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'''Level 4 equivalent''', abbreviated '''L4E''', is a [[workload measurement system]] endorsed by the Canadian Association of [[pathologist]]s.<ref name=Can_J_Pathol_2010_2_8-19>{{Cite journal  | last1 = Maung | first1 = R. | title = [http://andrewjohnpublishing.com/images/cjp%202-1.pdf Canadian Association of Pathologists guidelines for measurement of workload] | journal = Canadian Journal of Pathology | volume = 2 | issue = 1 | pages = 8-19 | month = | year = 2010 | doi =  | PMID = }}</ref>
'''Level 4 equivalent of 2014''', abbreviated '''L4E (2014)''', is a [[workload measurement system]] endorsed by the Canadian Association of [[pathologist]]s.<ref name=Can_J_Pathol_2010_2_8-19>{{Cite journal  | last1 = Maung | first1 = R. | title = [http://andrewjohnpublishing.com/images/cjp%202-1.pdf Canadian Association of Pathologists guidelines for measurement of workload] | journal = Canadian Journal of Pathology | volume = 2 | issue = 1 | pages = 8-19 | month = | year = 2010 | doi =  | PMID = }}</ref>


The development is described in a paper by Maung.<ref name=pmid15762279>{{Cite journal  | last1 = Maung | first1 = RT. | title = What is the best indicator to determine anatomic pathology workload? Canadian experience. | journal = Am J Clin Pathol | volume = 123 | issue = 1 | pages = 45-55 | month = Jan | year = 2005 | doi =  | PMID = 15762279 }}</ref> It has since been revised and is comprehensive with regard to academic practice and community practice.<ref>URL: [https://www.cap-acp.org/wkload.php https://www.cap-acp.org/wkload.php]. Accessed on: 14 July 2017.</ref>
The development is described in a paper by Maung published in 2010.<ref name=pmid15762279>{{Cite journal  | last1 = Maung | first1 = RT. | title = What is the best indicator to determine anatomic pathology workload? Canadian experience. | journal = Am J Clin Pathol | volume = 123 | issue = 1 | pages = 45-55 | month = Jan | year = 2005 | doi =  | PMID = 15762279 }}</ref>  


==Details==
The original system is covered in the article ''[[Level 4 equivalent of 2010]]''.  The 2014 version (dealt with here) is superseded by the 2018 version which is dealt with in ''[[Level 4 equivalent of 2018]]''.
===Surgical pathology===
 
The original L4E units for surgical pathology adapted from Maung:<ref name=Can_J_Pathol_2010_2_8-19/>
==Revised L4E of 2014==
One L4E unit is considered to be roughly equivalent to 10 minutes.
 
===Most surgical pathology===
As per L4E definition (2014) adapted from CAP-ACP:<ref name=capacp2014>Workload and Workforce Committee of the CAP-ACP. Workload Measurement Guidelines. Canadian Association of Pathologists (CAP-ACP). 2014. URL: [https://www.cap-acp.org/cmsUploads/CAP/File/CAP-ACP%202014%20Workload%20FINAL.pdf https://www.cap-acp.org/cmsUploads/CAP/File/CAP-ACP%202014%20Workload%20FINAL.pdf]. Accessed on: 17 October 2017.</ref>  
{| class="wikitable sortable"
{| class="wikitable sortable"
! Code
! L4E units 
! Description
! Description
! L4E units
! Details
|-
|-
| Surgical - level 1
| L1
| 0.15
| 0.15
| gross only specimens
| itemized in the "specimen list and codes"
|-
|-
| Surgical - level 2
| L2
| 0.33
| 0.333
| confirmation of normal
| must include histology
|-
|-
| Surgical - level 3
| L3
| 0.5
| 0.5
| small/simple biopsies
| includes most skin, cysts, GI tract specimens, small benign specimens - detailed in [[L4E rule 1-3 (2014)|rules 1, 2 and 3]]
|-  
|-  
| Surgical - level 4
| L4
| 1.0
| 1
| biopsies - most internal organs
| detailed in [[L4E rule 1-3 (2014)|rules 1, 2 and 3]]
|-  
|-  
| Surgical - level 5
| L5
| 5.0
| 5
|-
| complex biopsies
| Surgical - level 6
| includes medical and transplant biopsies, explant organs
| 15.0
|-  
|-  
| L6
| 10
| radical resections for malignancy
| detailed in [[L4E rule 9 (2014)|rule 9]]
|-
|}
|}


Modifiers to the base scores (above) - based on Maung:<ref name=Can_J_Pathol_2010_2_8-19/>
====All other surgical pathology cases====
As per L4E definition (2014) adapted from CAP-ACP:<ref name=capacp2014/>
{| class="wikitable sortable"
{| class="wikitable sortable"
! L4E units
! Description
! Description
! L4E units
! Details
|-
|-
| Additional stains & IHC<br>>=4 for case
| L2/block
| +1.0
| non-radical and benign resections, non-biopsy/non-L6 cases
|-  
| 10 blocks = 10 x L2; 10 x L2 = 3.33 L4Es; details in [[L4E rule 4 (2014)|rule 4]]
| Immunofluorescence
|}
| +0.5
 
===Cytopathology===
As per L4E definition (2014) adapted from CAP-ACP:<ref name=capacp2014/>
{| class="wikitable sortable"
! Code
! L4E units
! Description
! Details
|-
|-
| [[Intraoperative consultation]]
| C1
| 3
| 1
| simple (exfoliative) cytology
| pap test, urine, sputum, fluids (peritoneal, pleural)
|-
|-
| Each additional<br> [[intraoperative consultation]]
| C2
| 2
| 2
| complex cytology
| FNAs, brushes, washes
|-
|}
|}
===Additional block/levels===
Deeper cuts and the submission of additional tissue are dealt with in [[L4E rule 6 (2014)|rule 6]].
===Special stains and IHC===
Special stains and immunostains are dealt with in [[L4E rule 7-8 (2014)|rule 7 and rule 8]].
===Adjustments for micro only and teaching===
The workload is adjusted if the gross is not done by the pathologist or teaching is done as part of the sign-out.
Cases where the gross is not done by the pathologist are discounted 5%. Cases that include teaching are given a 30% premium.


===Total workload===  
===Total workload===  
Recommended mean workload per pathologist adapted from Maung:<ref name=Can_J_Pathol_2010_2_8-19/>
Recommended workload per pathologist:<ref name=capacp2014/>
{| class="wikitable sortable"
{| class="wikitable sortable"
! Practise type
! Mean annual L4E units
! Annual L4E units <br>(mean & standard deviation)
! Lower bound ‡
|-
! Upper bound ‡
| Rural
| 5,589 (5,393-5,784)
|-
|-
| Independent
| 7560
| 6,316 (6,095-6,537)
| 7115
| 8089
|-
|-
| Specialized
| 7,043 (6,797-7,290)
|}
|}
‡ Defined by mean +/- 2 standard deviations.
If one presumes 210 working days, on the basis 6 weeks vacation + 2 week CME + 10 stat holidays, the daily mean workload is 36 L4E.


==See also==
==See also==
*[[Workload measurement]].
*[[Workload measurement]].
*[[Level 4 equivalent of 2010]].
*[[L4E rules of 2014]].
*[[L4E quizzes]].


==References==
==References==
Michael
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