Dr Tim Bracey. Consultant Pathologist (RCHT)
Change is painful but necessary. As an aging man, I find myself increasingly resistant to it. Yet, throughout my life, I have endured my fair share of change. Growing up as the eldest child with young, enthusiastic parents who loved traveling, I attended eight different schools. When I left school, I aspired to become a biologist—tumor cell biology remains my passion to this day. However, my journey took several twists and turns, from pursuing a biology degree to completing a cancer research Ph.D., medicine, ITU, and surgery, before finally becoming a pathologist.
I love my job, but I am often dissatisfied with certain aspects of the work. I am passionate about challenging practices that seem wasteful, unnecessary, or inefficient. My father, a surgeon, was probably just as grumpy as I am when things didn’t go his way at work. He once told me that if something at work annoys you, the best course of action is to audit it and find a better way of doing it. Following his advice, I have successfully changed or abolished several processes in the lab over the years by demonstrating their inefficiency, unnecessary expense, or lack of evidence-based support.
However, these changes have not always been welcomed by my colleagues, who often resist change despite being unable to justify their opposition beyond the argument, “We’ve always done it this way, so it must be right.” For example, at my previous job, I set up an online rota for consultant activities. Initially, colleagues found it difficult to understand why I wanted to change the existing system, which was based on three separate Excel spreadsheets stored in obscure subfolders of the local server. The old system was cumbersome and often led to confusion, as it was unclear which version of the rota was current. In contrast, the online rota I created was accessible from anywhere, searchable, and always up-to-date. Interestingly, years later, when the online rota temporarily became inaccessible, colleagues who had initially opposed the change panicked, realizing how much they had come to rely on the new system.
Another example of change resistance involved the frozen section consultations used by orthopedic surgeons. These consultations are essential for oncological surgeons but can be costly and disruptive for a pathology department. The golden rule of a frozen section is that it should only be used when the findings are likely to have immediate implications for intraoperative management. Many years ago, I challenged the logic of a local frozen section service where we were expected to count neutrophils in frozen section samples taken during joint revision surgery. After reviewing the literature, I found little evidence to support the service’s sensitivity or specificity in diagnosing infection. It was not only expensive and time-consuming for both laboratory and consultant staff but also potentially misleading for the clinical team. Despite presenting my negative data at both departmental and regional meetings and arguing for the service’s immediate abolition, I encountered significant resistance from colleagues who believed that since we had always done it, the surgeons must need it. I eventually compromised by offering to continue processing the samples as paraffin sections while allowing surgeons to contact us for urgent cases. Interestingly, the surgeons never responded but quietly stopped sending the samples anyway.
These are just two examples that come to mind when thinking about the subject of change. My attempts to implement change at work however have been far from universally successful. There have been many instances where I have failed to convince pathology and clinical colleagues of the need for change. One such case involves the examination of cystic ovarian tumors via frozen section, a practice that often requires rigorous and extensive paraffin sections to diagnose and subclassify. Despite evidence demonstrating the inaccuracy of this method in local audits and numerous international publications, including a Cochrane review, the practice persists in many departments. Gynecological surgeons, who find these consultations useful, continue to include them in their battery of tests, even when the results lack accuracy.
Sometimes, change is necessary but impractical due to prohibitive costs or infrastructure limitations. In the NHS, we are often too busy and overwhelmed with work to have the time or resources to implement change. I have always been a strong supporter of pathology digitisation, but my experience with our regional efforts has made me question the NHS’s ability to fully benefit from this technology. Digital pathology should be “the icing on the cake,” but for it to be successfully implemented, the “cake” itself needs to be baked to perfection first. For a laboratory to be “digital pathology ready” tissue processing and slide preparation should have digitisation in mind, and LIMS systems should be optimised with QR coded blocks and a modern tracking system.
Unlike private businesses that can quickly evaluate the pros and cons of new technology and purchase the necessary hardware and software to rapidly implement changes, the NHS is hampered by a slow and expensive procurement process. By the time new equipment is set up and connected, it may already be outdated. Furthermore, the ongoing costs of repairs and updates can be so burdensome that the equipment can lie dormant for years. The primary benefit of digital pathology—enabling remote reporting across different hospital sites, nationally, and even internationally—is hindered by the NHS’s institutional infrastructure. Although the NHS is perceived as a single organization, even neighboring hospitals can have different cybersecurity rules. Internationally recognised digital pathology software is often locked down to prevent slide sharing outside a single institution. While the NHS at the national level is beginning to embrace “cloud-first” solutions, most local IT teams still favor local “on-prem” storage, believing it provides more control and security over data. Unfortunately, this necessitates the use of individual institutional VPNs, which can slow and limit image transfer over already congested NHS networks.
Cloud services provided by companies like Amazon and Microsoft offer intelligent and secure data storage and backup, ensuring fast transfers 24/7. Data that is less frequently needed, such as older slides, can be moved to cold storage at negligible cost and easily retrieved when required. Before the NHS embraced Microsoft Teams, we had other teleconferencing software solutions that worked locally, but it wasn’t until the benefits of a truly geographically agnostic system like Teams were realized that we could fully benefit from it in the NHS. I believe the same will hold true for digital pathology in the NHS. It is still needed, but without significant changes to the current mechanisms or embracing private partnerships to enable cost effectiveness and sustainability it may continue to remain “a future technology”.
Conclusion
Change, while often met with resistance, is essential for progress and improvement. My experiences in pathology have taught me that while initiating change can be challenging, especially in the face of deeply ingrained practices and institutional constraints, it is necessary for advancing the field and improving patient care. The NHS, with its complex infrastructure and slow adoption of new technologies, faces significant hurdles in implementing change. However, by breaking down organisational barriers, fostering partnerships with private companies, and embracing unified systems, the potential benefits of innovations like digital pathology can be realised. Change is inevitable, and while it may be painful, we need to ensure we remain open to change in pathology departments as it is the driving force behind the evolution of healthcare.