Time for a Reality Check
Ronald S. Weinstein · Archives of Pathology & Laboratory Medicine · 2008
I have been asked to talk about reality testing of educational aspects of new and emerging imaging technologies. Newer technologies, such as telepathology virtual slides (whole slide digital imaging), may have profound implications in many areas of education, including testing.12 These areas would include proficiency testing and might include new forms of service provider profiling. Some of these activities may take place in specially designed facilities that can accommodate multimedia presentations and state-of-the-art forms of interactive distance learning.3Yesterday, we touched on the topic of interobserver variability in surgical pathology diagnoses. This can be a significant issue in surgical pathology and is of interest to the education community. When I served as director of the central pathology laboratory of the National Cancer Institute–funded National Bladder Cancer Program in the 1980s, I observed that “experts” do not agree on some diagnoses. This applied to occasional surgical pathology cases that might ordinarily be regarded as “routine” as well as “difficult cases.” Even surgical pathology subspecialty experts can disagree on diagnoses, staging, and/or grading for some urinary bladder cancer cases. Interobserver variability can be an even larger challenge for urinary bladder cytopathology. These discrepancies may affect therapeutic decisions.Virtual slide telepathology has the potential to narrow the gaps between expert opinions by providing a way for immediate case-sharing and by providing a means for timely group discussions of diagnostic criteria for individual cases. Virtual slide telepathology may also be of great value for comparing the opinions of experts and establishing consensus diagnoses before therapy is instituted. Furthermore, and this is a more futuristic topic, virtual slide telepathology may provide insights into the inner workings of the minds of experts.At the University of Arizona, we are currently carrying out formal studies on how pathologists and medical students make decisions. We are using state-of-the-art assessment technologies that allow us to evaluate pathologists' performances in ways that are less subjective than methods we have used before. For example, Elizabeth A. Krupinski, PhD, a cognitive psychologist, and her group at the University of Arizona, including members of the Department of Pathology, are comparing the saccadic eye movements of medical students, residents, and pathology faculty members while they are examining histopathology sections of breast core biopsies displayed as DMetrix virtual slides. Thus far, Dr Krupinski, working with our faculty and trainees, has succeeded in documenting training-level–specific patterns of eye movements that may turn out to represent different levels of expertise (Figure 1). Such studies could be extended to the evaluation of the saccadic eye movements of subspecialty pathologists in the future.4 By documenting the virtual slide search strategies of expert pathologists as compared with trainees and novice pathologists, training procedures might be developed that could expedite the transformation of novices into experts over time. It is not inconceivable that eye movement profiling could become a pathologist assessment tool as part of proficiency profiling down the road (Figure 2).Digital images and virtual slide telepathology services are potentially transforming technologies in anatomic pathology. There are a number of relevant questions: Will digital imaging and telepathology be disruptive to the practice of anatomic pathology? Will changes in the medical school curriculum affect the profession of pathology? Today, many medical schools have abandoned their traditional second-year pathology courses. Could this affect the applicant pool for pathology residencies? Will changes in medical school curriculum have an impact on the practice of medicine by physicians in other fields?With respect to reality testing in education, digital imaging technologies, including virtual slides, have been shown to be effective in education. At the medical student level, some medical schools have replaced light microscopes and glass slides with virtual slides.Last year, the University of Arizona College of Medicine replaced its glass slide–based histopathology laboratories with virtual slide laboratories. In these virtual slide laboratories, a centrally placed faculty podium allows a faculty member to view each of the 10 pods of medical students' navigation through a virtual slide (Figure 3). It gives faculty control, from the central podium, of the virtual slides being viewed at each pod to point out and annotate areas of interest.Our students have used these virtual slide laboratories for more than a year and have given the facilities and our preclinical courses very good evaluations. Both the University of Arizona pathology faculty and their medical students have endorsed our virtual slide laboratories. We found that these laboratories also reduce our staffing requirements and let subspecialty pathologists interact directly with a larger number of medical students at individual laboratory sessions.An interesting outcome last year was that most of the second-year medical students chose to take their final practical examination using virtual slides instead of glass slides, although they had access to both types of slides during the year. We are very unlikely to go back to glass slides for teaching medical students in Arizona.There are a number of different environments in which virtual slides might be used for pathology education. For example, at our new University of Arizona College of Medicine Campus in Phoenix, we plan to experiment with the uses of telepathology virtual slides for education in a novel amphitheater environment (Figure 4). One scientific objective is to expand the field of view for histopathology slide viewing by students using virtual slides displayed on a large video cube wall. This could become an interesting area for medical education research.34 Construction of this somewhat unique education facility is nearing completion.3We have also implemented the use of virtual slides on our clinical services and this has added an extra dimension to our education programs. Currently, we use virtual slides for multi-institutional surgical pathology quality assurance conferences. Virtual slide telepathology is also used to obtain second opinion diagnoses from off-site faculty members. Virtual slides are used to document the pathology of patients prior to their enrollment in cancer treatment protocols.Based on the marked increase in interest in digital imaging, telepathology, and virtual slide technologies in recent years around the United States, let me make some predictions as part of this “reality check” exercise.Health care students at all levels could potentially have access to training from top professors in many subspecialties and not necessarily from their home institution. Broadband multimedia programming will become commonplace. With the widespread availability of virtual slides, 3-dimensional gross imaging of specimens, and even remote haptic palpation of specimens, the justification for individual institutions, such as smaller university medical centers, to have certain subspecialty pathologists on-site may decrease. There could be significant cost savings achieved by outsourcing pathology subspecialty cases to “virtual group practices” that ensure high-quality service coverage and rapid availability of expert second opinions.Payment for educational services may decrease in a competitive market. Branded education programs, offered by top-notch institutions, may have a competitive advantage over programs offered by smaller university programs. The international education market will be sensitive to the brand name recognition of higher prestige institutions. Subspecialty pathology faculty members at many university medical centers will need to find roles for themselves within educational consortiums, so that their services can be effectively cost-shared by multiple institutions. The questions are as follows: Who would organize such consortiums? What would be their form of governance? A related question is, will large reference laboratories begin to market educational programs to add value to their patient services? Initially, will this take the form of commercial laboratories recruiting “famous” pathologists away from university-based programs to compete with the high quality of services as advertised by university-based programs? Will pathology professional organizations begin to take on a larger role in undergraduate medical education? In resident education? These, and many other options, may be explored especially if virtual slide telepathology becomes readily available in the laboratory industry.I do not think there will be insurmountable technical barriers to the widespread implementation of virtual slide telepathology. There is little doubt that, sooner or later, digital imaging and virtual slide telepathology will become common procedures in the health care industry.Having made some predictions, and having considered briefly economic and technology implications, I would summarize my remarks by emphasizing the need for pathologists to increase their awareness of emerging technologies and alternative business models. Reference laboratories may be the 800-lb gorilla in the room for many hospital-based pathologists at this time. On the other hand, community-based pathologists may have certain advantages in the market place of the future. For example, expedited services and point-of-care testing may require proximities that are a challenge for out-of-area reference laboratories.5 Community-based pathologists may also be in the position to broker laboratory services and serve as the gateway for their institutions' patients to outside laboratories. Pathologists could benefit from being creative in engineering new paradigms for the delivery of laboratory services.Finally, I want to expand on my comments on expertise. There is a large literature on expertise and novice versus expert performance. What defines an expert? What defines a novice? Can we accelerate the training of a novice? Because expertise is probably related to experience in some way, might access to many study cases through virtual slide telepathology expand the pool of bona fide pathology subspecialty experts in the future? There are many other industries that look at these issues regarding training and expertise. Furthermore, there are training techniques out there that have not been used extensively in the health care industry but are potentially applicable to pathologist training. Virtual slide telepathology may turn out to be an enabling technology for a number of seemingly futuristic training strategies.