CIPI Connections: Pathology Innovation in the Third Dimension

Dr. M. E. de Baca:
Welcome to CIPI Connections, the podcast of the College of American Pathologists Council on Informatics and Pathology Innovation. Here we connect you with the leaders and committees shaping the future of pathology. I'm Dr. M. E. de Baca, Chair of the College of American Pathologists Council on Informatics and Pathology Innovation, also known as CIPI. Hi, this is Dr. de Baca. Today, we have the great pleasure of introducing to the CIPI Connections community, Dr. Nicholas Reder. who will be joining the Council on Informatics and Pathology Innovation of the College of American Pathologists beginning in January. Let's just jump straight into this conversation. Hey, Nick.

Dr. Nicholas Reder:
Hi, Doc. Thanks so much for having me on. I'm really excited to share my story with you and join the CAP CIPI community.

Dr. M. E. de Baca:
Oh, we're really looking forward to having you. I don't think anybody else knows this, but we're both Seattle-based, and today I just want to thank you for getting up so early because it's, about as gray as it gets here. And there are torrential rains. And I don't know, I think whole communities are getting swept away by the water. But that's a tangent. Can you tell me just a little bit about who you are and what you do?

Dr. Nicholas Reder:
I'm Nick Reder. I am a pathologist, but I no longer practice. I actually run a startup called Alpenglow Biosciences, where we have developed a technology spun out of the University of Washington, where we can actually digitize whole pieces of tissue in 3D, similar to whole slide images, but actually with the entire block of tissue. And so we think this could be transformative for pathology. That's actually why I, you know, went into this company rather than continuing to practice and really excited to share the story of what excited me about this field. I was excited about digital pathology and then just kind of when order of magnitude higher, once I found out you could digitize tissue without slides.

Dr. M. E. de Baca:
I must admit, I've seen your enterprise and seen it in action. And when walking by a room that looked like, I don't know, NASA headquarters and seeing all these screens, there were things that You were explaining to me, oh, this is small intestine or this is retinal epithelium, and it was really interesting because I felt like I had walked into something that I already knew. It was instantly identifiable as something that I had spent years trying to create in 3D in my head, and there it was in 3D for me, so I could think about things besides the putting the Legos together. I could think about what had been built already. It was really super cool.

Dr. Nicholas Reder:
Yeah, I think you've locked on to exactly what drew me to this technology in this field is that we go from trying to put in all this work to reconstruct these structures in 3D in our heads to saying, oh, that's what I imagined, but that little piece is different. Maybe there's something really important.

Dr. M. E. de Baca:
The path that you've taken is, you know, you went to medical school and you went to pathology and you understood this 3D-ness and the necessity and you saw digital, etc. But how did you decide to launch a company such as Alpenglow? And, you know, what was there a specific aha moment when you said, like, this needs to exist and I'm going to be the one who builds it?

Dr. Nicholas Reder:
When I was in medical school, I was one of those rare students who actually loved medical school. It was... One of the best times of my life. I absolutely love learning about everything. And the reason I went into pathology is it seemed like we were building up this knowledge base. There are all these mysteries that we were unraveling. And the pathologist was always the one that actually had the answer of why something happens or how it happens. And I thought it was just such a great field to combine science and medicine and have this deep understanding of the body and physiology and pathology. So it was obvious for me once the first pathologist walked in the room to teach our class in the first year of medical school. Then when I got to pathology, I found while that was true, there were so many gray areas. And it was a much more challenging endeavor to go about a diagnosis than we had been described in school. So, you know. although we had the answers, sometimes the answers were a bit equivocal or just in the gray zone. And so at the same time, I learned about a set of technologies where you can actually image tissue directly, produce 3D images. And I was really drawn to the idea of, you know, I think pathologists are doing their best. It's, you know, a great field. What if we had better tools and can do even better. What if, you know... Instead of seeing only a small sliver of the picture, we saw the whole thing. Could we provide better care?

Dr. M. E. de Baca:
So you were really lucky that you were also at the University of Washington, where there's so many people doing amazing research and things. I agree with you completely about the idea that pathology is definitely the place where people who are intellectually curious and prodding and poking and trying to push the envelope need to be. Do you think that that's something that is fostered in medical school, that curiosity?

Dr. Nicholas Reder:
Yeah, you know, I think it's probably the exact opposite. But, you know, you really almost need to be a rule follower in medicine because we have everyone going rogue and creating their own criteria for prostate cancer or diagnosis. You know, we have to have guidelines. We have to have flow charts. We have to have rules. And so combining kind of being an innovator while operating within the necessary constraints of medicine, I think is the art of kind of pathology innovation is that you really have to respect the past and understand why things are the way they are, why you need to have guidelines, but then also figure out how can the field move forward. So yeah, it's a fascinating topic because we have to be both conservative and extremely progressive at the same time.

Dr. M. E. de Baca:
What you said just totally resonates with me. And I find it really interesting that so frequently when talking about innovation, the response is, oh, but we have to have these rules. And I always find it interesting that we think that those two things are actually opposite. I agree that innovation feels very liberal, if you will, and following the rules, very conservative. I wonder why it feels like we're throwing away the baby with the bathwater if we're finding better soap for the kid in the tub?

Dr. Nicholas Reder:
Yeah, I mean, I think CAP actually walks that line really well, where it's the governing body certainly enforces the rules. We know very well why we need rules. CAP inspections are essential to the practice, but there are also committees like CIPI that are looking at, you know, where do we need to innovate? Where's the field going in five to 10 years? And we don't want to practice medicine the same way we do today in 20 years from now. We don't practice the same way today that we did, you know, in the early 2000s. And so it's a delicate balance. But I think that when you have the right people involved to understand why the rules are the way they are, but also what are the opportunities for improvement, I think that's where you can start to have really thoughtful innovation. I think we all fear in pathology maybe more than any other field very bold new way of doing things that creates harm to patients, right? So that's, you know, what we're battling against on the innovation front is you want to innovate in the right ways.

Dr. M. E. de Baca:
I agree 100% with that. And then if you think about it, you know, Virgo came up with a whole new subspecialty that was transformational to practice and to medicine. And we are the legacy of that. I think the... Measured criteria that pathologists use is not something that a person trained in pathology is going to jettison with any sort of rapidity because they're innovating. I think the idea of most of the pathology innovators who I know is that we just want to do this better and with even greater insight so that the care that we are offering and the diagnostic acumen that we are affording the profession increases. This is a fun conversation. I think it offers me some brain food for how we continue to communicate about what innovation in pathology actually means and what perhaps even more importantly, it doesn't confer. Now I want to jump into one thing that you said, and it was like how we will be practicing pathology in five or 10 or 25 years. And how do you think we will be? I mean, you're trying to change the world. So what's your pathology world look like? And how do we fit into the practice of medicine? And where do we make the most benefit?

Dr. Nicholas Reder:
Yeah, yeah, I think it's a great question. We think of it frequently. And I think a lot of pathologists do, you know. The one way the field is described in medical school is being the doctor's doctor. And I think you both need to think of that direct patient care, what are the benefits to patients. But I think when you think about it that way, it explains the history of pathology and where we could go. The way I've had one of the earliest, you know, goals of pathology described to me as surgeons were doing these surgeries, especially in oncology, and they were essentially flying blind. And by doing a frozen section and informing, you know, is this cancer? Is it not? It really helped guide the surgery and helped out the surgeons while performing the surgery and ultimately the patients. And so by taking some of those principles and thinking about where do we see these opportunities or these shortcomings right now, where is either the patient struggling or where is the clinician struggling with newer treatments or newer paradigms where a pathologist could help? And so I think there are so many opportunities now, probably more than ever in helping out because the treatment paradigms have shifted so much. Immunotherapies, precision medicine, there are new treatments coming out almost every single day that are transforming practice. And yet, if we don't change in terms of our classification of disease, predictive tests, supplying more information to make more informed treatment plans, then we're really not living up to the potential of our field. And so I think that's where we and many others in the kind of digital pathology and innovative vanguard of pathology are thinking is where can we add value? And ultimately, I think if you focus on where is there a shortcoming in clinical care, as opposed to how do I make my day-to-day life better? That's where we really get excited at Alpenglow.

Dr. M. E. de Baca:
I think with the computational opportunity that we now have, which is only new. It does then open windows or doors to allow us to use all of these data and all of the information that we've been dealing with for years on a much wider scale. So that our impact on prognostication, prediction, risk assessment, determination of adequacy of therapeutic decisions, etc. has the opportunity at least of becoming much more integral in the patient care journey, if you will. But if you start doing that, then you become not the person who gives an answer like, oh, acute appendicitis, you become the person who's actually holding the baton for the symphony.

Dr. Nicholas Reder:
Yes, yes, exactly. Which is how I always imagine the pathologist. And I think, you know, the opportunity with some of these advances in computation is there are two schools of thought, I think one is much larger than the other. One is the large one, I think, is this could come and take our jobs. We're fearful, you know, what if we just get replaced and an AI algorithm produces the diagnosis? The other smaller school of thought is, well, look at how powerful these AI tools are. They give these new abilities that enhance clinical care beyond what we ever thought was possible. If the pathologist is the one orchestrating these tools, integrating them and really taking an even more hands-on approach in the clinical care paradigm, then maybe pathology will increase in importance and it'll be an even more essential part of medicine. So that personally is where I think the field is going, is that there's just so much information out there, so many potential applications of AI, and we really need medical experts to orchestrate this, as you said.

Dr. M. E. de Baca:
For our listening public, you can now understand why Dr. Nick Reder is going to be such a great member of CIPI and how CIPI is trying very hard to be the thought leaders in careful, measured pathology innovation. But having said careful and measured, we really do want to change the world.

Dr. Nicholas Reder:
Yeah, that's where CAP and CIPI come into play is that we want to have dreamers and imagine these great applications. But one thing we're good at, you know, at times too good at is saying, where could this go wrong? How do we regulate this so it's safe, not only effective, but safe. And I think that's where CAP just plays a crucial role in AI and pathology is thinking about. you know, how could this go wrong? Where have we seen this in the past with other technologies? And what kind of checklists, what kind of regulation did we put in place to make sure that we get all the benefits, but we don't have some of the doomsday scenarios that people describe that aren't quite realistic?

Dr. M. E. de Baca:
Well, you know, if you're boldly going where no man has ever gone before, or no person has ever gone before, you really want to know. If you go to the left or the right, are you going to hit a meteor or are you going to go into Mach 4 into some new world? Right. This has been a whole lot of fun. I hope that the people listening to CIPI Connections have had as much fun here as I have. Thanks a lot, Nick.

Dr. Nicholas Reder:
Thank you.

Dr. M. E. de Baca:
Thanks for joining us for insights, updates, and the people beyond the innovation. This has been CIPI Connections, where ideas meet action in pathology.