College of American Pathologists

  Performance Improvement Program in
  Surgical Pathology (PIP)


Updated November 4, 2013

Introduction to PIP Introduction to PIP

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.

About PIP About PIP

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.

Contact Information Contact Information

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.

Commonly asked questions Commonly asked questions

Correctness of diagnosis

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.

Case mix

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 problems.

Slide quality

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 accurate diagnoses.

Inclusion in quality assurance program

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 test.

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 of PIP.

Ordering Information Ordering Information

To order PIP programs, call 800-323-4040 option 1# to speak with a customer representative.


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