Pathologists' Assistants in Nontraditional Roles: Uncovering the Hidden Value in Your Laboratory Open Access

PathAs are highly trained allied health professionals who play a critical role in the delivery of quality health care in both surgical and autopsy pathology. Their high level of education and broad skill sets provide valuable contributions to pathology practices and hospital-based health care institutions. Unique physician extenders who cannot directly bill for their services, PathAs complement and extend pathologists without creating redundancy. They are best described as collaborators in the laboratory and “are key partners in assisting the Pathologist to arrive at a pathologic diagnosis, but it is the sole responsibility of the Pathologist to render a diagnosis.”¹ 

The PathA profession was created at Duke University in Durham, North Carolina, by Thomas Kinney, MD, in 1969, a few years after the rise of physician assistants (PAs; now called “physician associates”), with the practical understanding that patient care skills were not applicable in pathology. Kinney wanted PathAs “to be an extension of the pathologist” as a response to a perceived workforce shortage in pathology. Although the physician associate profession was quickly embraced by the American Medical Association, the PathA profession struggled for decades to gain wide acceptance in the pathology community, often because of concerns regarding decreased quality and loss of job opportunities for pathologists, especially in academic settings. Pathologists in community hospital settings, particularly on the East Coast, were the first to accept PathAs. The PathA program at Quinnipiac University in Hamden, Connecticut, played a major role in this by building robust clinical rotations for their students to commute to. The rotation sites quickly saw the value of PathAs, and eventually, as more employers took a chance in hiring PathAs, pathologists in all settings found they were more than satisfied with their PathAs' work and the economic advantages to using PathAs.² 

Through efforts by the American Association of Pathologists' Assistants (AAPA), the National Accrediting Agency for Clinical Laboratory Sciences started external training program accreditation in 1995, with support from the College of American Pathologists (CAP) and the American Society for Clinical Pathology (ASCP). The profession moved from AAPA fellow certification to national independent certification through the ASCP in 2005, and the on-the-job training route to certification was phased out in 2008. Now, only graduates of 1 of the 13 National Accrediting Agency for Clinical Laboratory Sciences–accredited programs in the United States and Canada are eligible to sit for the Board of Certification exam and earn the credential PA(ASCP). Although a few programs offered a bachelor's degree until 2014, all of the accredited programs now result in a master's-level degree after 22 to 24 months. The first year consists of didactic coursework similar to that of medical students, including anatomy, physiology, medical terminology, embryology, general pathology, systemic pathology, medical photography, leadership/management, research, interprofessionalism, and histology. The second year consists of a clinical practicum with the respective PathA program–affiliated hospitals in various academic, forensic, or community pathology settings.³  To maintain PA(ASCP) certification, PathAs are required to participate in ASCP's Credential Maintenance Program and obtain 60 credits of continuing medical education across multiple topics, including cancer specimen examination and medical ethics. To align with similar professions, such as the PAs, the AAPA proposed increasing the required credits by 15, from 45 to 60, for each 3-year cycle. This was adopted by ASCP in 2018 and became effective for recertifications starting on January 1, 2022. The superscript CM after PA(ASCP) indicates the PathA is current with their certification maintenance.⁴ 

After a decades-long road to acceptance, training program accreditation, and board certification, the profession is now established in the United States and Canada. PathAs currently work in a wide variety of settings, including private practices, commercial laboratories, academic institutions, and government laboratories, and may be employed by a practice or a hospital. However, according to the AAPA, the PathA workforce is “still remarkably small in comparison to most other fields. … For the sake of context, there are approximately 18,000 pathologists, 350,000 laboratory technicians and technologists, and over 3,000,000 nurses in the US alone.”⁵  Currently, there are more than 2500 certified PathAs across North America and a few representatives worldwide, with more than 1800 AAPA Fellows—PathAs who have passed the ASCP Board of Certification Exam or, prior to 2005, passed the AAPA Fellowship Exam.⁶  In 2011, there were 1169 registered AAPA Fellows.⁷  The profession is still growing and evolving to support pathologists and the laboratory as health care transitions from fee-for-service to value-based care.

Originally hired as a cost reduction to fill a gap in the pathology workforce shortage, PathAs are trained to perform macroscopic examination (“grossing”) of surgical specimens and assist with intraoperative frozen sections and autopsies. According to the AAPA's Scope of Practice,⁸  these traditional roles encompass tasks such as obtaining patient clinical histories, discussing cases with surgeons and pathologists, ensuring proper specimen handling and fixation, obtaining samples for ancillary studies, taking specimen photographs, reviewing the macroscopic description transcription, providing quality assurance, ensuring proper storage and disposal of specimens, maintaining equipment, and provision of supplies. In the realm of postmortem examinations, the traditional tasks include prosection, assisting the pathologist with rendering the provisional anatomic diagnosis, writing the clinical history, recording the macroscopic anatomic findings, and submitting tissue sections for microscopic examination and ancillary studies, as outlined in Table 1. This allows pathologists to decrease their time spent performing these tasks and increase time behind the microscope working on the professional components of billing—a big revenue driver for the laboratory. In some settings, employing PathAs allows the pathologists to spend more time on administrative duties, teaching and research.

Relationship building is an unseen, albeit powerful, aspect of the profession. The most obvious relationship is the one cultivated between PathAs and pathologists. Saraswathi Nair, MD, of the Western Connecticut Medical Group, shares that “pathologists depend on [PathA]'s eyes and hands. If [PathA]s do not sample the right tissue, the final diagnosis affecting patient care can be compromised” (Saraswathi Nair, oral communication, November 2020). Building a level of trust and mutual respect with pathologists is an important part of relationship building and takes time, but it “provides long term benefits like improving the quality and efficiency of work,“ according to Monisha Bhanote, a board-certified pathologist (Monisha Bhanote, MD, oral communication, November 2020). When Geoff Snook first started at his private practice in Wichita, Kansas, he “was the first [PathA] in the hospital, and some pathologists were really reluctant to trust a [PathA] to grossing.” Over time, his pathologists grew to be “thankful for the role of the [PathA]” because it “freed them up to do more at the microscope” and helped them use their time in administration or other clinical activities (Geoff Snook, MHS, PA(ASCP)^CM, oral communication, November 2020).

As PathAs build trust with their pathologists, they may be invited into deeper levels of involvement with the practice. With pathologist support, trusted PathAs can also be the pathologist's eyes and ears beyond the gross room, providing the pathology perspective in meetings and bringing ideas back to the pathologist. Ryan Schniederjan, a PathA in Houston, Texas, with experience in private, corporate, and academic settings, was on a cancer committee and an operating room steering committee in an academic setting. “The need [for pathology representation on the committee] was brought to the Vice-Chair of the department and I asked if I could come to the first meeting. Then the pathologist encouraged me to go alone, and I came to be the new representative for the department” (Ryan Schniederjan, MHS, PA(ASCP)^CM, oral communication, November 2020). Susan Morgan, the director of pathology services at CellNetix in Seattle, Washington, extends her pathologists by standing in for them on various committees (Susan Morgan, BA, PA(ASCP)^CM, oral communication, November 2020).

Other relationships are cultivated by working in the gross room. PathAs have the opportunity to build relationships with surgeons during intraoperative consults and operating room staff during in-service training and daily workflows. PathAs can help radiology staff, nurses, and referring clinicians procure specimens in a safe and efficient manner, which improves processes, safeguards specimens, and ultimately enhances patient care through accurate diagnosis. These relationships will help achieve process improvements across departments, improve patient safety and outcomes, help nonlaboratorians understand where they fit into the big picture with shadowing opportunities, and even bring new work into the laboratory. For example, a good relationship with surgeons can lead to support that trickles down within the operating room to help track specimen cold ischemic times, which enhances patient safety and care. In a laboratory without a digital imaging and specimen radiography system, discussions with radiology about breast markers have the potential to optimize the PathA's ability to find the metallic markers in specimens upfront, minimize time spent in radiology looking for tiny markers, and potentially cut costs without adverse effects to the patient. PathAs also help pathologists communicate with surgeons and clinicians about delays that may arise from a reference laboratory, such as delayed results due to reagent shortages during a pandemic.

In addition to traditional roles at the grossing bench or in the autopsy suite, PathAs are capable of undertaking a variety of nontraditional laboratory roles. “We decided to hire our first [PathA] because we needed help doing the grossing and other things that we either didn't want [to do] or have the time to do,” says Dennis O'Neill, MD, president of Eastern Connecticut Pathology Consultants. “Pathologists who work in hospital labs have a lot of things to do other than looking under the microscope and providing diagnostic services (the professional component of pathology). If [PathA]s can help us do some of those other things, it makes our lives easier and more productive” (Dennis G. O'Neill, oral communication, December 2020). PathAs have had a desire to become more involved in these nongrossing responsibilities for some time.⁷  The 2021 AAPA membership survey, with responses from 759 AAPA members (41% of the membership and about 30% of certified PathAs at large), showed that many PathAs currently have nongrossing responsibilities, including frozen sections, teaching, administrative responsibilities, accessioning and coding, supply and instrument maintenance, tissue banking, quality assurance and quality control (QC), CAP inspection preparation, research/academic work, and management. Compared with the traditional roles of grossing, intraoperative consultations, and autopsies, teaching was the only nontraditional role performed by greater than 50% of respondents. The remaining nontraditional roles were performed by less than 50% of respondents,⁶  as shown in the Figure. Using more PathAs in these roles will bring value to the department, patients, and health care system as increased revenue, saved pathologist time, improved department reputation, higher quality of care, and decreased length of patient stays.

By virtue of their training and knowledge of the AP/Surgical Pathology section, PathAs are ideally qualified for the role of manager or supervisor of AP. Many PathAs are already successfully serving in supervisory roles. As shown in the Figure, 5% of surveyed PathAs spend more than 50% time in this role, and 35% have some supervisory responsibility but spend less than 50% of their time in this role. Their responsibilities (Table 2) include personnel management; workflow assessment; updating protocols; PathA scheduling and training; daily gross room supervision, equipment maintenance, QC, cleanliness, and guidance; supply and inventory management; specimen tracking; creating text shortcuts for voice dictation; developing and optimizing digital gross specimen imaging and annotation workflows; developing training and evaluation materials; and performance/competency reviews of AP staff, including accessioners, administrative support staff, and even registrars. Some of these responsibilities may also be performed by PathAs who are not in management roles and are separately reflected in the Figure.

With more experience and exposure, PathAs are capable of becoming more involved in practice management (Table 2) and can assist with strategies to broaden the practice. In his current role as executive director of a private group in Wichita, Kansas, Snook's tasks are diverse, such as writing and overseeing contracts with the hospital and gastroenterology physician practices, preparing reports on department activities for clinical staff, following up with the pathologists about a new voice dictation system, overseeing vendor payments, managing the employee retirement plan, acting as the compliance officer, and interacting with patients during billing follow-up (Geoff Snook, oral communication, November 2020). PathAs can take over physician scheduling, which is becoming increasingly complex, with many practices covering multiple sites, and manage pathologist work distribution. They can oversee or assist with physician credentialing for the practice's insurance and obtaining hospital privileges for staff. The relationships that PathAs and pathologists build at the hospital can also be realized off-site. “A big part of practice management is maintaining relationships with clients,” says Jon Wagner, former AAPA Board of Trustees chair and a PathA with 25 years of experience. In one position where Wagner served as both practice manager and PathA, he noted that his training as a PathA enabled him “to speak the language of healthcare and to begin to manage people and relationships” (Jon Wagner, MHS, PA(ASCP)^CM, oral communication, November 2020). Supervisory and managerial roles require extensive time away from traditional PathA tasks, however, and the impact on the workflow and staffing must be considered before assigning these duties.

More-experienced PathAs can also use their skills developed in AP laboratory management to serve as a clinical laboratory administrative director or director of laboratory services. To comply with Clinical Laboratory Improvement Amendments regulation 42 CFR 493.1443(b)(3)(i), it is necessary in a high-complexity laboratory to also have a physician or person with an earned science doctoral degree in the role of medical laboratory director⁹  to handle the clinical aspects of the lab. Although PathAs are qualified to function as technical supervisors in areas like histology, the laboratory would also need to employ technical supervisors to oversee technical operations that are outside the PathA's areas of expertise. Nonetheless, PathAs with strong leadership skills should be considered as candidates for administrative director positions, even without technical experience working in the clinical pathology laboratory.

Although not a common career path, becoming an administrative laboratory director is a reachable goal for select PathAs with experience in the clinical laboratory, management, and regulatory areas. Duties may include (Table 2) budgets, financial reports, quality assurance items, safety, human resources, strategic planning for laboratory and pathology services, participation in outside committees and capital committees, and maintaining accreditation checklists. Lara Goldberg, administrative laboratory director for Firelands Regional Medical Center in Sandusky, Ohio, did not see herself evolving into this role because she lacked a background in clinical pathology. However, after working in a laboratory for more than a decade, taking on administrative duties, building leadership skills through supervision of pathology and phlebotomy, and generating experience with clinical laboratory operations, she was offered the administrative laboratory director position when an opening became available. As an administrative laboratory director, she “has an even better relationship with the pathologists” than she did as a PathA, “because she understands what they need and what it is like to live in their world,” when advocating for the laboratory on their behalf with hospital administrators. As for her AP background, she believes that “knowing everything about the laboratory is not the most important thing. You need to surround yourself with smart people—the experts, the technical supervisors—and earn their trust, so they can help you understand it. You don't have to do the technical work, but you will be responsible for a lot of people—and that is hard! Someone taking on a director role needs to be prepared to work with people and be a leader.” Upon hiring her, Goldberg's boss “recognized that new leaders often failed, so I was mentored to be better at budgeting, human resources, and productivity. My boss wanted me to grow” as a leader. Goldberg aims “to represent the laboratory well” when interacting with doctors' offices regarding their pathology work, giving tours of the laboratory to hospital staff during lab week, educating high school and medical technician students about AP/clinical pathology, and discussing laboratory operations with hospital administration (Lara Goldberg, MHS, A(ASCP)^CM, oral communication, November 2020).

Although PathAs are not reimbursed for services like physician associates, some nontraditional roles may directly contribute to the revenue stream of the hospital or practice, as shown in Table 3. PathAs are often exposed to Current Procedural Terminology coding in laboratory management classes as well as in their traditional practice roles and can review billing codes, consult pathologists as needed for discrepancies or questions, and ensure reimbursements are not missed. Even when Current Procedural Terminology coding was combined with accessioning and transcription, less than 50% of survey respondents⁶  indicated involvement in these roles (Figure). PathAs can also help bring new tests in-house, such as polymerase chain reaction for molecular testing, and assist with validations.

The pathology laboratory generates valuable clinical and administrative data that can be used to manage the practice. PathAs can develop quarterly operations reports for the hospital, laboratory, or practice, including specimen volumes, overhead expenses, cost-cutting measures, cost comparisons for supplies and service vendors, productivity by pathologist or workgroup, and budgets. They can assist with budget requisition and proposals, equipment use, and staffing justifications. O'Neill understands that “some pathologists may find it threatening [to allow PathAs access to sensitive financial information about the practice because they believe it is] not the [PathA]'s job or what they are trained to do. This is understandable to an extent, but when you hire someone, work with them for several years and learn to trust them, they become a very valuable resource within the practice” (Dennis G. O'Neill, oral communication, December 2020).

PathAs can play a major role in marketing (Table 3) and enhancing the services pathologists provide to the community, acting as the “face of the practice” by visiting ambulatory surgery centers, physician offices, and outpatient clinics with a pathologist to acquire the potential client's business or maintain the relationship with the site on their own. This role may include routine visits to assess clients' needs and satisfaction with services, client follow-up to ensure adequate turnaround times and supplies on hand, determining client satisfaction by developing customer surveys and compiling findings to improve services, resolving issues through follow-up calls, directing questions to the appropriate staff member, and providing guidance on specimen collection and storage. Mike Sovocool, a PathA and practice administrator for a private group in Syracuse, New York, sometimes accompanies the pathologist and marketing representative to meetings at laboratories and physician offices. “For AP marketing, it really does matter to clients to have a physician (pathologist) to physician interaction” to start the conversations, but they include him “because [PathA]s know the testing requirements, and questions that we can answer often come up in these conversations” (Mike Sovocool, MHS, PA(ASCP)^CM, oral communication, November 2020). Using a PathA in this marketing role would be beneficial in both a private practice and a hospital-based setting.

There are ways for PathAs with the required skill set to bring in direct revenue through nontraditional roles (Table 3) when given the opportunity. Laboratory outreach is a huge financial boost to the overall bottom line of a health care facility or practice. PathAs may accompany a pathologist or marketer on sales calls and help negotiate client contracts, for both inpatient and outside physicians. Schniederjan brought in new clients to his practice by explaining who would be handling their specimens from the patient care perspective. “The medical staff, particularly the nursing staff, appreciated speaking to someone who could understand their clinical language and answer their questions about specimen care and handling. Knowing that a PathA, not just a technician, was going to oversee the grossing process gave them confidence in our lab's focus on patients and quality” (Ryan Schniederjan, oral communication, November 2020). A PathA in this role improves communication, relationships, and patient care by providing the help necessary for the clients to collect correct specimens and reduce errors.

PathAs can help a private practice gain a competitive advantage in the marketplace. “Our [PathA] has been indispensable in helping develop other assets,” noted O'Neill. “I can go out and talk to physicians about why they should have an in-office laboratory, but once we get the go-ahead, I need help to create the lab. Because our [PathA] understands CAP/state/public health standards, she can assist with licensing the lab, hiring histotechnologists, and developing the policies and procedures,” as well as mitigate the risk of noncompliance. Without this in-house resource, O'Neill explained he would have to hire a consultant to do all that work, “so the [PathA] in this role saves time and money.” This ability to build laboratories, manage them efficiently, and provide infrastructure to new assets to make them financially viable is “essential to our ability to expand in the marketplace. In Connecticut, it's kind of a dog eat dog world out there—if you aren't gaining work, you are losing it. Our [PathA] helps us compete more effectively in the marketplace” (Dennis G. O'Neill, oral communication, December 2020).

PathAs have the skills needed to provide direct support in the areas of quality improvement, quality assurance, and QC (Table 4), although only 36% of survey respondents⁶  were involved in this role (Figure). They can collect, collate, and present quality data, such as complex, noncomplex, and biopsy case turnaround time; frozen section turnaround time; cytology-histology correlations; frozen-permanent correlations; breast benchmarks, such as estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2; molecular data for lung, colon, endometrial, and breast cancers; and fine-needle aspiration adequacy results for use in audits, for monitoring and sharing with hospital administration, committees, or quality dashboards. Depending on the detail level of the report and laboratory information system used by pathology, data may be easy to capture, or they may be labor-intensive. Some reports, such as breast benchmarks, can be broken down further by client or pathologist to ensure everyone in the practice is meeting the benchmark. Other reports, including annual reports for the practice, may involve meeting with stakeholders to collect data and may be very time-consuming, especially when they are first being developed.

Developing a robust specimen tracking protocol is especially important in the pathology department to optimize efficiency with proper specimen triage, increase patient safety by preventing lost specimens, enhance quality by ensuring low ischemic times for molecular testing, and improve patient outcomes overall. PathAs may also oversee QC measures like frozen section stain and equipment temperature checks.

With precision medicine on the rise, cold ischemia time is becoming an increasingly important preanalytic variable in specimen handling, with benefits to patient outcomes and quality of care. A time of an hour or less between removal and fixation contributes to proper tissue quality by providing intact DNA and RNA for accurate molecular testing. Tissue quality is a fundamental patient safety issue because patient management decisions are based on molecular data, which could be compromised because of the lack of standardization of controlling or recording preanalytic variables that may affect tissue quality.¹⁰  The PathA is the perfect liaison to educate and coordinate with the operating room department staff and surgeons about reducing, controlling, and documenting cold ischemia times. Reducing cold ischemia times may be more challenging to adapt to in hospitals where the pathology laboratory is a significant distance from the operating suite, offsite from the hospital, or has staffing challenges because of afterhours complex cases. The relationship-building aspect of the PathA role would be beneficial here because having buy-in from surgeons will help with tracking and improving cold ischemia times.

Process improvement is another area where PathAs contribute value. Process improvement “is critical in maintaining quality patient care, retaining staff, and decreasing costs,” says Liz Rizzo, performance improvement consultant and former PathA at Dartmouth-Hitchcock Medical Center in Manchester, New Hampshire. While working as a PathA, Rizzo was involved with a system-wide laboratory Lean project and enjoyed it so much that she pursued her green and black belts in Lean Six Sigma. She now teaches classes on this topic and coaches people through their improvement projects, and she leads multidepartment improvements (Elizabeth J. Rizzo, MHS, PA(ASCP)^CM LSSBB, oral communication, November 2020). When Rebecca Karpa, a PathA in Maryland, first transitioned from academia to private practice, she initiated improvements by bringing “a workflow over [from her last job] that kept requisitions, specimens, and cassettes together in a single cube. It reduced errors dramatically” (Rebecca Karpa, BS, PA(ASCP)^CM, oral communication, November 2020). PathAs at the Mayo Clinic in Rochester, Minnesota, have a rotation where they help triage outside consults and set up outside pathology needing internal review. The case is assessed for missing information and the report is drafted in the institution's format before being routed to the correct pathologist (Monica L. Kendall, MS, PA(ASCP)^CM, oral communication, November 2020).

A PathA's knowledge of the daily tasks and requirements of the laboratory makes them well suited for various regulatory roles outlined in Table 4 and ensures compliance with regulatory agencies such as CAP, The Joint Commission, the Administration (OSHA), and state and local agencies. PathAs can provide valuable input into laboratory remodels or new designs and oversee the proper packaging and shipping of biologic AP specimens. An expert in macroscopic examination, the PathA can write, review, and revise surgical pathology and autopsy protocols as needed, and make sure they are reviewed annually by the staff.

PathAs provide vital support for the CAP accreditation and The Joint Commission inspection process by reviewing the inspection questions, collecting pertinent documentation, ensuring the applicable protocols, documents, and QC data are readily available during the site visit, and performing mock inspections. CAP inspection involvement was reported by 45% of survey respondents,⁶  with most spending less than 50% time in this role (Figure). Although inspections occur biannually, maintaining inspection readiness occurs throughout the year with the education of staff and review of protocols for relevant updates and changes. PathAs have also participated in CAP inspections of laboratories outside their hospital, and the experience and exposure they bring back to their practice are invaluable. New ideas, efficiencies, and workflows are realized when reviewing how other institutions operate.

PathAs are qualified to serve as safety officers for the entire department or the AP section. For those serving the entire department, additional training is needed to become familiar with clinical laboratory supplies and reagents. In this role, the PathA would be responsible for monitoring compliance with regulatory agencies (eg, OSHA); monitoring radiation, formalin, and xylene exposures; maintaining chemical inventory; recycling xylene and formalin; determining and implementing best practices; maintaining Safety Data Sheet documents; performing safety rounds to ensure proper personal protection equipment availability and use; keeping current and pertinent safety protocols for all areas of the lab; developing meeting agendas and following up on action items; and conducting monthly safety training in areas of safety, chemical hygiene, and infection control.

Although tissue banking is the most common research role (Table 5) for PathAs, only 36% of survey respondents⁶  perform this role and most spend less than 50% of their time tissue banking (Figure). Having a PathA triage the specimen and procure the tissue ensures clinical care is not compromised while maximizing the availability of tissue for research. With their training and understanding of what tissue is important for diagnosis, PathAs are able to make sure that the tissue taken for research does not compromise patient care but also satisfies the need of the project. PathAs also mitigate risk in the context of institutional review board (IRB) compliance by ensuring tissue only goes to investigators with approved protocols who have obtained proper consent from the patient. Hospitals that administer large tissue bank operations know the value of having a dedicated biobank PathA perform not only the tissue collection but the tracking and quality data on the cases as well. Mollie Patton, a full-time Biobank PathA and tissue acquisition manager at the Medical College of Wisconsin in Milwaukee, “helped expand the biobank to over 100 different studies” since being hired. She participates in “tissue procurements, hiring laboratory personnel, budget and distribution forecasts, and training pathology residents” and feels appreciated by her fellow grossing PathAs because they are better able to focus on their work. Patton was also part of the team that received CAP accreditation for their biobank (Mollie Patton, MS, PA(ASCP)^CM, oral communication, November 2020). PathAs in traditional roles at the gross bench, regardless of who employs them, are often asked to procure research tissue from specimens in systems without a dedicated biobank PathA. In this situation, negotiating reimbursement from the research group for procurement time should be pursued because procurement work takes time away from the PathA's grossing responsibilities.

In many systems, a gap exists between the clinical and research sectors, and PathAs help bridge that gap. Heidi Wagner, head of operations for the University Health Network Biospecimen Services in Toronto, Canada, states that “the clinical and research environments in healthcare were fairly siloed” before they had PathAs, “and [PathA] leadership was able to bridge that gap” by attending “cancer subgroup meetings with surgeons, pathologists, and investigators to understand their priorities, inform them of our collection processes and thereby, streamline biobank operations” (Heidi Wagner, BS, PA(ASCP)^CM, oral communication, November 2020). Brad Skilton, director of the Cleveland Clinic Central Biorepository, Surgical Pathology and Autopsy Services, in Cleveland, Ohio, bridges the same gap by “including the investigators in daily [PathA] huddles to explain why new procurements are happening” (Brad Skilton, BS, PA(ASCP)^CM, oral communication, November 2020). Biobank PathAs may also assist with obtaining consents, IRB proposal development, tissue storage logistics, tissue release, and review of protocols.

Various opportunities exist for PathAs to be involved in education (Table 5). More than 60% of survey respondents⁶  indicated that they are involved in teaching, although most spend less than 50% of their time in this role (Figure). Several PathAs at community and academic institutions are involved in the training of pathology residents and PathA students in macroscopic examination, which includes hands-on instruction, developing training materials, and giving lectures. Monica Kendall, PathA supervisor at the Mayo Clinic in Rochester, Minnesota, shared that “frozen section simulations for the pathology fellows were created by Erica Reed, a PathA who helps with surgical pathology fellowship orientation in the Frozen Section Lab, once the idea was envisioned by our Fellowship Director” (Monica L. Kendall, oral communication, November 2020). Because of their close interactions with trainees in the gross room, PathAs are also qualified to be a part of the resident and PathA student evaluations and competencies. Although many pathologists nationwide spend less time in the gross room than they used to, they are still expected to understand grossing concepts to advise PathAs on complex cases. It is important for pathology trainees to learn grossing to round out their training, and having the PathAs fill this role saves pathologist time and improves quality with consistent teaching.

PathAs can assist with preparing properly identified and annotated photo presentations for educational conferences and tumor boards, such as taking traditional or digital photomicrographs of marked slides and ensuring available specimen gross images are included. This helps pathology strengthen relationships with the clinicians who attend by providing clear understanding of the efforts undertaken in the laboratory to reach an accurate diagnosis for their patients after tissue leaves the clinic or operating room. More than 75% of survey respondents⁶  (Figure) reported involvement in gross photography and photomicrography, although more specific uses were not provided.

Information technology (IT) is an integral part of the pathology lab workflow, yet too often these systems are not optimized for the laboratory. PathAs are familiar with their day-to-day use of many systems and may fill a variety of roles, as outlined in Table 6. They should be involved in the evaluation and decision-making process when upgrading or purchasing a new system, such as the electronic health record, laboratory information system, bar coding and tracking, voice dictation service, integrated digital photography, electronic documentation system for policies and procedures, a telepathology system, and specimen radiography systems. This includes the entire equipment life cycle: discovery, implementation, testing, and maintenance. As a designated “superuser,” they receive extra training to support staff and resolve problems. It is also important to include PathAs in the discussion when redesigning electronic pathology requisitions to include the necessary information efficiently.

As AP moves toward digital workflows, the importance of gross specimen imaging and annotation in patient care is becoming more apparent. PathAs are the ideal candidates for developing and managing these digital workflows, such as taking photographs of sectioned tissue slices with annotations of inked margins, important features, and cassette maps in complex cases, such as lumpectomies or bone cancers. Gross photography is also required to fulfill accreditation standards in some cases, like documenting the integrity of the mesorectum for the National Accreditation Program for Rectal Cancer.¹¹  Workflows should also include having images readily available to the pathologist, who may be off-site as practices expand coverage.

PathAs, in coordination with an IT specialist and a pathologist leader, can assist with developing and updating the content of a practice or department Web site, including operating hours, contact information, available tests, specimen collection requirements, biographies of the pathologists, accepted insurance plans, and billing policies. An important tool for online marketing and boosting public exposure, the Web site includes news, blog entries, and important practice updates. If desired, the Web site can be linked to social media accounts that are moderated by the PathA. In the hospital setting, PathAs can develop and update content for an IT platform that allows different internal users to access the materials, such as a protocol for molecular testing requirements that operating room staff can access on the intranet, making it easier for the end user to collect correct samples.

Volel et al demonstrated that a lead PathA with administrative duties or a PathA supporting other mission-critical functions of the department will not be able to continue grossing the same caseload daily.¹²  There are multiple ways to accommodate the shift in time and resources as a PathA acquires more nontraditional roles, depending on the overall workload and the type of role. Offering protected administrative time away from the bench for projects, whether in small increments daily or as an entire day, will reduce the risk of grossing errors, improve patient safety, and increase productivity. All the aforementioned are impacted by common gross room interruptions like fresh specimens, frozen sections, phone calls, and questions from staff. Sites with multiple PathAs in nontraditional roles may explore having a rotating “triage” PathA. This designated PathA would be the first point of contact to handle most urgent interruptions, which will allow the other PathA team members to complete administrative tasks or gross more complex specimens without interruption or delay. In high-volume labs where it may be a challenge to accommodate time away from grossing, a per diem or part-time PathA may be able to fill this gap. Other sites may choose to hire an administrative PathA, a versatile position that can still provide grossing coverage when needed but allows enough focus to be effective in nontraditional roles.

Retaining good people is a necessity, and most successful organizations have acknowledged that high turnover is detrimental.¹³  The ASCP 2019 Wage Survey found that hiring, retention, and staffing challenges were the second top theme in the analysis and sometimes led to shortages in the workforce.¹⁴  A CAP Q-Probes study found that labs with the lowest amount of turnover invest in and show appreciation for their employees through development, opportunities, and recognition. Some personnel investment strategies include developing and communicating clear career paths and funding external laboratory continuing medical education.¹³  When PathAs feel supported to grow, they tend to stay—for a very long time. Rebecca Dilorio, who started 14 years ago as the only PathA, is the executive director at Eastern Connecticut Pathology Consultants in Waterbury, Connecticut, and “has not even considered leaving. The job is diverse, and the pathologists offer a lot of support, which has been very helpful.” She notes that they take the long view of how things should work and provide mentoring to help her achieve goals and grow professionally (Rebecca Dilorio, MHS, PA(ASCP)^CM, oral communication, December 2020). Being mentored and feeling like part of a team also contribute to job satisfaction. Almost half of the laboratory professionals (including PathAs) surveyed by the ASCP addressed being underappreciated, especially compared with nursing and other allied health professionals.¹⁴  Jon Bakst, the regional administrative director of laboratory services at Loyola University in Chicago, Illinois, had a mentor at a previous post who was “always willing to take time to talk, ask what you think about a topic. He encouraged people to find someone to guide [them] as [they] moved into different roles.” He believes that PathAs can offer the same support to their peers because “if you can help develop someone else professionally, we all benefit” (Jon Bakst, MHS, PA(ASCP)^CM, MBA, oral communication, December 2020).

Burnout is underrecognized and underappreciated as a cause of errors in the laboratory, putting patients at higher risk for an adverse event or error, and leading to greater liability of health care organizations.¹⁵  Problems with the workload and job demands, efficiency and resources, workplace culture and values, control and flexibility, social support and community, and work-life integration can lead to exhaustion and inefficiency. By addressing controllable factors, laboratory leaders increase chances for more engagement with employees.¹⁶  Chevanne Scordinsky, the supervisor at Hackensack University Medical Center, knows the value of being “put in a position of orchestration, [and] being able to provide the tools, structure, and facility people need to do their jobs well. [Managers should] create a whole environment. People are more averse to wasting their energy than to working hard, so you can be busy but feel accomplished because you achieved something.” She is working on “empowering the staff to be leaders and creating accountability among them” (Chevanne Scordinsky, MS, PA(ASCP)^CM, oral communication, November 2020). Diversity within the job leads to decreased burnout and improved productivity. Many of the PathAs in leadership roles recognize this and promote diversity. Kendall feels the satisfaction of her team of 20 PathAs at the Mayo Clinic “is good. They have different options and opportunities, are expected to work at a high level, and are proud of the contributions they make” (Monica L. Kendall, oral communication, November 2020).

PathAs are qualified allied health professionals capable of handling a wide range of nontraditional roles in the pathology laboratory. These innovative and creative roles have the potential to evolve the PathA profession while bringing value to pathology practices, PathAs, organizations, and patients through increased quality of care, saved pathologist time, improved department reputation, and higher revenues. Practices can choose the tasks that fit their specific needs and support their PathAs as they step into these new roles. Many PathAs currently in nontraditional roles were supported and mentored by pathologists as they advanced in their career. The value of growth opportunities, diversification, and mentoring toward positive job satisfaction is often overlooked but has enormous impacts on the employer in terms of employee retention. As health care transitions toward value-based care, pathologists and PathAs must work together to generate long-term value with continuous improvements that save pathologist time, optimize financial performance, improve competitive advantages, and increase quality and reputation for the department, hospital system, clinicians, and, most importantly, patients.

The author would like to thank Dennis O'Neill, MD; Saraswathi Nair, MD; Rajesh Dash, MD; Monisha Bhanote, MD; Jon Bakst, MHS, PA(ASCP)^CM; Rebecca Dilorio, MHS, PA(ASCP)^CM; Lara Goldberg, MHS, PA(ASCP)^CM; Leah Greene, MHS, PA(ASCP)^CM; Rebecca Karpa, BS, PA(ASCP)^CM; Monica Kendall, MS, PA(ASCP)^CM; Jesse McCoy, MHS, PA(ASCP)^CM; Stephanie Mercer, MS, PA(ASCP)^CM; Susan Morgan, BA, PA(ASCP)^CM; Lauren Morita, MHS, PA(ASCP)^CM; Mollie Patton, MS, PA(ASCP)^CM; Leeanna Ribera, MHS, PA(ASCP)^CM; Liz Rizzo, MHS, PA(ASCP)^CM; Ryan Schniederjan, MHS, PA(ASCP)^CM; Chevanne Scordinsky, MS, PA(ASCP)^CM; Brad Skilton, BS, PA(ASCP)^CM; Geoff Snook, MHS, PA(ASCP)^CM; Mike Sovocool, MHS, PA(ASCP)^CM; Heidi Wagner, BS, PA(ASCP)^CM; Jon Wagner, MHS, PA(ASCP)^CM; and Jenny Winters, MS, PA(ASCP)^CM for taking the time to share their experiences with non-traditional roles; the AAPA Board of Trustees for their support and introductions to members working in nontraditional roles; and Newport Group Inc for permission to reprint Figure 1 from the 2021 American Association of Pathologists' Assistants (AAPA) Membership and Salary Survey Report.⁶  I thank Saraswathi Nair, MD; Rajesh Dash, MD; and Robert Cottrell, PA(ASCP)^CM for their feedback throughout the process; and Robert H. Tessier, MPH; Allegra E. Klein, MBA; and Julianna R. Mastroianni, MLS(ASCP) for their initial research, guidance, review, and sharing their ideas and expertise.