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National Practice Characteristics and Utilization of Pathologists' Assistants.

Widespread adoption of managed care systems in the United States has prompted changes in the delivery of health services. With workforce modifications and cost containment major issues in health care delivery, the use of nonphysician providers has steadily increased in both primary care and specialty practices.[1-5]

Health services research related to the current use and usefulness of nonphysician providers has focused on physician assistants (PAs) and nurse practitioners, 2 of the largest groups of such providers. Little information is currently available in the literature regarding pathologists' assistants, a growing population of nonphysician providers whose current and potential future impact on the provision and cost of pathology services in the United States is significant.

A pathologists' assistant is an allied health professional, qualified by academic and practical training to assist in providing services in anatomic pathology under the direction and supervision of a qualified anatomic pathologist.[6] Pathologists' assistants are analogous to PAs, functioning as dependent practitioners with anatomic pathologists. They participate in the examination, dissection, and processing of tissue samples and in autopsy prosection.[6] Pathologists' assistants are currently employed in a variety of settings, including community and regional hospitals, university medical centers, private pathology laboratories, and medical examiner/coroner offices.[6] Approximately 500 pathologists' assistants are registered as members of the American Association of Pathologists' Assistants (AAPA), the national professional organization for pathologists' assistants. Although it is likely that at least as many nonmember pathologists' assistants and other laboratory personnel currently practice in the United States performing duties similar to those of pathologists' assistants, no data are currently available describing the numbers and/or type of other laboratory personnel who perform duties similar to those of pathologists' assistants. Similarly, no data are available describing utilization patterns for this group.

Pathologists' assistants obtain training either by completing a pathologists' assistant professional training program (presently, there are 5 National Accrediting Agency for Clinical Laboratory Sciences-accredited pathologists' assistant training programs in the United States) or by on-the-job training with a practicing pathologist. The first pathologists' assistant training program was established at Duke University in 1969.[6] The AAPA, incorporated in 1972 as a not-for-profit organization, is the only national professional organization for pathologists' assistants. The AAPA offers membership and a Fellowship Examination to program-trained pathologists' assistants and to pathologists' assistants with on-the-job training who have met minimum education requirements and have at least 3 years of work experience as a pathologists' assistant.[6] Currently, the Fellowship Examination is neither a licensure nor an accreditation examination.

Although the pathologists' assistant profession has been in existence for several decades, the conceptualization and enactment of the pathologists' assistant role most likely varies across settings. This variation is probably due to the relatively small number of pathologists' assistants (compared to PAs), the variability in pathologists' assistant training (program and individual on-the-job training), and the lack of a required licensure/accreditation examination for employment. However, essentially no data are available describing the practice characteristics and utilization of pathologists' assistants in the United States. The purpose of this study was to obtain this descriptive information.

METHODS

The Duquesne University Internal Review Board granted exempt status for this study prior to its initiation.

Study Sample

The study sample was a cross-sectional sample of 515 US pathologists' assistants registered as members of the AAPA in April 2000.

Survey Instrument

The survey instrument was a self-administered, mailed, voluntary, anonymous questionnaire designed by the study investigators, which included items modified from the annual national pathologists' assistant survey conducted by the AAPA for organizational purposes. Self-stick laser labels with AAPA member names and addresses were obtained from the AAPA. A cover letter was included with each questionnaire that explained the voluntary and anonymous nature of the survey, explained the purpose of the survey, provided instructions on how to complete the questionnaire, and informed the potential respondent that data obtained from the survey would be used to provide information to pathologists' assistants, pathologists, and other health care professionals about pathologists' assistants and their practice. Completion and return of the questionnaire was assumed to indicate the respondent's consent to participate in the survey.

The questionnaire was composed of 2 parts. Part A comprised 21 items relating to respondent demographics, professional characteristics, and practice characteristics. Part B comprised a list of 24 tasks. Respondents were first instructed to indicate which tasks they performed in their current position. For those tasks currently performed, respondents were then instructed to provide their best estimate of the average amount of time they spend performing those tasks, using the most appropriate unit of time for the denominator (eg, 4 h/d performing surgical gross examinations or 1 h/wk attending a departmental conference). Respondents were asked to provide the most accurate and representative time values possible, and the cover letter explaining how to complete the questionnaire asked respondents to refer to specimens logs or other laboratory databases to provide the most accurate information possible. The last 2 items of part B instructed respondents to indicate (1) their best estimate of the average number of surgical specimen gross examinations and autopsy prosections they performed per year, and (2) the total average number of surgical specimen examinations and autopsies performed at their institution per year.

Pilot testing of the instrument was performed in February 2000. Twenty questionnaires were mailed to a convenience sample of pathologists' assistants by one of the study investigators (T.L.R.) to monitor the ease with which the respondents completed the questionnaire and the ease of administration and analysis. Nineteen of the 20 pilot questionnaires were returned (response rate 95%). Modifications were made to 5 items in part A of the questionnaire and to the last 2 items in part B to construct the final version of the questionnaire, which was distributed to the study sample (n = 515) in April 2000.

A modification of Dillman's total survey design approach was used to maximize the survey response rate.[7] A follow-up postcard reminder was sent 3 weeks after the initial mailing to nonresponders, followed by a follow-up letter and a replacement copy of the questionnaire to nonresponders at 5 to 6 weeks after the initial mailing. Returned questionnaires were received through August 2000.

Data Analysis

Data analysis began in June 2000 and was completed in September 2000. Descriptive statistics were used to describe the data in terms of measures of central tendency and dispersion. The data analysis did not include the 19 questionnaires from the pilot testing.

RESULTS

The response rate was 66.8%, with 344 questionnaires returned. Three of the returned questionnaires were not used for data analysis because the respondents indicated they were not currently practicing. Thus, 341 questionnaires were included in the data analysis. For the majority of the items in part A, there was a small percentage of questionnaires with missing data. Missing data were analyzed as such, and for this reason some data do not equal 100%.

Geographic Distribution

Figure 1 summarizes the geographic distribution for the questionnaires sent and for those received from respondents. No questionnaires were sent to Kansas, Mississippi, Montana, North Dakota, or Washington, DC, because no labels were received from the AAPA for these locations. There were 3 questionnaires for which the respondent's state could not be discerned. The remaining 338 questionnaires were returned from 44 of the remaining 46 states; no questionnaires were returned from Louisiana or Utah.
Figure 1. Geographic distribution of mailed
questionnaires and respondents

 Questionnaires

Geographic region B.S. M.S.

NE 104 164
SE 92 134
MW/SC 74 140
W 68 77
Unknown 3

NE = Northeast; SE = Southeast; MW = Midwest;
SC = South Central; W = West

Note: Table made from a bar graph.


Demographics

Demographic data are summarized in Table 1. Of all respondents, 74.2% reported working in a nonacademic hospital setting, and 21.1% reported working in an academic/university hospital. The majority of respondents were less than 40 years old and had less than 10 years of experience.
Table 1. Demographic Data

Variable % of Respondents (n)

Sex
 Men 53.1 (181)
 Women 46.6 (159)
 Data missing 0.3 (1)

Age, y
 20-24 1.2 (4)
 25-39 56.4 (192)
 40-49 30.5 (104)
 50-54 8.8 (30)
 >54 3.2 (11)

Years of practice
 1-2 11.4 (39)
 3-10 48.6 (166)
 11-15 12.9 (44)
 16-20 10.9 (37)
 >20 15.8 (54)
 Data missing 0.3 (1)

Practice site population
 <10 000 1.2 (4)
 10 000-50 000 7.3 (25)
 51 000-250 000 33.8 (115)
 251 000-1 000 000 33.7 (115)
 >1 000 000 19.4 (66)
 Data missing 4.7 (16)


Education and Background

The academic background of the respondents is summarized in Figure 2. The majority of respondents from this sample indicated having master's degrees, either master's of science degrees or master's of health science degrees. Of all respondents, 71.0% reported obtaining their training through completion of a pathologists' assistant training program, and 27.9% reported having received on-the-job training; 85.9% reported being AAPA fellows. AAPA fellows are members of the AAPA who have passed the Fellowship Examination. Pathologists' assistants who have been trained on the job obtain membership as AAPA affiliate members before they take the Fellowship Examination. The 14.1% of AAPA member respondents who did not indicate being AAPA fellows were presumably AAPA affiliate members.
Figure 2. Academic background of respondents.

Academic Background

B.S. 39%
M.S. 20%
M.H.S. 34%
M.D. 3%
Pd.D. 2%
Missing 2%

Note: Table made from a pie chart.


Reported previous occupations of the respondents are summarized in Figure 3. Of those respondents reporting "other" as their previous occupation, over half (56.0%) reported a previous health care-related occupation, either providing direct patient care (eg, medical military personnel, nurses, surgical/operating room technicians) or indirect care as laboratory professionals (eg, cytotechnologists, laboratory technicians, electron microscopy technicians). Of all respondents, 4.0% reported other medicine-related occupations (eg, salespersons for medical instrument companies), and 40% reported previous nonmedical occupations. The 5 most prevalent specific "other" occupations reported were (1) non-US pathologist, (2) funeral director, (3) cytotechnologist, (4) laboratory technician, and (5) medical military personnel.
Figure 3. Previous occupation of respondents.

Previous Occupation

Student 33%
Med Tech 22%
Histotech 13%
Research 7%
Autopsy Asst 6%
Other 18%
Missing 1%

Note: Table made from a pie chart.


A summary of the responses to a question regarding the mechanism of respondent introduction to the pathologists' assistant profession is shown in Table 2. The vast majority of currently practicing pathologists' assistants from this sample reported either having an immediate interest in the profession when exposed to it or developing an interest when exposed while working in another health care position.
Table 2. Introduction to the Pathologists' Assistant
Profession

 % of
Mechanism of Introduction Respondents (n)

Immediate interest in profession when exposed 46.3 (158)
Interest developed from prior health care
 experience 36.4 (124)
Job description matched with personal
 academic/professional qualifications 14.7 (50)
Movement into position with elimination of a
 pathology residency position 1.5 (5)
Data missing 1.2 (4)


Personal Practice Characteristics

Respondent personal practice characteristics are summarized in Table 3. The majority of respondents reported working 30 to 40 hours per week; however, a significant number (43.4%) reported working more than 40 hours per week. The majority of respondents reported working in a practice setting employing 2 full-time pathologists' assistants.
Table 3. Personal Practice Characteristics

Characteristic % of Respondents (n)

Years in current position
 <2 26.4 (90)
 2-6 35.2 (120)
 7-10 15.0 (51)
 11-15 11.1 (38)
 16-20 5.3 (18)
 >20 6.7 (23)
 Data missing 0.3 (1)

Hours worked per week
 <20 1.2 (4)
 20-29 2.1 (7)
 30-40 53.4 (182)
 >40 43.4 (148)

Annual salary range (x$1000)
 25-35 0.9 (3)
 36-45 6.2 (21)
 46-55 13.8 (47)
 56-65 35.5 (121)
 66-75 26.4 (90)
 76-85 10.0 (34)
 86-95 3.5 (12)
 >95 2.6 (4)
 Data missing 1.2 (4)


Employment Benefits

A summary of the responses relating to specific employment benefits available to respondents in their current positions is shown in Figure 4. In addition to the vast majority of respondents reporting availability of health care and retirement benefits, more than half of the respondents also reported continuing medical education funding, professional association dues payment, and travel monies as currently available benefits.

[GRAPH OMITTED]

Professional Activity Participation

Respondents reported participation in a variety of professional activities (summarized in Table 4). Respondents were asked to indicate which, if any, activities they had ever participated in while employed as a pathologists' assistant. Examples of nonpathology organization professional meetings respondents reported having attended or presented at included histotechnology and electron microscopy meetings.
Table 4. Professional Activity Participation(*)

 Respondents
 Reporting
 Participation,
Professional Activity %

Annual AAPA meeting attendance 87.4
Presentation at annual AAPA meeting 7.0
Professional pathology organization meeting
 attendance 26.7
Presentation at professional pathology
 organization meeting 5.0
Other professional organization meeting
 attendance 34.3
Presentation at other professional organization
 meeting 9.4
Co-author of peer-reviewed publication(s) 14.1
Perform formal teaching 34.9

(*) AAPA indicates American Association of Pathologists' Assistants.


Factors Contributing to Profession and Job Satisfaction

The last 2 items of part A of the questionnaire asked respondents to indicate up to 3 factors that they feel are the most interesting/satisfying aspects of the pathologists' assistant profession and to indicate up to 2 factors that they feel are the most important for their own personal job satisfaction.

The top 3 factors indicated by the respondents as the most interesting/satisfying aspects of their profession were (1) performance of surgical pathology-related tasks (54.8%); (2) being in a working environment with continuing exposure to medical basic sciences (eg, anatomy, physiology, pathology, pathophysiology) (40.4%); and (3) satisfying professional relationships with colleague pathologists (37.0%).

The top 2 factors indicated by the respondents as being the most important for their own personal job satisfaction were (1) their professional relationships with pathologists (65.7%), and (2) their salary (34.3%).

Task Analysis

The proportions of respondents reporting performance of either pathologists' assistant-specific tasks or non-pathologists' assistant-specific tasks are summarized in Tables 5 and 6, respectively. For those respondents reporting performance of each of the specific tasks, a summary of their estimates regarding the average time spent on each task is presented in columns 3 through 5 of Tables 5 and 6. During data entry, respondent estimates of time spent on each task were compared to their indicated work hours per week to identify any possible obvious overestimations of these reported times. No obvious discrepancies were identified. As estimated by the respondents, the top 4 tasks, in descending order of time spent per day, were (1) performing surgical specimen gross examinations, (2) training other gross room personnel, (3) assisting with frozen sections, and (4) assisting pathologists with surgical gross examinations. For those pathologists' assistants reporting that they took weekend call, the next task they spent the most time on was weekend call. For those pathologists' assistants not taking weekend call, the next group of tasks they spent the most time on included nonpathologists' assistant-specific tasks, such as answering the phone and logging specimens. These nonspecific tasks were reported to involve more of the respondents' time (both those pathologists' assistants taking call and those not taking call), on the average, than other specific tasks, including autopsy prosection or research. These findings correlated with the respondents' estimates of their productivity regarding performance of surgical gross examinations and autopsies. The respondents estimated that overall, they individually performed 46.0% of the surgical specimen gross examinations at their institutions, whereas they estimated only performing 22.0% of the autopsy prosections. When asked to indicate what type(s) of surgical specimens they routinely examined, 92.4% reported examining biopsies, 94.4% reported examining small routine specimens, and 94.7% reported examining large resections.
Table 5. Respondents' Performance (% Indicating Performance) of
Pathologists' Assistant-Specific Tasks

 Time Spent Performing Task
 (min/d)

Task % Median Mode Range

Assisting pathologist with
 surgical gross examination 31.1 15.0 60.0 0.3-120.0
Performing surgical gross
 examination 97.7 300.0 360.0 6.0-510.0
Frozen sections 71.0 30.0 60.0 1.0-320.0
Autopsy prosection 71.3 21.0 24.0 0.1-320.0
Specimen photography 82.7 12.0 12.0 0.3-60.0
Photomicroscopy 23.2 7.5 3.0 0.3-60.0
Electron microscopy 0.9 4.8 1.0 1.0-60.0
Tissue handling for banking 32.8 12.0 12.0 0.3-360.0
Research 15.5 12.0 12.0 0.5-240.0
Supervision of other personnel 45.2 60.0 60.0 2.0-480.0
Training of other personnel 55.4 45.0 120.0 0.4-480.0
Attendance at department
 conferences 72.4 12.0 12.0 0.5-120.0
Preparation for departmental
 conferences 29.6 6.0 12.0 0.3-90.0
Departmental manual preparation 53.7 4.7 3.0 0.1-180.0
Billing 27.9 30.0 30.0 3.0-192.0
Other administration 49.9 24.0 24.0 0.5-99.0
Table 6. Respondents' Performance (% Indicating
Performance) of Non-Pathologists' Assistant-Specific
Tasks

 Time Spent Performing
 Task (min/d)

Task % Median Mode Range

Specimen retrieval 39.0 12.0 30.0 0.5-90.0
Logging specimens 49.0 30.0 30.0 1.0-210.0
Answering phone 60.4 15.0 30.0 0.6-360.0
Ordering supplies 30.8 6.0 6.0 1.0-60.0
Cleaning gross room 51.9 15.0 30.0 1.5-90.0
Cleaning autopsy suite 25.8 5.4 3.0 0.1-60.0


The data in Tables 5 and 6 show which tasks the majority of respondents spent most of their time performing. However, the range of responses shown in the last column of these tables also shows that a large degree of variation exists among the individuals in the sample, suggesting a large degree of diversity in the specific roles pathologists' assistants play in anatomic pathology practices.

COMMENT

To our knowledge, these findings provide the first detailed description of pathologists' assistants and how they are used in anatomic pathology practices in the United States. A limitation of this study is that the sample surveyed was composed exclusively of pathologists' assistants registered as members of the AAPA. It is unknown exactly how many currently practicing pathologists' assistants are not registered members of the AAPA, and it is unknown how many other laboratory professionals (eg, histotechnologists) are currently used to perform pathologists' assistant tasks such as those listed in Tables 5 and 6. Neither of these groups were included in our sample, but they make up part of the target population of laboratory professionals currently assumed to be performing the role of pathologists' assistants, if only on a part-time basis. Further studies are needed that describe these groups of the target population.

The lack of previous information regarding pathologists' assistants precludes meaningful assessment of our findings in terms of possible shifts in their practice characteristics with the evolution of the managed care system and/ or changes in anatomic pathology practice over time. Therefore, in order to provide some context for consideration of the pathologists' assistant practice characteristics, we performed a comparison of our findings regarding pathologists' assistants with current practice characteristics of PAs. A comparison of the most recent PA practice characteristics obtained from the PA national organization[8] with our findings for pathologists' assistants is shown in Table 7. A comparison of the percentages of PAs receiving specific fringe benefits with the reported available employment benefits of pathologists' assistants reveals similar percentages for all the fringe benefits, including paid national organization dues and continuing medical education funding.
Table 7. Comparison of Physician Assistant and Pathologists'
Assistant Practice Characteristics

Practice Characteristic Pathologists' Physician
 Assistants Assistants

Sex 47% female 54% female
Age 25-39 y: 56.4% Median = 42.0 y
 40-49 y: 30.5%
Education
 Baccalaureate 39.6% 62%
 Master's 53.6% 25%

Years in practice 3-10 y: 48.6% Median = 7.0 y

Population of service
 area
 <50 000 8.5% 31%
 50 000-250 000 33.8% 29%
 250 000-1 000 000 33.7% 20%
 >1 000 000 19.4% 21%

Geographic
 distribution(*)
 Northeast 31.2% 24%
 Southeast 26.0% 24%
 Midwest/South Central 27.2% 33%
 West 15.0% 19%

Hours worked per week >40 h: 43.4% Median = 42 h
On call 49.3% 36%
Annual income $56 000-75 000: 61.9% Median
 All years: $64 780
 New graduates:
 $57 113
(*) Based on number of questionnaires sent.


Pathologists' assistants as a group appear to be slightly younger, overall, than practicing PAs. In contrast to PAs, the majority of pathologists' assistants in this sample had master's degrees. This finding may reflect sampling bias, as discussed previously. It also may be a reflection of a basic difference in the professional training programs for the 2 provider types; despite the fact that there have always been only 4 to 6 US pathologists' assistant training programs at any given time, the majority have been master's programs. Of the 5 presently accredited pathologists' assistant training programs, 4 are master's programs. In contrast, of the more than 120 accredited PA programs, only 49% presently offer a master's degree, and many of these programs have recently added their master's option.

Whereas the greatest numbers of providers for both professions are located on the East Coast of the United States and the lowest numbers are on the West Coast, slightly more PAs practice in the Midwest/South Central portion of the country, and there tends to be many more PAs servicing areas with populations of less than 50 000. This is undoubtedly a reflection of practice specialty, because the majority of PAs practice in primary care specialties. Additionally, one of the missions of the PA profession has been to provide care to underserved areas. Pathologists' assistant anatomic pathology specialty practice would be expected to be concentrated in more heavily populated, urban settings.

On the average, pathologists' assistants appear to work fewer hours per week than PAs, which is also most likely a reflection of their specialty and nonclinical practice; however, more pathologists' assistants in our sample reported taking call than the average percentage reported for PAs. Annual incomes for both groups appear to be similar.

The most valid method for obtaining task performance information is an observed time-motion study. Therefore, a potential limitation of the task analysis portion of our survey is that it was based on self-reported data. The reliance on self-reported data--as a consequence of the use of self-administered, mailed questionnaires--is a well-recognized disadvantage of the use of this method for survey administration.[9] However, the advantages of using self-administered mailed questionnaires, including sample-related advantages (wider geographic coverage, convenient use of a larger sample, wider coverage within a sample population) and significantly lower cost make self-administered questionnaires one of the most frequently used methods for collecting data in health research studies.[9] For the current study, our desire to obtain information from a large, national sample of pathologists' assistants drove our decision to use this method. Results from the pilot questionnaires also strongly suggested that respondents would provide complete responses that appeared to be internally consistent with their reported numbers of work hours per week. Another example of a recent study using this method for obtaining information about the practice characteristics of nonphysician providers is a study by Running et al[5] that describes practice characteristics of nurse practitioners. Because of its advantages, this method is commonly used by professional organizations for collecting workforce data.[4,8,10,11]

Results from the task analysis portion of our survey show that the majority of pathologists' assistants from our sample spend the majority of their time performing gross examination of surgical specimens. The consistency of this response supports the validity of the data, and this finding also confirms results from our earlier study examining the economic benefit of pathologists' assistant surgical specimen grossing practice, where the model pathologists' assistant was found to spend the majority of her time examining surgical specimens.[12] This task also was reported as the most interesting aspect of the profession by the majority of respondents.

A significant portion of time was reported to be spent on training other personnel in the gross room, including residents, medical students, and/or various allied health students, and this training time was not reported exclusively by pathologists' assistants working in academic centers. Although further study is needed to elucidate details regarding the specific interactions between pathologists' assistants and other personnel in anatomic pathology practice settings, these findings suggest that pathologists' assistants are taking on an increasing amount of teaching responsibilities in anatomic pathology that most likely belonged previously to pathology residents and/or pathology faculty and staff.

The majority of pathologists' assistants' daily time was reported to be spent on what may be considered pathologists' assistant-specific tasks, meaning that these tasks correlated with skills specifically taught and emphasized in training programs and were skills for which pathologists' assistants were assumed to be responsible in daily practice. However, approximately half of the respondents also reported spending a significant amount of time on nonspecific tasks. The most prevalent average time reported by these respondents for logging specimens, answering the phone, and cleaning the gross room was 30 minutes for each, amounting to 90 minutes per day spent on these 3 tasks. Some respondents reported spending even more time on such tasks per day. Although such nonspecific tasks are a necessary component of any professional position, given the background and reported salary ranges of pathologists' assistants reported here, spending 20% to 25% of time performing such nonspecific tasks may not be cost beneficial. Further studies are needed examining anatomic pathology gross room workflow dynamics in order to provide information relevant for suggestions regarding the "optimum" gross room work environment.

Related to the fact that many respondents reported spending significant amounts of time on nonspecific tasks are our findings related to the relatively small amount of reported time spent on certain specific tasks, notably autopsy prosection and research. Although 71.0% of respondents reported performing autopsy prosection, they also reported only being involved in an estimated 22.0% of cases at their institutions. Only 15.5% of respondents reported assisting with research. Given the consistent evidence documenting the usefulness of postmortem examinations and the apparent desire for postmortem examination by clinicians[13-18] in the face of decreasing autopsy rates, one possible solution for pathology practices attempting to maintain and/or enhance this presently nonreimbursable service is to increase the utilization of pathologists' assistants in autopsy prosection. Similarly, for those pathologists engaged in research, use of a pathologists' assistant for research assistance could be beneficial. Further studies are needed examining specific practice benefits derived from the use of pathologists' assistants.

The generalizations one can formulate from the data described here regarding pathologists' assistant practice are valuable, but equally important is the observation that there was a great degree of variability reported among the individual respondents in the task analysis portion of the study. Similar to PA practice, pathologists' assistant practice appears to incorporate a large amount of diversity in terms of individuals' roles. Such diversity would be expected for these practitioners, who provide services for supervising pathologist(s) in accordance with the needs of the individual pathologists and the specific needs of the practice.

References

[1.] Kovner C, Rosenfeld P. Practice and employment trends among nurse practitioners in New York State. J N Y State Nurse Assoc. 1997;28:4-8.

[2.] Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA. 1998;280:788-794.

[3.] Anderson AL, Gilliss CL. Nurse practitioners, certified nurse midwives, and physician assistants in California. West J Med. 1998;168:437-444.

[4.] American Academy of Physician Assistants. Physician Assistants Statistics & Trends 1991-1998. Alexandria, Va: American Academy of Physician Assistants; 1999.

[5.] Running A, Calder J, Mustain B, Foreschler C. A survey of nurse practitioners across the United States. Nurse Pract. 2000;7:15-16, 110-116.

[6.] American Association of Pathologists' Assistants Web Site. Available at: http:// www.pathologistsassistants.org/. Accessed November 21, 2000.

[7.] Aday LA. Designing and Conducting Health Surveys. A Comprehensive Guide. 2nd ed. San Francisco, Calif: Jossey-Bass Inc; 1996.

[8.] American Academy of Physician Assistants. 1999 AAPA Physician Assistant Census Survey. Alexandria, Va: American Academy of Physician Assistants; 2000.

[9.] Bourque LB, Fielder EP. How to Conduct Self-Administered and Mail Surveys. Thousand Oaks, Calif: Sage Publications; 1995. The Survey Kit; vol 3.

[10.] American Medical Association. Physician Socioeconomic Statistics. Atlanta, Ga: American Medical Association Press; 2001.

[11.] College of American Pathologists. Practice Characteristics Survey Report. Northfield, Ill: College of American Pathologists; 1997.

[12.] Grzybicki DM, Galvis CO, Raab SS. The usefulness of pathologists' assistants. Am J Clin Pathol. 1999;112:619-626.

[13.] Veress B, Alafuzoff I. Clinical diagnostic accuracy audited by autopsy in a university hospital in two eras. Qual Assur Health Care. 1993;5:281-286.

[14.] Szende B, Kendrey G, Lapis K, Lee PN, Roe FJ. Accuracy of admission and pre-autopsy clinical diagnoses in the light of autopsy findings: a study conducted in Budapest. Hum Exp Toxicol. 1994;13:671-680.

[15.] Khong TY. A review of perinatal autopsy rates worldwide, 1960s to 1990s. Pediatr Perinat Epidemiol. 1996:10:97-105.

[16.] Goldstein B, Metlay L, Cox C, Rubenstein JS. Association of pre mortem diagnosis and autopsy findings in pediatric intensive care unit versus emergency department versus ward patients. Crit Care Med. 1996;24:683-686.

[17.] Deiwick M, Lohrer A, Hoffmeier A, Baba HA, Bocker W, Scheld HH. Postoperative death should be followed by autopsy--an analysis of the autopsy findings of the years 1990 and 1991 in a heart surgery center. Thorac Cardiovasc Surg. 1999;47:82-87.

[18.] Kumar P, Angst DB, Taxy J, Mangurten HH. Neonatal autopsies: a 10-year experience. Arch Pediatr Adolesc Med. 2000;154:38-42.

Accepted for publication February 20, 2001.

From the Department of Pathology and Laboratory Medicine, Allegheny General Hospital, Pittsburgh, Pa (Drs Grzybicki and Raab and Mss Hart and Galvis); Duquesne University School of Health Sciences, Pittsburgh, Pa (Dr Grzybicki); and the Department of Pathology, The Miriam Hospital, Providence, RI (Mr Reilly). Mr Reilly is presently with Rio Grande Pathology Associates, Department of Pathology, St Joseph Hospital, Albuquerque, NM.

Presented at the Annual Meeting of the United States and Canadian Academy of Pathology, Atlanta, Ga, March 2001.

Reprints: Dana Marie Grzybicki MD, PhD, Department of Pathology and Laboratory Medicine, Allegheny General Hospital, 320 East North Ave, Pittsburgh, PA 15212.
COPYRIGHT 2001 College of American Pathologists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2001 Gale, Cengage Learning. All rights reserved.

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Author:Grzybicki, Dana Marie; Reilly, Thomas L.; Hart, Alison R.; Galvis, Colleen O.; Raab, Stephen S.
Publication:Archives of Pathology & Laboratory Medicine
Geographic Code:1USA
Date:Jul 1, 2001
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