College of American Pathologists

  Performance Improvement
  Program in Surgical Pathology




Created December 5, 2005

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 and external quality assurance and is designated for 40 CME credit hours (Category 1 and A1) for each participating pathologist completing the entire program year.

Ten unknown cases with patient histories will be mailed four times per year. The pathologist will select the appropriate diagnosis from a master list provided with each case. The completed questionnaire is then returned within 15 days to the CAP, where it is tabulated for peer group response. Upon receipt of the questionnaire, a critique of each case, including the diagnosis, comments, and review, along with a certificate for CME credit, is mailed to the pathologist. A report tabulated for peer group response will follow. The slides become the property of the PIP subscriber.

PIP case selections:

  • Adrenal lesions
  • Lesions of the breast
  • Lesions of the colon
  • Lesions of the kidney
  • Lesions of the liver
  • Lesions of the lung
  • Oral or maxillofacial lesions
  • Lesions of the ovary
  • Lesions of the omentum
  • Lesions of the pancreas
  • Lesions of the endometrium
  • Lesions of the brain
  • Lesions of the bone
  • Lesions of the spleen
  • Lesions of the skin
  • Lesions of the soft tissue
  • Lesions of the stomach
  • Lesions of the testis
  • Lesions of the thyroid
  • Lesions of the uterus

The Performance Improvement Program in Surgical Pathology (PIP) is the single largest activity of the Surgical Pathology Committee. As such, it is also the most common source of communication addressed to the committee from the CAP membership. Although usually complimentary, some questions are often repeated and therefore seem appropriate to address in a venue such as this. Members of the CAP Surgical Pathology Committee are asking for your assistance in providing material for future mailings of PIP. Click here for a list of the kinds of specimens that are most desirable, but any surgical pathology diagnosis is suitable for consideration for inclusion in PIP.

About PIP
PIP is the single largest activity of the Surgical Pathology Committee. As such, it is also the most common source of communication addressed to the committee from the CAP membership. Although usually complimentary, some questions are often repeated and therefore seem appropriate to address in a venue such as this.

PIP began in 1977, under the direction of Donald Penner, MD, as a Slide Exchange Program, not unlike the current Interlaboratory Comparison Program in Cervicovaginal Cytology (PAP). In 1989, the format changed to the one currently used, which allows for the retention of glass slides by the participants. During the course of the year, the participants receive 40 cases, 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 1,977 laboratories (4,873 participating pathologists) enrolled for 1997. The Surgical Pathology Committee deals with issues pertaining to case selection, slide quality, critique and question quality, and program evaluation on a regular basis.

Commonly asked questions

In general, the questions most often raised by participants concern: 1) correctness of the diagnosis, 2) case mix, 3) quality of the slides, and 4) the appropriateness of utilizing the program for quality assurance.

Correctness of diagnosis
With regard to the first question, the success of the program is also the source of one of its potential weaknesses. The practical limit for the program is approximately 2,000 slides. At this volume, 30-40 blocks of tissue are required. This means that it is difficult to guarantee that every slide contains exactly the same information as every other slide. Although great efforts are made to maximize the uniformity of the material sent to the participant (as a routine, every 20th slide is reviewed, and in some cases virtually every slide is screened), it is not always possible to be absolutely sure that every slide shows exactly the same thing in every case. For instance, it is possible that one may receive a slide showing only adenocarcinoma or squamous carcinoma in a case of adenosquamous carcinoma. Moreover, because of the nature of some cases it may be necessary to combine material from several patients in order to accumulate sufficient numbers of blocks to proceed. This is another cause of heterogeneity.

Case mix
The amount of material needed also helps to answer the questions concerning case mix. The need for large amounts of tissue tends to skew case selection towards large specimens and away from diagnostic biopsy material such as needle biopsies of liver or small biopsies of the gastrointestinal tract or endometrium. We are attempting to increase the spectrum of subjects covered by utilizing photomicrographs in such cases. Other factors that enter into case selection include perception of the subject as a difficult one in diagnostic pathology, and the availability of new information which makes the lesion an interesting one to review.

Quality of the slides
The quality of slides sent to a participant is occasionally brought into question and the committee utilizes careful quality control to assure optimal histology. Nevertheless, occasionally, unsatisfactory slides are generated. The committee makes every effort to identify causative factors in such cases so these can be corrected. The committee follows the quality of slides carefully by the vendor who prepared them and on occasion requests that participants who have poor quality slides send them to the committee so that they can be reviewed and possible etiologies addressed.

It is interesting to note, 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 an attempt by a participant to include the PIP material into the labs QA program. While it is certainly possible to do so, it should be emphasized that the PIP material is meant to be an educational exercise rather than a test of competency. The aforementioned inhomogeneity and the artificial situation of attempting to make a difficult diagnosis on a single H&E stained slide, makes PIP's use as a proficiency test hazardous as the program is currently structured.

The committee continues to view PIP as a program in evolution. Issues for consideration include how better to serve a growing population of subscribers. Can newer methodologies such as CD ROM technology be economically and effectively applied to histopathology? Can the cases be made to reflect even closely "real life" situations in diagnostic surgical pathology? Can new question formats be generated that increases the ability of this portion of the program to address important and useful information while still not giving away the diagnosis?

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


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