The gross examination of anatomic specimens is a critical component of pathology, forming the foundation for accurate diagnosis. However, the complexity of grossing means that errors – especially when performed by untrained personnel – can lead to serious consequences for patients.
Historically, grossing was performed exclusively by pathologists and pathology residents. However, as workloads increased, specially trained pathologists’ assistants (PAs) were introduced to provide necessary support. PAs complete formal education and training through accredited programs, equipping them with the advanced knowledge required for surgical specimen processing.
Meanwhile, grossing technicians (GTs) have been introduced to support other areas of the pathology lab without the intense training undertaken by PAs. Today, PAs and GTs perform the majority of grossing tasks, raising important questions about the scope of practice, training standards, and regulatory oversight.
The growing shortage of pathologists also presents a significant challenge. Fewer medical students are choosing pathology, and advancements in personalized medicine means pathologists now spend more time reviewing complex cases under the microscope – leaving little time for grossing.
A pathologist once told me, “diagnosis begins at the gross bench.” Choosing the right tissue samples is critical; even the most skilled histology staff cannot compensate for poorly sampled tissue. As pathologists’ roles shift away from the grossing room, it’s more important than ever that those doing the work are properly trained and qualified. Clarification of non-pathologist grossing personnel are essential to ensure patient safety, maintain diagnostic accuracy, and optimize workflow.
Lacking regulatory oversight
Despite the critical role of grossing personnel, regulations remain minimal. The only federal guideline – Clinical Laboratory Improvement Amendments (CLIA) ‘88 – classifies grossing as high-complexity testing but only requires an associate degree in lab science or medical technology. Only three US states currently license PAs, and the rules vary significantly. California is the only one that has taken initial steps to differentiate PAs from other grossing personnel by establishing a tiered supervision system.
While CLIA-qualified personnel may be adequate for low-complexity cases, such as routine biopsies that don’t require dissection, it’s concerning that moderate- to high-complexity cases – including cancer resections – aren’t more strictly regulated. These cases require an advanced knowledge of pathology. Even routine specimens, like an appendix, can contain unexpected findings that can be overlooked by inadequately trained personnel.
Defining roles
The roles of PAs and GTs need to be clearly defined, with proper education, training, and scopes of practice. The American Association of Pathologists’ Assistants (AAPA) has issued a position statement, recommending that GTs are limited to “macroscopic examination of routine biopsies and low-complexity specimens that do not require selective sampling,” due to their limited formal education and standardized training.
In contrast, PA accredited programs include in-depth education in pathology, anatomy, and disease processes, plus over 10 months of hands-on-lab experience. PAs not only perform highly complex grossing, but also review patient histories and assist in writing autopsy reports – tasks that were once handled by pathologists. In this way, PAs function as physician extenders, much like nurse practitioners and physician associates.
A recent CAP Today article highlighted improvements in lab efficiency and workflow by utilizing PAs as pathologist extenders. An ideal lab setup would have pathologists focused on microscopic diagnosis, PAs handling moderate to high-complexity grossing and frozen sections, and GTs handling only low-complexity grossing.
Strengthening regulations
To maintain high standards and keep patients safe, the AAPA recommends the following:
PAs should graduate from a National Accrediting Agency for Clinical Laboratory Sciences (NAACLS)-accredited program and pass the ASCP board certification exam. This allows them to hold responsibility for grossing high-complexity specimens that require selective sampling.
GTs should meet CLIA requirements for high-complexity testing personnel, but only work on small routine biopsies and low-complexity specimens where the entire tissue is submitted for microscopic examination without selective sampling.
Licensing or additional regulations could help clearly define the responsibilities of each role. Licensing PAs would enhance lab efficiency, safeguard diagnostic accuracy, and give pathologists greater confidence in delegating grossing tasks – allowing them to focus on microscopic diagnosis.
By formalizing these distinctions, we can ensure the highest standards of patient care while maximizing the skills of all pathology professionals and support attending pathologists, who bear the ultimate responsibility for rendering accurate diagnoses.
For more details on PA licensure, visit the AAPA’s resource page: Why Licensure.
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