Anne Paxton
April 2024—With the technology now available, could and should remote diagnostic pathology, or at least a hybrid model, become more the norm in the future?
Timothy Craig Allen, MD, JD, and Casey P. Schukow, DO, of Corewell Health in Michigan, in an editorial published recently, say the time for one or the other or both has come (Schukow CP, et al. Arch Pathol Lab Med. Published online Dec. 22, 2023. doi:10.5858/arpa.2023-0385-ED).
Thanks to digital pathology and the freedom to practice remotely remaining intact post-pandemic, they write, “the time is now to address the logistics that will allow remote-practicing pathologists to move forward for the benefit of current and future patients.”
Pathologists are in short supply, and the priority, Dr. Allen tells CAP TODAY, is to “make sure we keep things moving to keep our patients taken care of and provide colleagues with the tools they need and the opportunities to work in a hybrid situation with the digital, AI, and computational pathology components that will make us better and faster.” Dr. Allen is chief of the pathology service line at Corewell Health East, Royal Oak, Mich., and chair of pathology at Oakland University William Beaumont School of Medicine, Rochester, Mich.
“Even if every medical student in the country decided to be a pathologist today, they wouldn’t sign out their first case for another five or six years,” he says. “So we need to make things economical and efficient, to get hard cases that take hours done more efficiently.”
Remote or hybrid pathology practice would also help solve the problem of costly hospital space. “When I go to leadership and say we need another four offices, that doesn’t resonate well,” Dr. Allen says.
“There was discussion of moving us farther away from the expensive hospital space that we inhabit now because they want that space for more focused patient care. But after exploring it, the administration found the cost was prohibitive, so we’re still here,” he says. “But I think if we were to say, ‘Okay, we’re going to more of a shared space’ and in fact we ended up recruiting more faculty, it’s not like we’d have to get another wing of the hospital to provide them office space. That will be very attractive to our senior leaders who are looking at space as a cost.”
Rather than treat remote versus in-office practice as an either-or question, Dr. Allen and Dr. Schukow, a pathology resident at Corewell Health William Beaumont University Hospital, advocate a both-and approach. With the variety of ways pathologists could combine remote and onsite spaces for practice and teaching, they say, such hybrid arrangements would be a win for all.
The preferences of Corewell’s pathologists suggest a favorable climate for a hybrid model. Of the 65 faulty members Dr. Allen leads at Beaumont—55 of them anatomic pathology related, plus a robust clinical pathology team—“a few might say, ‘I live close to work and I don’t want to do anything at home,’ while others declare, ‘I’d work from home all the time if I had the opportunity.’ But the vast majority of faculty are going to be hybrid,” he says.
In the Corewell network, the department of radiology hired its first fully remote radiologist recently, and Dr. Allen foresees the same happening in pathology. “Say I have a pathologist who likes being here, who is doing a great job, but their spouse has transferred for family reasons” to another location. “Instead of, ‘Okay, you’re no longer on faculty,’ they work remotely. Maybe not for administrative roles, but for teaching and signing out cases, we could see their smiling face every day and they’d still be a faculty member here at Corewell. That way, we can retain our greatest people even if they move away from us.”
Dr. Allen
Dr. Allen has made it his goal to start pushing for remote diagnostic options for Corewell and for the field. “Once something is substantial,” he says, “we need to be on board.” And with the high volume of cases at Corewell, “the economies of scale here would be much more robust than in a smaller place if we utilize these tools.”
Given the cold weather and snow in Michigan, Corewell pathologists shouldn’t find it difficult to leave their customary commutes behind, he says. “I’m going to get up, heat up the car, put on my coat, and drive slowly to work just to look at digital files I could look at at home? That doesn’t make sense. We need to free ourselves from these sorts of shackles because the tools allow us to, but we have to do it carefully.”
Corewell is roughly at the middle range of institutions in wanting to move forward on remote practice. “There are some places like Ohio State University where this is old hat, and there are others that can barely imagine a virtual conference. But mostly I think the pandemic has broken all of that loose.”
Ohio State University has an extensive digital pathology setup, and during the pandemic there was a lot of at-home work, says Jose Otero, MD, PhD, associate professor of pathology at Ohio State University College of Medicine.
But obstacles arose. “In the first two months, it was difficult to sign out from home because people found their internet speed was not fast enough,” Dr. Otero says. There was a shortage of internet provider techs, “so getting them to your door to put you on a higher bandwidth and speed was not automatic here in Ohio. So it took a while for people to come around.”
Other things couldn’t be changed. “For example, you have to do a frozen section or fine-needle aspiration, an autopsy, or bone marrows—those aren’t scanned. I would say about a third of the pathology workforce in our group continued going to the hospital when they were on service because they would need to be doing those where the technologist would be available.”
An additional problem was that digital telepathology scanners can be problematic. In Dr. Otero’s experience, about 10 percent to 15 percent of pathology frozen sections fail when they are remote owing to a connection problem. “And there’s not necessarily one cause.” On weekends, if he is on call, “I will usually ask the resident to go in and make sure everything’s running beforehand. But sometimes when things get busy the resident will forget. Then when you need it, there’s an update that has to be installed.”
“There is a technologist who will do the frozen and you could read it remotely, but during business hours you need to have a physical backup,” he continues. “So you can do frozen through telepathology. In fact I do a lot of it during business hours. But there has to be a person physically in the hospital because telepathology fails are daily occurrences.”
The lessons learned during the pandemic have been useful, he says. “It did force us to do digital work from home, and once people were able to increase their internet speeds and so on, things did work out for patient care.”
Less so for resident education, he says. “Let’s just say there’s a live scanner. That’s different from whole slide imaging. It’s not FDA approved, but for a preliminary diagnosis that live scanner might work really well. But the moment you put that scanner on a hospital IT system, there are constant problems with it.”
“For example, in one case there was nothing wrong with the scanner but there had been an IT update. And since it was my first time logging on remotely to that system after the update occurred, it took 20 minutes for the whole thing to reboot because of all the updates being installed.”
“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.