Pathologists' Roundtable - What Residents Need to Know about Digital Pathology

• Digital Pathology Topic Center
• Residents Resources

Julie McDowell:

In this CAPcast roundtable leading pathologists provide a primer on digital pathology and discuss what pathology residents need to know about the burgeoning field of digital pathology. CAP digital content committee members, doctors Nicole Riddle and Ziad El-Zaatari are facilitating the discussion with Dr. Eric Glassy and Kamran Mirza, both of whom have an interest and expertise in digital pathology.

Dr. Nicole Riddle:

Excellent. Thank you. Welcome, everyone. Before we get started, let's do a brief round of introductions. I'll go ahead and start with myself. My name is Nicole Riddle. I am a practicing general pathologist in Tampa, Florida.

Dr. Ziad El-Zaatari:

Hi, I am Ziad El-Zaatari. I am also a practicing pathologist in Houston, Texas. And I do mostly surgical pathology and GU and renal pathology.

Dr. Eric Glassy:

You're too polite. I'll just jump in. My name is Eric Glassy. I am a community pathologist, 40 person group that is predominantly located in Southern California.

Dr. Kamran Mirza:

Hi, everyone. My name is Kamran Mirza and I'm an associate professor of Pathology and Laboratory of Medicine at Loyola University Chicago's Stritch School of Medicine. Here I serve as the Vice Chair of Education and Hematopathology Fellowship Director in the Department of Pathology. I'm also the co-founder of PathElective.com.

Dr. Nicole Riddle:

Excellent. Thank you, gentlemen, very much for being here with us today. We very much appreciate it. Let's go ahead and start our conversation maybe with some sort of background for digital pathology. In your words, maybe more for you, Dr. Glassy, where digital path started and where, as a whole, digital pathology is now. And maybe touch on the difference between telepath, digital path and then AI.

Dr. Eric Glassy:

Do you have an hour?

Dr. Nicole Riddle:

A brief synopsis.

Dr. Eric Glassy:

No, very brief. Okay.

Dr. Nicole Riddle:

Anyone who hasn't seen Dr. Glassy's hour long talk on this is missing out. It's actually very good. I'm asking a lot of them to put it into a brief synopsis.

Dr. Eric Glassy:

Thank you for that. Just say the history of digital path goes back at least 100 years. And that's when microscope images were captured onto photographic plates. And about 50 years after that we had telepathology, which allowed images to be shared at remote sites.

And then things heated up about 10 to 15 years ago when pathology began to undergo what I would call a true digital transformation. We moved away from analog glass slides to a more electronic environment. Today, digital pathology predominantly means whole side imaging, which is turning a glass slide into a digital image that can be scanned, panned, zoomed, manipulated, much like a glass slide on a microscope. But there's a lot more that can be done. We'll talk about that later with that whole site image. But that's basically a thumbnail background.

Telepathology itself is sharing images remotely from several different sites. But with whole site images you can do a lot more like image analysis and artificial intelligence and machine learning and things like that, so much more in terms of having the image completely digitized.

Dr. Nicole Riddle:

Great. Thank you. Dr. El-Zaatari. I believe you have the next question.

Dr. Ziad El-Zaatari:

Yeah, yeah. Thank you, Dr. Glassy. My question is, we all know that digital pathology is coming up in more and more ways in our daily lives. What do you think are the current ways or what do you know are the current ways that digital pathology is being used in our practices?

Dr. Eric Glassy:

Kamran, do you want to jump that one?

Dr. Kamran Mirza:

Sure. Sure. Absolutely. Dr. Glassy is saying, this isn't new, but I think that the way people think about digital pathology is different. And I think that right now it's variable across institutions. However, there is some mechanism, I would say, of either acquisition of data or management of pathology information or sharing or interpretation of that information, which basically is the definition of digital pathology happening at various kind of levels in different institutions.

I would say maybe we would think about it threefold. Right now perhaps what's happening is that we're using it in limited situations in most institutions for diagnosis, but definitely for education. And I think that people are now jumping on this bandwagon of the flexibility that it allows, the reach, the lack of the geographic restrictions that are associated with digital pathology and diagnosis. And for academic institutions or any educational institution I would say that digital pathologies is at the heart of pathology education in any medical school right now.

Dr. Eric Glassy:

Good.

Dr. Kamran Mirza:

I think it's very variable though. Dr. Glassy, I'm sure that we know of institutions that are implementing it in much more detail as well.

Dr. Eric Glassy:

Right. There's certainly, at least when I started out virtual IHC. That was the reason we bought a scanner was we had a large reference lab. I wanted to get the images out to our clients as quickly as possible. Those came off the IHC stainer about two in the morning, and we'd scan the slides. And then they'd be available and out in Los Angeles.

It could take, with commuter traffic, a couple hours to get slides to our more distance clients. And having the availability of the virtual image would allow pathologists to sign the case out that morning. We also, in our group at least use it for tumor board extensively and consultations. It also has a very valuable quality assurance part of it. For me personally, I do a lot of image analysis. Breast mismatch repair gene and the like using image analysis algorithms is predominantly how I spend much of my day.

Dr. Kamran Mirza:

Yeah. I mean, a couple of years ago when I was a resident helping teach medical students, we had hundreds of microscopes lined along the walls because they weren't being used anymore. And maybe 10 years ago, the institution of digital pathology imagery for medical education was a novel thing. But now I think everyone's selling their microscopes. Those microscopes for education is a thing of the past I think. It really has moved into the digital space.

Dr. Nicole Riddle:

The American Board of Pathology is selling their microscopes.

Dr. Kamran Mirza:

I bought one.

Dr. Nicole Riddle:

I bought one too. I bought one too. Yeah. If they're digital, and so now since they're digital, they can be done from anywhere theoretically. Excellent. And then I know you guys are in slightly different practice settings, which I think is good for this next question. What are, in your estimations or from your perspectives, the employer expectations related to digital path? For listeners who might be on the job hunt right now, or I don't know, maybe early residents and want to make sure that they are getting the education that they need to be viable candidates, what do you feel would be good for an applicant to have looking for a job?

Dr. Eric Glassy:

Well, I'll start off. I'm in a community practice setting, as I said, so private practice. We expect new hires to have obviously solid surgical pathology background with the additional knowledge of clinical lab to be able to take call. Often that relies on some ability to handle blood bank questions. We want them to have good communication skills, but we expect new hires to be 20% pathologists.

They need to be the best and the brightest. And that means they should know something, at least a little bit about informatics and of course digital pathology. They don't need to be computer scientists or statisticians, but they need to have at least a passing understanding of new technology. Many of the folks that we've interviewed have strong background in molecular testing or IHC stains.

But to me, in addition, newly minted pathologists should have an understanding of how to manage data about computer technology, data sets and other digital tools. To me, these are becoming core competencies required of every pathologist in training. And therefore those competencies would carry over to us old guys in our practice who rely on the younger folks to tell us what the heck we should be buying or how we should implement these new 21st century digital technologies.

Dr. Kamran Mirza:

But age is nothing but a number, Dr. Glassy. Because I would say that everyone younger than you looks up to you to teach us about digital pathology.

Dr. Nicole Riddle:

I was about to say the same thing.

Dr. Eric Glassy:

No.

Dr. Nicole Riddle:

I think you know the most when it comes to informatics.

Dr. Kamran Mirza:

Right. Exactly. I mean and like Dr. Glassy was saying, I think that the biggest thing for someone in the job market would be flexibility. I think that an employer, if they're faced with a flexible individual who may not be an expert in digital pathology or informatics, et cetera, but has the willingness to perhaps learn whatever the acquisition system is or whatever the workflow of that institution they're applying for is, having your head in the sand about the fact that things are digital or that AI is here or is becoming more and more active, used is not a good look I think for a person who's in the job market. I would say being open to digital experiences within whatever your diagnostic or educational roles would be is probably a good first step.

Dr. Nicole Riddle:

And I just have to say as somebody who is in a very large hospital who is about to undertake bringing in beaker and trying to bring in some whole slide imaging, et cetera, that yes, definitely having some informatics background and digital path background and AI, because they're asking me about it is definitely helpful because you're the one as the pathologist people will go to. And we want to be helpful and we want to show our use and our values.

Dr. Kamran Mirza:

Great.

Dr. Ziad El-Zaatari:

Yeah. I have the next question over this. Obviously, now we're in the COVID pandemic. Unfortunately it's still going on. And how do you think COVID has impacted digital pathology training and teaching?

Dr. Kamran Mirza:

I'll take a stab at that. I think that we were prepared I think. COVID-19 overnight, the inability to have in-person teaching, which is the cornerstone of pathology education. We sit at the microscope with an individual one-on-one. But all this while in the last decade or so, we had been developing mechanisms to do digital pathology education. And any change in our pedagogy requires lots of stakeholder meetings and looking at this and that.

But COVID-19 really didn't allow us that chance. There was no time. Overnight we had to consider how education would continue. And in a way, pathologists were actually prepared. Whether they liked it or not, they were prepared to go digital because we had already started, we had initiated this concept of being able to learn or teach in the digital space.

I think that COVID-19 impacted digital pathology training and teaching in a way that it actually pushed it to a front and center. Because it became the only way for quite a while there that individuals were being taught. It also allowed for the emergence of several new collaborative educational platforms, maybe even newer pedagogical technologies, all of which were possible because of the foundation of digital pathology that was already there.

Dr. Eric Glassy:

From my side of things, I can't think of anything that COVID hasn't affected, no matter whether you're an academic or community setting. The pandemic did expose weaknesses though in implementing digital pathology. An enlightened institution, but not every institution had access to digital pathology. Or if they did have a scanner, it was sitting somewhere only for research and needed to be dusted off and get ready for the chance to sign out cases remotely.

Residents and fellows may not have been exposed widely to the technology in every instance. And now they had a chance to be more interactive and review their cases online. And teachers actually had to become better at teaching. It's sometimes easier, and often is easier to teach live. One-on-one, you're around the scope and multi-headed scope. But when you have to do everything remotely, that changes the paradigm quite a bit. That changes how you interact with residents and fellows over how cases are managed and discussed.

And I know in some institutions that departments hired experts to teach the faculty how to teach remotely. And so, it's not a skill we're all born with, but we certainly learned quickly, as Dr. Mirza said. We were forced to scramble and get things implemented quickly. And I think by and large, we were successful.

Dr. Nicole Riddle:

I agree. And Dr. Mirza, do you mind expounding maybe a little bit about what some of the educational offerings are that are out there?

Dr. Kamran Mirza:

Absolutely. Absolutely. There's naturally a little bit of a bias here because I'm familiar with some of them and I'll talk about those more than other ones that I might not be familiar with. But for example, there are websites now that allow for hosting pathology slides and sharing very freely.

We have PathPresenter. If anybody hasn't seen it, please check it out. You know PathPresenter. There's KiKo, the knowledge platform that linked with social media, many of our pathologists are on. There are databases, institutions, many institutions have histology databases, and actually unique case databases, many across the United States. And there are lists that have been developed for where those educational digital pathology sites can be found.

And so, I think that starting from there, institutions have expanded on their digital pathology offerings. And then naturally, there's been a robust increase in social media-based teaching, for example, which obviously is again based in digital pathology. And I had mentioned that I co-founded PathElective.com. This is a free website. We don't earn any money or charge you ever for it, but it allows for a modular distribution of pathology lessons across anatomic and clinical pathology.

And the reason I think it's relevant in the COVID-19 and the digital pathology question is because it literally was developed because of COVID-19. It was developed at a time when in-person electives had gone away, and we decided that we needed a mechanism to make sure that medical students are exposed to pathology in as good a way as possible without having them rotate in person.

And so, while I hope that it does not become the sole way for medical students to experience pathology, but in the post-pandemic world or the hybrid world that we're looking at, I'm hoping that technologies or collaborative platforms such as PathElective, they can continue to supplement our medical students' pathology education in a way that we didn't have before.

Dr. Eric Glassy:

In addition, I'll just say that pathology is uniquely gifted because we are such a visual specialty. If you think about how to teach, having a whole site image and move around and zoom in and out and interact with that image, I mean, that's something that we're used to. And it was easy to transform that experience under a microscope to the screen.

Other specialties, much more challenging. They had to get someone holding up a camera and there was movement around and much more basically PowerPoint where a whole bunch of bullets show up that you have to review and stuff, and occasional images. I think it's really good that pathology was uniquely able to adapt and quickly bring in these new technologies to really not miss out a beat at all in terms of getting our medical students and residents up and running.

Dr. Nicole Riddle:

I think you're exactly right, Dr. Glassy, I always said that pathology, radiology as well, same reason why social media lends itself so nicely to a little vignette of pictures and a snippet about it. It's the exact same reason why we could go to virtual so easily because through the monitor we could show the same thing and show people exactly what we were looking at.

And thank you, Dr. Mirza for expounding on some of those educational opportunities. And you're right, there are numerous others. I could list several different people that did it, and I'm sure I'd miss some. To anybody who's listening, I just want you to know that they're appreciated and thank you for them. And of course, it cannot go without saying that, of course, CAP on a dime started making their virtual lecture series, which was really good and amazing. And I'm glad that we had the opportunity to record them and watch them and that they're still available for people. Because that was amazing how they got that going very quickly after everything shut down.

Real quick, Dr. Glassy, we were talking about how, of course, digital path is expounded because of COVID or et cetera. But how about talking about signing out from home and how the CLIA waiver that is currently still in process affects that? And if you're willing, expounding on your thoughts on if that will stay waived or someday be reinforced again.

Dr. Eric Glassy:

Well, as you know, CMS put a waiver on the requirement to have a CLIA license at a remote site that allowed pathologists to more easily sign out their cases remotely, either digitally or with glass. In my group, we have dermatopathologist and GI docs and stuff. And many of those, we just shipped the glass, couriered the glass over to them in the morning. Others were more comfortable reading out cases digitally. It was a mix.

It's COVID has called on a number of skill sets that we need. One is how you validate and train people at validate the scanned images so they can be read out appropriately, remotely. There's training associated with that. We have two systems that have been FDA approved for primary diagnosis, but you don't need that FDA approval. You just go through your own set of validations to.. And CAP has published validation protocols in their guideline series. And so, there's a stepwise approach that you can do to implement digital pathology in a remote setting.

But in addition, besides learning these new terms like VPNs and all that, HIPAA compliance needs to be taken into account. If you're signing out on your kitchen table, there's patient information there. And it could just be the name of the patient on a glass slide. And all the paperwork is really electronic on the monitor. But someone can walk in and say, "Oh, you're looking at Mrs. Jones's slide. I see her name on the side." And that's completely inappropriate.

Pathologists that are doing these kinds of cases remotely need to be able to be completely HIPAA-compliant. You should theoretically have a secluded site that's quiet, that's away from kids or dogs or cat, whatever, so that you can sign out these cases in a very secure fashion, keeping in mind that these patients should have their confidentiality maintained.

And that confidentiality applies to glass as well. A courier that brings in a stack of slides shouldn't leave them, or you shouldn't leave them on a stack in the house if that's where you're signing out. Other people can just be curious and wonder what's going on. And that's not appropriate either, as I said.

These are things that are common sense, but we take them for granted when you're in a hospital. You've got an office, you've got a door, you've got people that are used to security and patients and confidentiality. And that's all built into the hospital structure. That's completely different when you're at home and don't have those additional safeguards for patient information.

Dr. Nicole Riddle:

Thank you, Dr. Glassy. And yeah, those are all the things we're hoping you would say, and I appreciate it because I think a lot of people don't understand all the nuances to trying to sign out from home and what all the rules and regulations are. Thank you, Dr. Glassy and Dr. Mirza, for the discussion. Before we leave, either Dr. El-Zaatari or Dr. Mirza, Dr. Glassy, do you have any last questions or final thoughts that you wanted to share with the group?

Dr. Kamran Mirza:

Yeah. I think that many people, especially those in the pipeline thinking about or maybe not thinking about pathology as a career, always wonder about digital pathology and artificial intelligence and whether that is the future and whether pathologists will not have a job. And I want to tell everybody that our reality as pathologists is that we have always been AI embracing. Clinical pathology has had artificial intelligence for years. And we have been digital modality embracing and using physicians for decades now who have continually incorporated what I would say are novel technologies in our clinical practice.

And I think that that is something that we aren't really well known for. We're generalized to be completely different individuals. But the thing with machine learning or digital pathology is that you still need a specialist. Even if it's machine learning, you still need an expert to teach the machine what to do.

Dr. Kamran Mirza:

And so the future of pathology remains strong and it remains bright, and AI isn't taking that away from us. There will be some adjustments I'm sure as AI becomes more and more incorporated, but the digital revolution is here. And I would say that we should embrace how forward-thinking we've always been and make that the norm when it comes to people talking about us.

Dr. Eric Glassy:

Agree. I'll just make a couple additional comments. Perhaps maybe a warning about remote sign-out. Pathologists are known as more introverted than our other clinical colleagues or many of us are. And I like the saying, when you are remote, don't be remote. Be very willing to call or even Zoom with a clinical colleague about results. And those opportunities to interact remotely are really important to maintain that front and center importance of pathology. That would be my caveat and suggestion to pathologists that are doing cases remotely.

The other thing I'd say is I can't think of a better time to be a pathology resident. We've got all these whole new fields opening up with personalized medicine or molecular testing, genomics, and now digital pathology. And as Dr. Mirza mentioned, AI machine learning. These are major disruptions in pathology and they're crucial to patient care. These are great tools and don't be afraid to embrace them.

Digital pathology is now being increasingly viewed as an enabling technology. We need to use it wisely. We need to adopt before we have to adapt. And digital pathology allows you to be more inventive and more interesting and more compelling. And it's just an exciting time I think to be a student, a resident, a fellow, all those wonderful opportunities to learn and then share that learning with others.

Dr. Ziad El-Zaatari:

Thank you. Thank you very much, everyone. I just wanted to say a final thought. The theme here has been adapting and being ready for new things. And digital pathology is definitely I think going to become more prevalent in our daily practice. I'm excited to see what the future holds and I'm optimistic. And I could tell from Dr. Glassy and Dr. Mirza that I think you definitely feel the same way. Yeah, thank you very much.

Dr. Eric Glassy:

When you're with Dr. Mirza, you cannot help but be excited. I mean, this guy is, he's just terrific. He's a great educator and innovator and with PathElective and a visionary. And then being willing, just such a very generous person with his time. I think this is...

Ziad El-Zaatari:

I voted that we take an out from this. Look who's talking, Dr. Glassy. You-

Dr. Eric Glassy:

No, I think...

Dr. Nicole Riddle:

I was about to say I think most people would say that about both of y'all. Quite literally that's why we thought-

Dr. Kamran Mirza:

I know that and nobody can see me, but I'm blushing here, Dr. Glassy. That is too kind. But we...

Dr. Eric Glassy:

I'm successful then.

Dr. Kamran Mirza:

Yeah.

Dr. Eric Glassy:

Very good. But I truly mean it. It's just terrific. You've done so much for the profession. And CAP and thank you and all the other organizations that you're so closely involved with. Thank you as well for your leadership in this. And medical students everywhere, I'm sure. Very good.

Julie McDowell:

Thanks to everyone for this discussion. For more on digital pathology, please visit cap.org and search for digital pathology to locate the digital pathology topic center. And if you are a pathology resident, the CAP has numerous resources to support you during your training. Just visit cap.org and visit the residents section under the member resources tab.

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