During her first year of pathology training, Alexandra Rapp had severe allergic reactions to numerous chemicals – including many used within the laboratory and hospital – such as formalin and xylene. This eventually led to a diagnosis of mast cell activation syndrome (MCAS), a condition characterized by inappropriate mast cell degranulation in response to various chemical stimuli. By winter 2020, during her second year of residency, she was no longer able to work onsite in the presence of most laboratory chemicals without experiencing debilitating reactions requiring intermittent treatment with prednisone. Coinciding with this, a new virus – SARS-CoV-2 – was emerging, leading to a national stay-at-home order and provisions from the American Board of Pathology that allowed remote training in certain circumstances, including those with certain chronic medical conditions. Suddenly, a vast portion of the population was working from home – including Rapp. On the forefront of the remote work revolution, Rapp blazed a new trail in medical training that could ultimately serve as a blueprint for the future of laboratory medicine.
At the beginning of the COVID-19 pandemic, Rapp was tasked with fulfilling all her pathology training requirements while working virtually from home. She worked closely with the administration of the University of Texas Medical Branch (UTMB) Pathology Residency Program and her supervising attendings to develop avenues in which she could complete all training program requirements. Using multiple tools, she was more than able to fulfill her residency duties. In clinical chemistry, for example, she was able to complete toxicology reports via the electronic medical record and participated in chemistry rounds via Skype for Business. On the coagulation service, she used electronic medical records to complete Diagnostic Management Team (DMT) assessments of patients with complex coagulopathies. Even on more challenging services, such as hematopathology, she was still able to fully participate and meaningfully contribute through the use of virtual tools, such as microscope cameras, as well as a platform that can capture static images of peripheral blood smears named Cell-a-Vision.
With creativity and open communication, she found a remote work set-up was possible on each rotation.
As she continued to work remotely, the benefits to her own wellbeing and the work of her institution became increasingly clear. With her chemical exposure symptoms now lifted, she found herself being more productive, resulting in numerous publications, virtual presentations, and virtual teaching experiences alongside her clinical work. The absence of a commute allowed her to devote previously lost hours to her work, and with no social distractions to take her attention, she remained focused throughout the day. With the relief of both stress and symptoms, her productivity flourished – to the point where she was actually covering multiple services at a time. Amazingly, Rapp – while still in training as a resident on other rotations – was involved in the creation and dissemination of patient-specific interpretive comments for COVID-19 test results for UTMB’s COVID-19 DMT service. This experience more than adequately prepared her for her subsequent role as an attending, in which she would again juggle the competing demands of multiple services simultaneously, including the COVID-19 DMT service.
From an institutional standpoint, Rapp’s increase in productivity was just one benefit. Creating a remote work option allowed UTMB to begin recruiting from a wider geographic talent pool. In fact, UTMB was able to recruit the best and brightest in pathology without the added burden of relocation. In the current laboratory workforce shortage, this helps UTMB retain staff as the institution can offer the bonus of location flexibility. A career in academic laboratory medicine often means relocation every 1–2 years – but UTMB is forging a new work model, relieving the burden of location, while obtaining the highest productivity from staff.
Of course, there can be some challenges to remote work. Without open communication, the structure of remote work can fall apart. Closing off channels can quickly lead to discrepancies regarding work performance expectations. Lack of communication can also be difficult emotionally for those who receive the bulk of their social support from their work environment. While working from a household with multiple family members or small children may be less isolating, this too can also have its own set of obstacles, notably through potential distractions that introduce difficulty in concentration and focus.
Rapp has faced all these challenges and more. But because there was open and consistent communication from the start of her remote work endeavors, she was able to complete all clinical responsibilities successfully and maintain strong relationships with her supervisors, co-workers, and mentees. She frequently communicates with her colleagues through email, chat, text, and video conferencing software. She has even developed her own methods of breaking the ice for new residents who are not used to engaging in remote sessions, often introducing her cat, Gracie (assuming Gracie does not introduce herself first!).
Rapp completed her residency training at UTMB in the summer of 2021, after which she immediately began her full-time position as a faculty member of UTMB’s pathology department. Because she had garnered glowing reviews for her remote work as a resident, she was able to continue this arrangement as an attending clinical pathologist. She continues her work with the COVID-19 DMT service, signing out the majority of the interpretation reports and has also revitalized ANA test reporting at UTMB. To directly oversee technologists’ antinuclear antibodies (ANA) testing and reporting work, Rapp uses SharePoint files.
Additionally, she leads education conferences via Microsoft Teams for the technologists to improve their recognition of rare and dual ANA patterns. Rapp also provides individualized interpretation reports of ANA and autoimmune serology testing for patients, maximizing her time to also educate pathology residents on the nuances of these types of tests.
Her work on the COVID-19 DMT and ANA/Autoimmune DMT services has generated an approximately 328.5-fold increase in work relative value units to what was expected. All of these impressive achievements were made possible by enabling remote work capabilities for someone who would have otherwise been excluded from the lab – a point that highlights another profound benefit of remote work: enabling qualified persons with disabilities or physical limitations to meaningfully contribute to their fields when they might have otherwise have been prevented. This benefit has been widely reported, but to simply summarize – creating flexibility by introducing remote work allows for truly talented people to participate and contribute to the workforce, which can only benefit a growing institution such as UTMB.
Rapp remains a trailblazer for the pathology department. In the past two years, UTMB pathology has supported several other remote faculty members, which has helped further increase the diversity of its faculty. We hope Rapp’s story – and her enormous success – can act as a blueprint for remote work for the field of laboratory medicine as a whole.
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