Hybrid practice model beckons as solution

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 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.”