Level 4 equivalent of 2018

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Level 4 equivalent, abbreviated L4E, is a workload measurement system endorsed by the Canadian Association of pathologists.[1]

This article covers the 2018 revision of L4E. The original system is covered in the article Level 4 equivalent of 2010. The 2014 version is covered in Level 4 equivalent of 2014.


It is comprehensive with regard to academic practice and community practice.[2]


The development is described in a paper by Maung published in 2010.[3] The system was revised in 2014 and 2018.

L4E of 2018

One L4E unit is considered to be roughly equivalent to 10 minutes.

Most surgical pathology

As per L4E definition (2018) adapted from CAP-ACP:[4]

Code L4E units Description Details
L1 0.125 gross only specimens itemized in the "specimen list and codes"
L2 0.25 confirmation of normal must include histology
L3 0.5 small/simple biopsies includes most skin, cysts, GI tract specimens, small benign specimens - detailed in rules 1, 2 and 3
L4 1 biopsies - most internal organs detailed in rules 1, 2 and 3
L5 5 complex biopsies includes medical and transplant biopsies, explant organs
L6 10 radical resections for malignancy detailed in rule 9

All other surgical pathology cases

As per L4E definition (2018) adapted from CAP-ACP:[4]

L4E units Description Details
L2/block non-radical and benign resections, non-biopsy/non-L6 cases 12 blocks = 12 x L2; 10 x L2 = 3 L4Es; details in rule 4


As per L4E definition (2018) adapted from CAP-ACP:[4]

Code L4E units Description Details
C1 1 all cytology, except fine needle aspirations (FNAs) pap test, urine, sputum, fluids (peritoneal, pleural)
C2 2 fine needle aspirations (FNAs)

Additional block/levels

Deeper cuts and the submission of additional tissue are dealt with in rule 6.

Special stains and IHC

Special stains and immunostains are dealt with in 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

Recommended workload per pathologist:[4]

Mean annual L4E units Lower bound ‡ Upper bound ‡
7560 7115 8089

‡ 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


  1. Maung, R. (2010). "Canadian Association of Pathologists guidelines for measurement of workload". Canadian Journal of Pathology 2 (1): 8-19.
  2. URL: https://www.cap-acp.org/wkload.php. Accessed on: 19 May 2019.
  3. Maung, RT. (Jan 2005). "What is the best indicator to determine anatomic pathology workload? Canadian experience.". Am J Clin Pathol 123 (1): 45-55. PMID 15762279.
  4. 4.0 4.1 4.2 4.3 Workload and Workforce Committee of the CAP-ACP. Workload Measurement Guidelines. Canadian Association of Pathologists (CAP-ACP). 2018. URL: https://www.cap-acp.org/cmsUploads/CAP/File/CAP-ACP_Workload_Model_2018_Final_2020180907(1).pdf. Accessed on: 19 May 2019.