Hybrid practice model beckons as solution

“Of course, some of that is technically preventable,” he says, “and there’s miscommunication and so on, but it’s so common that these updates and security patches have to occur for patients, pharmacy, safety, et cetera. And it often creates problems with some of these technologies.”

Dr. Otero says he dislikes having to sign out digitally with a resident in a different location. “I found that the strain of having Microsoft Teams going while I’m doing digital pathology makes the system intolerably slow, and I know there are ways to get that fixed, but nothing ever does get fixed. The solution will be just to get off the Teams or the Zoom call. Then it goes faster.”

The lack of face-to-face communication between the mentor and trainee can be a problem, he says. “And this is critical, because I might say something and then when I see the trainee’s reaction, some will understand what I’m saying,” but others don’t, “and I need that nonverbal cue to verify whether they understand.”

When Dr. Otero is on service for frozen sections, he has to be in the hospital physically. “When I’m off service, like today, I’m talking to you from home and I’m waiting on an IHC. I will sign out remotely from home today. So it does enable more moving around, but you still have to have a pathologist layer that needs to be reconstituted where you are. And you need an approved monitor and approved this and that, and an approved space to do it.”

Rules for approved sign-out spaces have become more liberal, however. “I can result a case from my home—I just have to say that I resulted from home or whatever location.” OSU recently started checking compliance through self-monitoring. “So, did we have a test for the digital monitor? Did we use the right kind of bandwidth? We check boxes to confirm.”

Dr. Otero has no concern about remote pathology work in the short term, but longer term he sees risks to going 100 percent remote. “There’s continuing medical education and there are conferences, but what is probably even more valuable are the spontaneous interactions you have with your colleagues who pose questions to you.”

He finds his own version of hybrid remote to be reasonable. “When I’m on service, I’m getting new cases, I’m in the hospital, I’m there frequently. And then on the day I’m off, where I mop up the case from home—that kind of hybrid is fine. But if you’re saying pathologist x is on biopsies today and they always do those every day from their home, I don’t know how good an idea that is.”

“That was more likely to occur during the pandemic than now,” he adds.

For now, Dr. Allen’s pathology department is still building its tools and recruiting more staff.

“My goal is to just get back to a steady state of sorts before I drop this bombshell about hybrid practice on people. But we’re already starting to talk about it, and the informal response I’m getting has been generally supportive.” The computational pathology that goes with digital will help make remote practice attractive, he adds. “It’s not just reading the slide remotely. It’s signing out your case. It’s helping you classify and clarify tasks. Those are going to be big winners.”

The home equipment required for remote practice is reasonable, he adds. “You basically have to have a HIPAA-compliant place, you have to have the tools that FDA blesses, and it’s important to make sure it’s ergonomically appropriate with the right bells and whistles.”

In the hospital, configurations like portable cubicle walls can provide an ad hoc ability to reconfigure to meet space needs, he says. “When people think of portable walls, they think of a secretarial pool. But we’re talking about walls that go from floor to ceiling. The walls may not be entirely soundproof but they’re soundproof enough so that we can get our work done, and you can move them around. You have the ability to create a large room, if needed, and it’s cheaper than bricks and mortar. I think, more and more, this is the way people are going to go.”

As far as teaching, “we have to do the education piece right,” he says. “I’m not sure we were as efficient in education during the pandemic as we should have been. We need to fine-tune that and make sure this hybrid experience is superior, not just as good as.”

At the University of Mississippi, where Dr. Allen was working during the pandemic, “we started teaching from home,” he says, with some faculty coming in one day, others on another day. “It worked. And since then we have become a more face-to-face world, which we value. But we should not forget that some remote teaching, not through email but with phone calls and virtual meetings, can have greater value than having everything face to face. And that’s a bitter pill for some people to swallow.”

Digital pathology makes it possible to think about practice and education a little differently, says coauthor and resident Dr. Schukow. For many people who thrived in the pandemic environment, “going back to 100 percent in-person for everything is not the best way forward.”

During the pandemic, for example, he and other residents liked having the YouTube videos by Geisinger Medical Laboratories pathologist Jerad Gardner, MD, to use for interactive case conferences or journal clubs. “In his sessions, he’s driving the digital screen and showing high-power and low-power views, and I feel like I’m sitting there with him at the microscope even though I’m at home,” Dr. Schukow says. “We want to go back to the way things were then.”

“Digital pathology and these new platforms offer us a flexible way of doing things differently without sacrificing patient care or the ability to learn.”

Corewell is implementing digital pathology now. “That will improve productivity, improve patient care, and quite possibly improve the practice lives of our pathologists and trainees moving forward,” Dr. Schukow says. “We have the slide scanners and the validation study IRB protocol submitted. I don’t think we’ll have a complete digital practice; it’s going to be a gradual, stepwise process to get there. But we have a blueprint in mind, and in Ohio State University, where they’ve already made a full transition to digital, we have an institutional role model.”

Predicting pathology’s future can be tricky, Dr. Allen says.

“Things are moving at the speed of light. And we have to get ourselves out of the idea that it will take 10 years to do this. This is an evolution where we start slowly and quietly and it’s not going to be thrown upon people in a moment. It’s going to be discussed and made part of the routine. You’re hoping to acclimate people and change the culture before you can flip the switch for it.” His aim is to find a middle ground in the quantity of time away and onsite.

He predicts it won’t be long before people will look back and think it odd that someone sat at a desk looking through the microscope when they themselves have a screen to do it in their office or home office.

“We’ll get used to it, it’ll be the new thing, and we’ll say, ‘Haven’t we always done it this way?’” Dr. Allen says. “But we also recognize a very deep threat of losing our connectivity, our collaborative mindset. It will take careful design so we don’t run the serious risk of negative results like dissociation from colleagues.”

Anne Paxton is a writer and attorney in Seattle.