Draft article. Formal article to follow in press.
The COVID-19 pandemic has undoubtedly been (and continues to be) a global catastrophe, both medically and economically, and the future will be recorded with reference to before early 2020 and the different world left in its wake after the pandemic. In Spring 2020 some medical and intensive care colleagues saw an enormous increase in workload, but for for UK pathologists it initially seemed most would be redeployed to acute clinical care, or relegated to giving telephone advice to concerned patients, rather than using hard earned diagnostic skills.There was a dramatic reduction in diagnostic workload in most laboratories, both as a result of reduced surgical procedures, and almost complete cessation of routine/aerosol generating samples such as endoscopic biopsies being received in the lab. Multidisciplinary meetings (MDTs) continued for urgent cancer work, but the number of patients discussed in the meetings reduced. Postmortems were expected to increase in number, but advice from Coroners (concerned about a quickly overwhelmed service) led to reduced scrutiny of deaths, and more natural deaths were written up without postmortem examinations, leading to reduced autopsy workload.
Most labs (including my own workplaces) prior to the pandemic had a considerable reporting backlog to clear, and the reduced workload presented an opportunity to catch up with that at last. Although the workload markedly decreased, there was still plenty of work (especially with more staff off sick and shielding) to keep staff busy enough, and to necessitate technicians, scientists, consultants and trainees back at work when they were fit and well.
Pathologists are sometimes portrayed as solitary and antisocial workers, but although most consultants are still privileged to have their own offices, training, and quality safe reporting requires considerable collaboration with clinical colleagues, as well as trainees and laboratory staff. The mainstay of surgical pathology training has always been the double-header or multi-header microscope, which only affords elbow-room rather than the one or two metres currently prescribed. Wearing a mask for microscopy is uncomfortable and unpractical, and even for those of us who don’t wear spectacles, masks cause eyepieces to fog, and I’m sure it’s even worse for the bespectacled pathologist.
MS Teams and other screen sharing software
On March 16th, NHS Digital rolled out Microsoft Teams to enable nhs workers to “be able to use instant messaging and audio and video calls to share advice and updates on their patients, wherever they are”.
Since the advent of the COVID-19 pandemic, Microsoft have provided their teleconferencing software (teams) to enable multisite socially distance meetings, through the nhs.net secure digital portal.
The ability to easily share desktop microscopy (and other relevant data) has been transformative for pathologists like myself and many of my laboratory medicine and clinical colleagues. I now find I can be more efficient presenting from my own office where I can easily find everything I need, and have my own optimised ergonomics. I now don’t have to walk to the MDT room, spend several minutes logging in to a relatively unfamiliar system with a pile of slides and a poor quality microscope. I can keep an eye on what is happening in the MDT but multitask more easily, getting on with some useful work while my clinical colleagues are discussing operative approach or chemotherapy trials. Please note that I will not be discussing alternative software applications such as Zoom, Skype or Cisco Webex in this article as the pros and cons of using each of these in pathology have been discussed in detail elsewhere *.
Setting up MS Teams software is incredibly easy for NHS employees. All that is needed is any computer where the internet can be accessed (or even a smartphone connected to a 3G or 4G mobile network) and you can then teleconference with multiple colleagues wherever they are, especially if they have a nhs.net email address. Connecting with colleagues who are not on a nhs.net email address involves sending a calendar invite through Outlook, but from nhs.net email addresses, messages and calls can be made instantly, more easily even than making a phone call. Teleconferences can be made from within a prepared “team” group, or even more easily from the chat window by pressing either the telephone or the camera button. The third icon within the chat window is arguably the most useful for pathologists. This allows screen sharing even from outside of an active meeting; when this button is clicked, the user is prompted to share a currently open window or one of their screens. If you have a microscope camera, that active window can be shared, demonstrating to any other user what is on your microscope, or alternatively a report or any other document for example. You will also notice there is a files tab in each window to show any copied and pasted, or uploaded file into the chat screen, and these files are then tabulated in the files list for later reference. Additional individuals can be added into the chat by clicking the next icon to the right, and the chat can be renamed to be used later which is useful for a group of colleagues regularly contacted.
MS Teams for MDTs
We have been using Teams for all our local MDTs and almost all of those who meet across more than one NHS hospital site. The advantages during the pandemic were immediately clear; health professionals could meet and discuss without having to share the same physical space, and teleconferenced meetings facilitated working from home or from individual offices, enabling social distancing. Communication with multiple individuals in a conventional face to face cancer MDT can be difficult without using this technology, and although initially there were some teething problems with “muting etiquette” and microphone feedback, team members quickly adapted to the new norm. Teleconferencing using teams and other similar software is designed to work best with every member calling individually into the meeting, rather than several members using the same room microphone. The sound quality is best of all when each member has a headset or earphone with mic (such as those supplied with most smartphones these days). Laptops and mobile phones have a facing camera, but if using a standard work PC, a separate webcam may be needed (many of these actually include a microphone and can be bought very cheaply online). Just as in conventional MDT discussions, members are encouraged to take their turn to speak and present, with well chaired meetings running most efficiently.
In my experience the MDT I attend that most quickly adapted to the use of Teams teleconferencing was the most complex multi-site meeting I attend. Core members of this particular cancer MDT have been familiar with a similar format of teleconferencing for the ten years I have been involved, although prior to the pandemic this involved all members being seated together in one of five conference rooms at each of the Peninsula hospital sites. Since the MDT has a very organised method of sequentially discussing the details of the patients from each hospital in turn and each specialist has learned when it is their turn to present, the move to MS Teams was very smooth. I am unaware of any core members who have a desire to return to the previous, non-socially distanced meeting format, even after restrictions are lifted.
Clinicopathological meetings with dermatologists and other physicians
My prior experience is that physicians (particularly those with a pathology leaning such as haematologists, dermatologists and renal physicians), have more interest and patience for scrutinising histology than surgeons. Surgical pathology MDTs concentrate on confirmation of a malignant diagnosis, and in post-operative cases clarification of the pathological stage and margin status. Clinicopathological meetings can have a combined therapeutic and educational focus, and presentation of histology findings in more detail may be more appropriate than in surgical MDTs, where long lists of patients with a standard diagnostic workup and treatment plan are usually discussed.
MS Teams for Speciality training and examinations
We now use screen sharing with teams for all our routine reporting with our trainees and for regional teaching / training days. For reporting, the trainee lets us know that they have left some slides they have looked / and provisionally reported in our trays. We then arrange a time to call the trainee and look at the slides together using MS-Teams. Other trainees and colleagues can easily join the teleconference by arrangement for a “black box” meeting and different member of group can take turns sharing their own screen to share and discuss their own cases. Unlike conventional black box meetings these do not have to be at the same physical site, which enables the potential for more frequent training sessions per regional trainee, and considerably less traveling. Prior to the use of this technology some of our trainees would be expected to travel a 6 hour return journey for training day, which might only last a couple of hours. We also now use teams for our ARCP meetings to avoid having to dedicate a whole day traveling, paying for venue hire and the cost of hosting external representatives. Even specialist examinations are now being done through online platforms such as testreach.com
MS Teams for remote cutup supervision
I am in the somewhat unusual position of being the pathology lead for a specialty based at another hospital that is not my primary employer. The specialty hospital (University Hospital Plymouth) is currently short-staffed and has a lot of complex dissection work. When I worked in Plymouth as my primary consultant job I dissected a large proportion of the almost 90-100 radical oesophageal and gastric resections done there. Since I now only work on site at the specialist centre half a day a week, I have limited time to cutup the specimens myself. The logistics of transporting slides are more straightforward than moving wet specimens between hospitals and it is advantageous for a pathologist to have seen a specimen prior to receiving the slides of a complex case for reporting. We now have MS-Teams on computers in our dissection rooms, cameras over the cutup benches, and high quality wireless recording headsets. This enables me to supervise a trainee pathologist or biomedical scientist remotely, overseeing dissection and block taking. When I am reporting the case I can also give feedback to the BMS using Teams and ask for additional blocks to be taken in occasional cases where further sampling is required. I would highly recommend this way of working at other centres where pathologists are working remotely, or shielding during a pandemic.
Whole slide imaging (digital pathology)
The cost and logistics of whole slide imaging (WSI) has meant slow adoption in NHS pathology departments but that might be about to change with NHSI promoting the formation of regional networks and encouraging the future of cross-site reporting. Several laboratories within our wider South West region now have slide scanners, and some are actually being used for some clinical reporting. With increased pressure for sub-specialisation, departments are finding vulnerable specialities such as soft tissue and lymphoma difficult to cover with appropriate expertise and whole slide imaging could facilitate the formation of pan-regional cover for urgent tissue diagnoses. For cross-site work however, there have been compatibility problems between different systems, and most frequently issues with enabling access to shared slides outside of the hospital where they are situated (even for teaching and educational work). As unbelievable as it might sound, it has been often easier in the past to load whole slide images onto a memory stick (or resort to glass slides) and physically post them, rather than enabling them to be viewed across different NHS firewalls using VPN systems or enabling logins to a different hospital or university networks. Clearly with precious slide collections and cytology, sharing digital images is preferable to the risk of losing the slides, and the delay of passing them from trainee to trainee at different sites. I have been successful in using a file format agnostic WSI sharing and archiving system (Pathomation.com) to store and share images acquired on different scanners, and have embedded some of these in my own website pathkids.com with clinical detail and quizzes. The preparation time required to not only arrange the collections but download from one system and upload enormous files to another, can be prohibitive but the benefits to trainees in a dispersed geographical region, are obvious.
The advantage of using WSI in conjunction with teleconferencing systems like Teams, allows the digital images to be projected using screen-sharing to different NHS sites or to homes and mobile devices without concern that the transfer will be blocked by a firewall. Screen sharing technology can introduce a slight time lag in the viewing of WSI remotely, but is generally very economical in the use of bandwidth compared with transferring entire whole slide images. This way of working however requires a pathologist working at both sites to enable the relevant areas of slides to be shown or shared. In addition, although royal college guidelines for reporting digitally have been relaxed slightly since the pandemic, the majority of pathologists are not yet comfortable and experienced enough with WSI to report more than a minority of their clinical work in this way.
WSI and working from home
An increasing number of UK homes are now equipped with fast fibre broadband networks and these are ideal for digital histopathology. I have intermittently worked from home for several years and rather than having separate home and work computers I chose to have a laptop, with a base-station connected to monitors at both sites. When working from home I simply take my work laptop (one of the two I have now I work for two NHS trusts) and connect this to my home base station. This allows me to access the same applications at home as I do at work. I also have two large high-quality monitors connected to my base station at home as I do at work. I do not have especially expensive medical grade monitors at home, just good standard High Street branded screens of “gaming quality”. I self-validated several years ago following the previous guidelines. I was pleased to see some more pragmatic guidelines published by the Royal College of pathologists*, after the beginning of the pandemic. It has always been my opinion that digital pathology is not especially different to using a microscope, and how we come to our written interpretations and opinions should be trusted to our own professional integrity rather what brand and type of equipment we use. Pathologists use a combination of Pattern recognition and clinical correlation to make a diagnosis. It’s often the latter than limits us the most, and a pathologist should never try to make a clinically significant diagnosis on substandard image quality (either glass or digital). The pros and cons of different kinds of equipment are beyond the scope of this article.
My advice to those who are in the process of investing in a digital pathology system, however would be to look at the whole process, from end to end, including most critically in my opinion, a robust link between the image management system (IMS) and the reporting system (in most cases the laboratory information system [LIS]). The real benefits of whole slide imaging pathology are reaped when tracking, extra work ordering, prioritisation and streaming of specialty workloads are all incorporated into an IMS which communicates seamlessly with the laboratory database and ideally the patient information system and radiology systems in addition.
Artificial Intelligence in Digital Pathology
In my opinion, our speciality will be transformed when we are able to utilise artificial intelligence algorithms in histopathology. Histopathologists are familiar with the morphological changes we see on H&E stained sections as a result of genetic and epigenetic events in neoplasia. “A picture paints a thousand words” is more than just a fitting analogy for histopathology; there are not enough hours in the day to report all of the complex features we see in an average cancer biopsy and high quality digital images of H&E sections are ripe for diagnostic and prognostic data mining. Digital pattern recognition “neural networks” mimic the way biological brains recognise these patterns, with the advantage that computers can learn to reproducibly recognise and quantify even those intangible features we all see and recognise but cannot put into words. The first clinically validated algorithm for identification and grading of prostate cancer is about to be used in the NHS* and more will surely follow. AI may eventually replace the human pathologist but algorithms will need human pathologist guidance and careful clinical contextual interpretion of results for many years to come.
Smart phone microscopy and social media
Modern smartphones are convenient and packed full of technology enabling easy networking. Some of the more recent phones also have better quality cameras than many expensive professional scope-mounted devices and a host of apps. Social media sites such as Twitter and Facebook are increasingly full of high quality smartphone images of common to rare pathological entities. With practice, the “Morrison technique” * can be used to take photos with your smartphone “freehand”. Alternatively, simple mounts can be purchased, and some free software is available to enable “stitching” of static images to make low quality WSIs for sharing and teaching. YouTube also has some very good quality and up to date lectures on a range of histopathology subjects, often with multiheader microscope sessions from USCAP and other international conferences.Sharing of anonymised cases with microscopic images has become commonplace on social media sites and pathologists are able to see examples of cases they might otherwise very rarely see. Many of these cases are shared by internationally recognised experts. Others are shared for opinions but pathologists who are unsure of diagnoses and many of these receive guidance and informal opinions from experienced and knowledgeable specialists around the world, sometimes receiving many opinions and comments almost immediately. Although these informal opinions do not replace conventional formal opinions they can be an excellent alternative and rapid source of ideas and knowledge and it may be possible to use this microscopic image archive in the future for artificial intelligence driven data mining guided by with morphological and clinically-relevant comments made by pathologists interacting with the posted photomicrographs online. As a pathologist working in a relatively remote geographical area, I find social media to be a very good source of CPD and a good way to keep in touch with colleagues around the world. When I was immersed in the academic world, there was a considerable amount of learning which took place merely by being regularly attending conferences, and traveling to present at meetings. Perhaps the new post pandemic world will “level the playing field” somewhat and allow pathologists who previously struggled to attend meetings and conferences due to distance, to attend more online conferences and CPD on the web.
As with all forms of image and data sharing, these methods should be all be considered carefully within the guidelines of your own local organisation, and great care should be taken not to breach patient confidentiality.
Thr Covid19 pandemic has had some unexpectedly positive consequences for NHS pathology services by encouraging the increased use of remote telepathology technology including screen sharing software such as MS Teams, and increased adoption of whole slide imaging. We are a speciality relying on the transmission of clear verbal and written communication, but through the use of this technology we can limit viral transmission without sacrificing the quality of safety of our essential work.
Browning, Lisa & Colling, Richard & Rakha, Emad & Rajpoot, Nasir & Rittscher, Jens & James, Jacqueline & Salto-Tellez, Manuel & Snead, David & Verrill, Clare. (2020). Digital pathology and artificial intelligence will be key to supporting clinical and academic cellular pathology through COVID-19 and future crises: The PathLAKE consortium perspective. Journal of Clinical Pathology. jclinpath-2020. 10.1136/jclinpath-2020-206854.
Williams BJ, Brettle D, Aslam M, Barrett P, Bryson G, Cross S, Snead D, Verrill C, Clarke E, Wright A, Treanor D. Guidance for remote reporting of digital pathology slides during periods of exceptional service pressure: An emergency response from the UK royal college of pathologists. J Pathol Inform 2020;11:12
Pantanowitz, Liron & Quiroga-Garza, Gabriela & Bien, Lilach & Heled, Ronen & Laifenfeld, Daphna & Linhart, Chaim & Sandbank, Judith & Shach, Anat & Shalev, Varda & Vecsler, Manuela & Michelow, Pamela & Hazelhurst, Scott & Dhir, Rajiv. (2020). An artificial intelligence algorithm for prostate cancer diagnosis in whole slide images of core needle biopsies: a blinded clinical validation and deployment study. The Lancet Digital Health. 2. e407-e416. 10.1016/S2589-7500(20)30159-X.
Mukhopadhyay, Sanjay & Booth, Adam & Calkins, Sarah & Doxtader, Erika & Fine, Samson & Gardner, Jerad & Gonzalez, Raul & Mirza, Kamran & Jiang, Xiaoyin. (2020). Leveraging Technology for Remote Learning in the Era of COVID-19 and Social Distancing: Tips and Resources for Pathology Educators and Trainees. Archives of Pathology & Laboratory Medicine. 10.5858/arpa.2020-0201-ED.
Morrison, Annie & Gardner, Jerad. (2015). The Morrison technique: A free-hand method for capturing photomicrographs using a smartphone. Journal of cutaneous pathology. 43. 10.1111/cup.12650.
Arends, M J & Salto-Tellez, M (2020) Histopathology 77, 518– 524. https://doi.org/10.1111/his.14174 Low-contact and high-interconnectivity pathology (LC&HI Path): post-COVID19-pandemic practice of pathology