of slides for every case, and this information is
shared with the slide vendors to help identify areas for improvement.
Slides that are less than optimal may be used in cases with limited amounts
of tissue, in rare lesions, or in cases of particular interest.
Of interest, there appears to be little correlation between the assessed
quality of the slide and the likelihood of a correct diagnosis in a given
case. This may reflect the “real life” fact that in our daily
practices, even though not all slides are optimal, we are able to make
Another frequent question relates to attempts by participants to include
the PIP material in one’s departmental QA program. It should be
emphasized that the PIP program is designed solely as an educational exercise
and not a test of competency. The aforementioned inhomogeneity among slides
sent to participants, the inability of a participant to obtain additional
data when needed, and the artificial situation of making a difficult diagnosis
on a single H&E stained slide prevents using PIP as a true proficiency
The committee welcomes any comments or suggestions from CAP members and,
as always, welcomes donations of tissue blocks
from interesting and informative cases. The latter is the life blood
To order PIP programs, call 800-323-4040 option 1# to speak with a customer