Stanley J. Robboy, MD

February 2012

Stanley J. Robboy, MD

The DigitalScope experience

In a series of debates that the Paris Academy of Medicine hosted in 1854, top scientists squared off over what some said was a dangerous innovation, perhaps even “something of the occult.”

The object of their concern was none other than the tool that is the core of our specialty: the microscope. In this debate, one side engaged in pro-innovation exhortation that drove a transformation. Their opponents were selling fear of the unknown, hardly a charismatic position. Innovation invariably inspires, and that was the battle to be won.

I believe we are now at another crossroad in microscopy. A single glass slide stained with hematoxylin and eosin contains an enormous amount of information that until recently was impossible to replicate in any other medium. In the 158 years since those Paris debates, we have tussled with image transmission without a satisfactory result. There was the carbon arc microscope—flame throwers that projected reasonably well but destroyed the slide by decolorizing (“burning”) small areas in the slide. (I lost many a key slide in that manner.) Then there were 35-mm Kodachrome slides (with rich, highly saturated colors whose brilliance musician Paul Simon memorialized in a song), and most recently, liquid crystal display. All had drawbacks. Finally, several years ago, whole- slide digital imaging made its appearance, yet it, too, has had major drawbacks. How were images of multigigabyte size to be sent through the worldwide Web in a manner that would be sufficiently smooth, efficient, and comfortable for the user?

I wonder what the 1854 technophobes would have said about DigitalScope, a new viewer that smoothly and pleasingly enables real-time sharing and manipulation of extremely high-resolution whole-slide images over the Internet. This robust new technology closely mirrors the experience of looking through a microscope. Images have a 3D feel. Cells can be examined in context, and the examiner can move easily to see neighboring fields. Contrast and brightness adjust with a mouse click. The zoom function is instantaneous. Is this Google Earth for slides?

As the Google Earth analogy suggests, DigitalScope is an experience. Seeing is believing, and I recommend a prompt visit to www.cap.org/DigitalScope. Visitors to the site can manipulate, zoom, and adjust samples just as they would when working under the microscope. Try it and let me know your opinion. Several CAP councils have begun to explore the possible educational and quality control uses for this technology. Your suggestions are welcome.

That DigitalScope became available just as tissue shortages have become more acute is probably no coincidence; more likely necessity was the mother of invention. George Fiedler, CAP vice president, Division of Proficiency Testing, notes that advances in preventing cancer and detecting it early have had the impact of limiting the availability of tissues for Surveys. We used to receive large excisional diagnostic biopsies with excess tissue; now with tiny needle biopsies there is no spare tissue for QA or PT purposes.

DigitalScope came to us via Proficiency Testing Service (PTS), a company that has worked closely with the CAP for more than 20 years to secure and distribute Surveys materials. Nick Serafy Jr., the president and CEO, and Eric Vanderslice, PhD, PTS technical director, have laboratory experience. They understand the challenges of locating scarce samples and shipping fragile materials.

PTS collaborated with Aptia Systems, a custom software development company in Houston, to create DigitalScope. Dr. Vanderslice, who has postgraduate training and professional experience in computer science and what he calls a recreational interest in game programming, saw advances in online imagery and manipulation as shape shifters in the service of Surveys. The technology was already out there for individual viewers looking at many slides, he says. What was needed for PT (and for education and quality control) was a viewer that would allow many users to view the same slide at once, without the pixilation-driven lags typically associated with transmission of large images.

The College made DigitalScope available to proficiency testing customers with unprecedented speed. We first learned about this advance in January 2011, and subscribers to the first offering, Virtual Peripheral Blood Smear (VPBS), received their first challenge eight months later. DigitalScope technology is now integral to 10 Surveys and will soon be added to many more. The educational possibilities could be game changing.

Serafy envisions this technology enabling the College to create a virtual biorepository of images qualified by CAP experts via consensus. Static reference manuals published years apart could be replaced by a continually updated collection of images vetted by international experts. The implications for quality of medical education and patient care are mind-boggling.

A word to fellow Kodachrome users: Yes, we mourn its passing. I have a personal gynecological pathology Kodachrome collection of more than 30,000 pictures. The good news is that a curated image collection will inevitably replace and amplify our static images. Someday soon, students will rely less on lectures to see examples than on organized registries interactively responsive in real time.

Last month, I clipped an article from the Jan. 7 New York Times titled “Virtual anatomy, ready for dissection.” The story describes a program in which medical students are learning anatomy and dissection via 3D glasses. A faculty member refers to it as a “living digital textbook.” So it seems.

We are riding the cusp.