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Digital Pathology: Embracing a New Gestalt

BY Richard Friedberg. July 12, 2016

Dr. Richard Friedberg’s Keynote Address at Inspirata’s Workshop at APC 2016 – Digital Pathology: Embracing a New Gestalt

Dr. Richard Friedberg, President of CAP; Chair, Department of Pathology Baystate Health; Medical Director Baystate Reference Laboratories; Professor and Deputy Chairman Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, presented the keynote address during Inspirata’s workshop at APC 2016.

Click here to view transcript

My talk is going to be a little philosophical. I want to get you guys thinking about a few things. So our youngest daughter Jenna just completed a semester abroad in Russia. That’s her picture right there. We were able to join her for a week this past Spring and one of our sons was able to join us for a few days as well. And Jenna kept a travel blog on Tumbler … her name there was Jenna Karenina. And reading through her blog, it brought back way the way it feels when everything is all at once foreign yet familiar. Russia has a very rich culture; there’s a lot to take in. One day like this, we were in St. Petersburg and we were just strolling through Palace Square, an area which a century or so ago a few revolutions started, and our path crossed with a local family who had kids about the same age. And we had that sort of conversation that takes place when you don’t natively speak the same language but you know you have a lot in common. And this family, they had a son. And the son was about to depart Russia for study abroad in the U.S. And the family was a little worried about his safety. I gave the young man my card and encouraged him to call us anytime. It was just an unremarkable conversation … nothing special about the conversation for the adults, because parents often have a shared, common cultural ground. But it really was somewhat awkward for the kids. But not so awkward that Jenna wouldn’t blog about it later. “Dads,” my loving daughter wrote later on, “can be embarrassing in any language.”

So we wanted our children, our kids, to travel so they’d comfortable with other cultures; we’d hope the experience would engender and support an open mind and perhaps an open heart. And they would see for themselves that foreign, yet familiar, can reside comfortably side by side. And sometimes it’s necessary to embrace a new gestalt. A perspective that so tightly integrates distinct components that the functional whole is greater than the sum of the parts.

So why did I start with this story?

I wanted to start with the story about foreign yet familiar because digital pathology is going to more than a technical shift. It’s going to be foreign yet familiar. There are cultural and educational pieces that pathologists really need to appreciate. So speaking literally, digital pathology is going to change the way we use our brains. It’s going to shift the visual field that’s employed to process what we see. In anatomic pathology, we’re going to have to learn to diagnose a bit differently. This won’t feel unnatural to new and practice pathologists or those in training who have grown up with non-stop images on their cell phones, but let’s be kind of gentle for ourselves and our colleagues who are going to be reluctant to make the decision. Eventually, digital pathology will be more efficient and we’re going to view many more images yet it’s going to be more quickly. We’re going to work with much more information, yet greater flexibility. So what’s not to like? Well many people are going to have a deep-seeded hesitation that probably they won’t be able to put into words. And, if you think about it, in pathology, we were all trained to focus on a few static slides. But it may actually be more natural and efficient to view many sequential images in rapid succession. And digital pathology will subtly change the way we diagnose and, for some, there’s going to be this initial unease.

There will be some who are uncomfortable with that technology, but the reason they reason they may be uncomfortable is that they may be subconsciously registering signs that different paths of their brain/different parts of their brain are being called upon. And they’re correct. If you think about it, when we were trained in anatomic pathology, we were trained to have the microscopic view fill your entire view. Everything you saw was the slide image. And we learned to scan the landscape for what just didn’t look right. Yet with Whole Slide Imaging, we’re going to sit back and you’re going to use your central foveal vision to process the image. At first, it’s going to feel a little different for many. Not wrong; but strange. Foreign; yet familiar. And if someone resists the transition, talk to them about the visual field shift. Explain that it’s natural and temporary and, again, keep an open mind … this too shall pass.

Today digital images are well accepted in medical education. The vast majority of medical students rarely, if ever, see a microscope. We have actually had to add Microscope 101 training to incoming residents because many of them are not seeing microscopes during their training … not much at all. Nevertheless, some traditionalists remain uneasy about teaching histology via digital imaging. And there are always going to be some persistent questions about its use in medical licensure testing, but, regardless of how you feel about it, board exams routinely use digital imaging today. And there’s no question that CAP’s digital imaging application, Digital Scope, has enhanced proficiency testing in education by enabling online viewing and easy sharing of clear, accurate whole slide digital images in context. So I think the cultural and historical barriers are equally understandable but readily resolved. And there you can see some digital images in the training environment.

We are the specialty that laid the foundation for all of medicine. Our heroes—from Galen and Virchow through Coons and Köhler—worked alone for many years and with great patience.

And now, here we are in an era that soon may be thought of as akin to the transition from silent black and white movies to talkies with color! Our work will be faster and easier. And, no, that does does not mean the future work is going to be “pathology light”—it’s going to be “pathology to the max”! This transition will drive a fundamental shift in our gestalt, and enable an equally profound evolution in how we acquire and share information. Those who were not in a position to witness firsthand the move from analog film to digital images in radiology may not be prepared for exactly how much things are going to change. But it’s all good change that will greatly benefit our patients. Some might feel that it does not honor our tradition. I disagree, but that perception will be there. And it’s something to keep in mind.

The move from physical, traditional glass to virtual images that are easily manipulated, shared, overlayed and viewed to be compared side-by-side could soon put the pathologist in the cockpit of the future for diagnostic medicine.

I can easily imagine working with three monitors:  one for digitized pathology images, one for digital radiology images and continually updated references, and one for the electronic medical record.

Digital pathology for primary diagnosis will present a new gestalt. Perhaps as much for our colleagues and administrators as for all of us! But it’s a tool, it’s a tool, nothing more. Yet it’s a tool that will enable a pivot to possibility.

One word about cost.

In the 1990s, a good-sized radiology group might read 60,000 images a year. Today, that same group would nearly a quarter million images. We’re going to have many more images and quicker turnaround time. Our work volume will increase. We’re going to have a transition across the laboratory—more scanners, more displays, more storage, more support. And, yes, storage and support will be issues. And not everything is predictable. In the short run, there’s going to be interoperability challenges, unknown complications, expenses. But it will be temporary. And, in the end, digital imaging will make it easier to explain our thought processes.

Our practices will be more interactive. We will participate in more tumor boards, provide more consults, and spend more time explaining microanatomy and microphysiology and macroimplications.

A few years from now, it may seem that we must have had a language barrier before whole slide imaging. Future generations might hear stories of a time—our time—as medicine rapidly became more technical yet different specialists shared a culture but not a vocabulary.

Digital pathology will foster connections by making the scope of our work accessible, understandable and concrete. And these images will enable us to show and tell, to discuss cases with our clinical partners using our new visual aids.

Indeed, the emergence of whole slide digital imaging is likely be compared to the paradigmic shift away from the first silent movies. Or the difference between spending the evening flipping through dozens of pictures from your brother’s vacation versus opening a YouTube video sent from Yosemite with images, motion and sound.

I think our clinical partners will welcome this change because we all want our patients to be safe. We all want to communicate more easily. And we all want to share our diagnostic evidence. That’s the cultural common ground.

I want to take an illustration from the world of cancer and genomics. In The Emperor of All Maladies: A Biography of Cancer, Siddhartha Mukherjee describes the work of two pathologists and a hematologist working 20 years apart, who created the modern gestalt for our understanding of cancer.

In the 1950s, Philadelphia pathologists Peter Nowell and David Hungerford discovered that patients with a particular type of leukemia were missing a piece of chromosome 22 that would later be known as the “Philadelphia chromosome.”

Two decades later, a Chicago hematologist, Dr. Janet Rowley, was working from home while her children were small, studied staining patterns that indicated chromosomal abnormalities in cancer cells. And she perfected a staining technique in her dining room table, that Mukherjee said was, … and it’s a very interesting quote from Mukherjee … he says it was “as much an art as a science…an oddly anachronistic art … like painting with tempera in an age of digital prints.”

She had provided a tool to visualize the translocation involving what would prove to be an oncogene that signified chronic myelogenous leukemia.

Dr. Rowley figured out that in these patients that a little piece of 22 had been swapped for a piece of chromosome 9.

And beyond the diagnostic value of her discovery was a concept that Mukherjee describes as “much more profound.”

Rowley’s work, he wrote, showed that, “Cancer was not disorganized chromosomal chaos. It was organized chromosomal chaos.” We’re not going to detour into chaos theory today, although it would kind of be fun. And Rowley died last year, so we can’t really ask for her opinion, but it really would be interesting to hear or to know what she would say today about the powerful genomic tools in use that we use routinely with computers and software unknown in her time. She was a traditionalist. But I think she would be delighted.

And the transition to digital tools is certain to be disruptive. It will, for a time, affect our efficiency. And the laboratory is traditionally an island of precision. So, yes, any hiccups we have will get more notice. People rely on us to be predictable. That’s another cultural piece.

But we will need to educate our administrators, collect the evidence and recruit support so that we can be ready for when FDA approval comes through.

Talent is drawn to technology, and patients are drawn to talented physicians.

The time to full launch can be prolonged, depending upon your starting time, but delay could have a prohibitive opportunity cost. At the end of the day, our colleagues need us to shepherd development of new diagnostic technologies, and bring new tools to the field where targeted therapies can be deployed.

Our best allies in making this case are likely to be radiologists, whose work is almost 100 percent digital right now. They appreciate its value. But they also know that compatible diagnostics are good for everyone.

There’s still a lot to learn, and a lot of untested potential. And CAP has developed some tools to enlighten the inquiry. The next big river to cross though is primary diagnosis. And proper validation will be absolute. Validation is indeed a critical step toward its use in the clinical setting, enabling direct links among a test, a recommended treatment and a successful patient outcomes.

And, fortunately, the CAP Pathology and Laboratory Quality Center has published guidelines for validation.

Some of us are using whole slide imaging for limited purposes, preparing to transition to digital for primary diagnosis when FDA approves. But almost all laboratories are still 100 percent analog.

So how can these groups estimate the cost of the transition? How are they going to know what the opportunity cost would be if they don’t do it? With so many unknowns, how can they write a budget? And what do they need to know in order to negotiate terms? The CAP has developed tools to address these questions.

The CAP’s Digital Pathology Resource Guide is the place to learn about that research. It is one of four guides developed by CAP pathologist members to facilitate adoption of specific hot-topic technologies.

The other three guides cover precision medicine, in vivo microscopy, and clinical informatics. Every practice should have them on site.

The Digital Pathology Resource Guide was developed by the CAP Digital Pathology Committee. Written by and for pathologists, it anticipates questions and highlights unknowns in only 417 pages of succinct prose. It’s designed to make digital pathology accessible to those practicing in remote locations by elucidating practical considerations tied to education, research, second opinions and eventually primary diagnosis.

Each CAP Resource Guide presents a curated set of journal articles, a description of relevant CAP resources, including learning opportunities, proficiency testing and accreditation.

An “Insights from Adopters” section adds perspectives from pathology leaders in the field. And these are invaluable sources of knowledge and expert commentary on current and emerging applications, regulatory concerns and education.

The biggest question right now is interoperability. The digital systems will have to talk and listen to each other and to the LIS. Countless other handshakes will have to be worked out.

Let your IT team know well in advance that you are thinking about this. Get them involved from the start. There’s a lot they can tell you—as their field is evolving right along with our own. Let them be your partners!

Workflow concerns also loom large. That’s familiar territory to all of us! But the payoff, when the kinks are ironed out, will be magnificent.

Dr. Andrew Evans of the University Health Network in Toronto writes in the Digital Pathology Resource Guide, “Digital Pathology can maximize the amount of time pathologists spend doing diagnostic work while minimizing the time looking for missing slides.”

That about covers it; says quite a bit.

WIRED magazine occupies the niche between technology and culture, much as pathology lives between science and medicine. It’s a good read.

A guy named Daniel Burrus wrote an article for WIRED about the Internet of Things—IOT—the Internet of Things. And that’s the idea that machines talking to machines are going to soon be in charge and cloud computing is going to happen at a level above our puny little brains.

Burrus doesn’t see it that way. He says that the sensors that gather data and the machines that put it to use can’t connect without an infrastructure, and that the right infrastructure leverages the power of data by capturing it and converting it to a useful form. Think about it; that’s exactly what we do, we capture data and convert it to a useful form. Burrus points out that the Internet of Things does not create knowledge; it just translates and transmits what comes its way.

“And so when people talk about ‘the next big thing,’ they’re never thinking big enough,” he writes. “The future is always within sight. You don’t need to imagine what’s already there.”

As medicine’s translators, we understand that things are not always as they appear. As medicine’s scientists, we are inclined to chase things down. We know that some indicators will make everything pivot, and others become cautionary tales.

Digital pathology is a pivot point.

Anatomic diagnoses are becoming more quantitative. Our thought processes increasingly include traditional clinical pathology concepts such as analytical precision, reproducibility, accuracy, reliability, specificity…, and we are reaching for diagnostic results that can guide treatment. More and more often, we’re getting there. And digital pathology is a powerful tool that fits.

Early adopters have been honest about the downsides; clear about the uncertainties—but also clear that the precision of quantitative assessments can be markedly improved with digital pathology.

Our big-picture thinkers are focused on the potential value of systems that can bring access to cutting-edge technology to so many patients in underserved and remote communities. And our most forward-looking leaders see a certain inevitability. They tell me that the quality and flexibility of digital platforms will bring such benefit to patient care and research that their prevalence can only grow.

And with our new-in-practice and pathologists in training, who carry more powerful technology in their pockets every day than was on the Apollo lunar landing mission or any of the Space Shuttles, can’t see what the fuss is all about. That’s worth considering because there’s a transition, no question. And waiting too long may have its own consequences for patient and staff recruitment.

Risks and benefits are not yet nailed down but, at the end of the day, not to decide is to decide. And some practices may be reaching the tipping point on the opportunity costs. So, we have our work cut out for us.

Some of us will study, some of us will review the literature, and some of us will consult with early adopters.

Some will be more informal, some of us will speculate and, yes, some will even pontificate about the pros and cons.

But it’s time to come to grips—and that’s the message. Because as Daniel Burrus says, disruptive technology is only disruptive if you didn’t know about it ahead of time.

So please, introduce the CAP Resource Guides into your departments and practices, and encourage your colleagues to check them out because digital pathology is refining, expanding and reframing the diagnostic gestalt.

And those who say that the only things certain in life are death and taxes should include a new third certainty, an inevitability in this competitive environment. And that is: the market moves.

Driven, in medicine, by technology, discovery and science, the market is always evolving. We must do the same by evaluating and adopting what is useful.

Achieving a certain comfort with the foreign yet familiar, and recognizing that this train is leaving the station. It’s time to get on board.


Richard Friedberg