Pathologists' Assistants: A Profession Comes to Maturity.

There are many definitions of a “profession.” Justice Brandeis in a 1912 commencement speech at Brown University defined a profession versus an occupation as having the following 3 characteristics:

“First. A profession is an occupation for which the necessary preliminary training is intellectual in character, involving knowledge and to some extent learning, as distinguished from mere skill. Second. It is an occupation which is pursued largely for others and not merely for one’s self. Third. It is an occupation in which the amount of financial return is not the accepted measure of success”[1]

A fourth key feature of a profession is self-regulation, whereby an occupational group enters into an agreement with government to formally regulate the activities of its members,[2] a premise formally recognized in the National Industrial Recovery Act of 1933.[3] These 4 foundational elements are delineated in the history and significant milestones in formation of the pathologists’ assistant (PA) profession, presented in this issue by Reilly and Wright[4] and in a prior Archives publication by Wright.[5] Given the potential decline in the pathologist workforce, their review is timely.[6,7] The current article traces the history of the profession, starting with endorsement by the American Society for Clinical Pathology (ASCP) in the late 1920s for the training and certification of clinical pathology technologists to assist pathologists, to the founding at Duke in 1969 of the first formal university-based master’s training program for PAs, through to the formation in 1972 and maturation of the American Association of Pathologists’ Assistants (AAPA). Three topics (1) training, (2) employment, and (3) licensure are worthy of further comment.

Training

Using Justice Brandeis’ definition, we consider PAs as professionals with a greater degree of responsibility in contrast to pathology technicians. Reilly and Wright point out that formal university-based training of PAs met with opposition regarding existing concepts of on-the-job (OJT) training of pathology technicians, initially for autopsy prosection. As the role of PAs quickly expanded to include grossing surgical specimens, the issue of OJT became more pointed.[4] The issue of OJT-trained versus master’s degree-trained individuals was in contention within the AAPA for many years. Starting in 1976, an examination was made available to OJT individuals for “fellow” membership in the AAPA. In 2004, the AAPA partnered with the ASCP to achieve national certification for PAs. The only route now for earning the PA (ASCP) certification is graduation from a National Accrediting Agency for Clinical Laboratory Sciences accredited Pathologists’ Assistant masters training program and passage of the ASCP Board of Certification examination. The question at this time thus becomes, what responsibilities in a clinical laboratory (inclusive of anatomic pathology) may be assigned to a pathology technician, as opposed to a certified PA? We hold that a laboratory director is ultimately responsible for the hiring, training, and assessment of competence of persons employed in a clinical laboratory. Competency for the assigned tasks and professionalism are the guiding factors. This then leads immediately to the question of employment.

Employment

It is an institution’s obligation to justify and document the qualifications of its employees. In its capacity as a Joint Commission-deemed inspection agency, the College of American Pathologists (CAP) accreditation laboratory standards assign the responsibility of clinical laboratory employee oversight and job assignment to the laboratory director.[8] The CAP-endorsed scope-of-practice for PAs is in alignment with that of the AAPA.[9] Following on the above considerations for training, the hiring of PAs (ASCP certified or noncertified) or pathology technicians with OJT training for assigned tasks is based on the complexity of services offered, economics, and needs of the institution. Although the explicit professional activity of a PA is the gross examination of surgical specimens and the performance of forensic, medicolegal, and hospital autopsies, these specific activities may occupy only 22% to 64% of the PA’s time.[10] The actual scope of practice can be much more comprehensive.[11] This includes management and supervisory activities for pre- and postanalytical aspects of surgical pathology, triage, and processing of tissue specimens for special studies, photography and other imaging activities, and broader responsibilities for management of an autopsy suite. Indeed, such managerial experiences give PAs opportunity to rise to more senior ranks within the organization, as has occurred in both of our organizations.

A specific professional role in academic institutions is the providing of education to pathology residents, medical students, PA students, and other clinical laboratory personnel and support of tissue-based research as through involvement in biobanking. We consider that master’s-level PAs are ideal for helping to fulfill these teaching roles. We have been fortunate to serve in institutions in which the contributions of PAs to the institutional teaching mission can be recognized by their formal employment as members of the department faculty.[12] This employment option is an exception; our experience is that terminal degrees (ie, MD, DO, PhD) are usually required for faculty employment in a medical school.

Licensure

Each state has the statutory authority to regulate professions to protect its citizens. Reilly and Wright list several states where state licensure of PAs is a requirement for practice. In such states, just as other laboratory medicine specialists are licensed, we feel it important that PAs be specifically recognized. On occasion, state licensure requirements for PAs may be at odds with the national standards for PA professional status, requiring legislative action in order to obtain remedy.[13] In the example given (New York State), advocacy by leadership of academic departments of pathology in the state, with the support of the Greater New York Hospital Association and the CAP, led to successful resolution of this issue. We are greatly appreciative of support of the profession of PAs by the family of pathology societies, now well beyond the AAPA and its certifying organization, the ASCP.

In conclusion, the current article by Reilly and Wright is a valuable contribution that documents the maturation of the profession of PAs in the house of medicine. Both for the practice of pathology and for the concept of professions as a whole, this an important story to be told.