Long-Distance Learning – With a Heart

The COVID-19 pandemic has forced near-immediate changes to all aspects of daily life. To limit transmission of the virus, some cities have adopted travel restrictions and social distancing policies that have made office-based work all but impossible. On top of that, many hospitals have created policies that require trainees to work from home. For pathology trainees, these measures have disrupted traditional educational activities, including sign-out at a multi-headed microscope and attending (often crowded) didactic and slide conferences. Training programs were forced to go virtual (1)(2)(3), but the transition strained an already-pressured group of faculty tasked with conforming to the new restrictions while simultaneously managing the pathology laboratory through the pandemic.

On April 1, 2020, the College of American Pathologists (CAP) launched the CAP Virtual Pathology Lecture Series to help sustain residency program education in these unprecedented times. To date, more than 9,500 individuals have registered for the series and it has garnered more than 76 million impressions on Twitter. A CAP survey found that 97 percent of the 1,347 respondents found the lecture series “satisfactory or very satisfactory” – and all surveyed faculty described a very positive experience, saying that they would lecture again and recommend the series to their colleagues (4).

What did we learn from launching an international lecture series in under a week during the pandemic? Here are our top eight lessons.

1. Identify the need

To solve a problem, you have to see the problem.

On March 13, 2020, the CAP began to receive reports from pathology trainees and faculty across the country, warning them of the looming educational crisis. The CAP identified a need for free pathology education that could be accessed by thousands of learners from all parts of the world – immediately.

2. Assemble a team

“Look for the helpers.” – Fred Rogers

Just two weeks later, Teresa Burgin suggested a CAP-sponsored virtual lectureship series during a Curriculum Committee conference call. “I heard Teresa Burgin describe the lecture series and I recognized this as the perfect solution to multiple crises,” says Christina Arnold. Later that day, the two identified key educational topics and strong educators who could be mobilized quickly. Arnold solicited faculty volunteers and, within 24 hours, more than 30 educators had volunteered more than 40 topics. The CAP Virtual Pathology Lecture Series was born – and its launch was a mere five days away.

3. Get the word out

“This will be a success if we have 40 learners.” – Teresa Burgin

Developing projects for large organizations typically involves setting out a clear mission, outlining objectives with deadlines, recruiting key people, establishing goals for success, vetting these programs through experienced committees, and promoting them widely via member directories, email, and social media. These processes are important – but they take time, a resource that was in short supply. Instead, a fast-moving ad hoc committee replaced the traditional workflow.

To recapitulate the daily lecture series most training programs offered before the pandemic, the CAP decided to offer free one-hour lectures Monday through Friday, with an additional 30-minute question-and-answer session for each lecture. Burgin worked with Kamran M. Mirza, Adam L. Booth, Michael A. Arnold, and Christina A. Arnold to produce balanced, high-yield educational content for the April schedule. The CAP team scheduled lectures based on priority topics and educators’ schedules, secured a virtual platform to host up to 1,000 learners, enlisted technical support, and developed artwork and digital assets for promotion. At this point, all promotion was exclusively through the social media platforms of the involved pathologists. Would anyone attend the sessions?

“This will be a success if we have 40 learners,” said Burgin.

Arnold was more optimistic. “I think the numbers will be much higher, but I am not sure where we will land.”

The first promotional tweet went out less than 24 hours before launch. Within four hours of opening registration, more than 400 people had registered. Within 72 hours, that number had well exceeded 3,000 – surpassing all expectations. According to CAP President Patrick Godbey, “This program has been a tremendous success, with an average daily attendance of more than 1,000 in April.”

4. Forget perfect – just get it done

“Perfection is the enemy of progress.” – Winston Churchill

Launch day arrived. The lecture series was not formally promoted until a half-hour before the first presentation. The remaining April schedule was still in progress.

“We are building this plane as we fly,” Burgin commented.

“Expect hiccups,” Arnold added. “These things never go perfectly.”

Nervous anticipation set in. Would anyone tune in to listen? Would people stay for the whole hour? Would anyone ask questions? Would the technology execute smoothly? Would learners come back for day two? 

Barbarajean Magnani, the first scheduled speaker, delivered the first of a three-part toxicology primer on April 1, 2020. An international clinical chemistry and toxicology expert, Magnani commanded an audience of 879 on day one.

Was this a fluke? Would the lecture series have staying power?

The next day, Michael A. Arnold offered a “Survival Guide to Pediatric Tumors” – a specialized topic that rarely garners high viewing numbers. Nonetheless, the room reached its 1,000-learner capacity within six minutes. Every subsequent day of that week was similarly overbooked, with senior faculty members often exiting to make room for trainees. “I would make sure that I logged in 30–45 minutes early just so I could secure my place. The live lecture series had already become part of my routine and I didn’t want to miss it!” says Ashley Holloman, a fellow in neuropathology. Although all lectures were recorded for learners to access at their convenience (5), people wanted to be “in the room” during the live lecture. Ultimately, the lecture capacity was increased to 3,000 (see Figure 1).

5. Make space for mistakes

#CoffeewithCAPKen

Ken Molay, the webcast moderator for the lecture series, arranged to meet with each speaker 30 minutes prior to the lecture to run through audio checks and familiarize presenters with the software controls. During the pre-broadcast set up on the very first day, Molay and Magnani accidentally found themselves in broadcast mode. It was 9:45 a.m., with 15 minutes until the lecture officially started, and the speakers were unexpectedly broadcasting live to hundreds of people… with no planned content.

Molay didn’t miss a beat. He engaged with the audience. He asked them to type their locations into the comment box and shared them live. People tweeted photographs of their “classrooms” (see Figure 2) and Molay described them to listeners. Lockdown restrictions had isolated people – but the chat brought them back together.

By the next day, the pre-session dialogue was branded #CoffeeWithCAPKen and became an important fixture of the series. Topics included the learners’ favorite music, diagnosis, pet, hobbies, movie, childhood game, non-pathology career choice, cell, and more. “#CoffeewithCAPKen had an amazing sense of community and a message of humanizing the medical field, promoting hobbies and work-life balance,” one anonymous survey respondent shared. And the organizers felt the same. “I love #CoffeeWithCAPKen,” says Mirza. “I have to admit, some days when I am very busy, I only tune in for that.” 

6. Look for surprise wins

Building future leaders
Well-established leaders with excellent teaching skills draw large audiences and deliver quality educational content.  However, the pace of building this lecture series sometimes required finding a presenter within 24 hours – often impossible with a senior faculty member’s busy schedule. This need for flexibility prompted us to include junior faculty as educators, and they did not disappoint. The arrangement was a win-win; early-career pathologists had a global platform on which to demonstrate their knowledge and educational skills – and we found a group of lecturers with flexible schedules, recent training, and comfort with online educational tools.

Sustaining trainee programs
As the COVID-19 crisis continued, residency programs across the nation built the CAP Virtual Pathology Lecture Series into their calendars. Many asked, “Can we count on this to continue?” It was clear from the audience size, social media presence, and feedback that the series resonated with learners. Lectures were described as “a once-in-a-lifetime opportunity,” “the best thing that has happened in 2020,” and even the “pathology version of Netflix!” One anonymous survey respondent said, “For two and a half months I was ordered to work as an emergency doctor. In this process, your lectures kept me connected to pathology and continued my education.” 

By making free, high-quality lectures by known experts accessible to all, the lecture series removed barriers to education – hopefully elevating and unifying pathology training. No matter where a person trained, how small their training program, or how many senior pathology leaders were at their institution, they could all learn the latest techniques from leaders in the field – on their own time in their own homes. In fact, the series was so popular and so successful that it was ultimately extended throughout May.

An international experience
Although CAP members are predominantly American, the CAP Virtual Pathology Lecture Series drew an international audience. By the end of April, almost two-thirds of the audience was outside the US (see Figure 3). The steady audience of global learners showed that the combination of an easy-to-use platform, quality educational content, and an evolving social community was contributing to pathology education not just among CAP members, but worldwide.

Beyond residents
The CAP Virtual Pathology Lecture Series was originally referred to as the “CAP Virtual Resident Lecture Series,” but the team quickly realized that their audience was more than just residents. Medical students, technicians, fellows, practicing pathologists, and other professionals also found the series worthwhile. “Really learning a lot from tonight’s #capvirtualpath lecture! Lots of things that I don’t think I was able to learn even during residency,” tweeted Philippines-based pathologist Celestine Trinidad. Brian McMillen, another long-time pathologist, echoed her sentiments. “These are great not only for trainees, but practicing pathologists as well… I’ve listened to the talks by @RaulsGonzalezMD and @Williams_SR; both were full of great practice points.”

Giving back to the pathology community
Pathology educators who would ordinarily travel as part of visiting professorships or to lecture at national or international meetings had their trips canceled in the pandemic. “The CAP gave me a way to give back to the community on a scale and platform that I could not have done on my own. While quarantined at home, I could share my prepared lectures with hundreds of learners across the globe and feel like I was doing what I could to help others in a time where almost everything was uncertain,” says Arnold.

Improving patient care
The CAP Virtual Pathology Lecture Series did more than educate learners and build a social community. It also had an immediate, positive impact on patient care. How? On April 29, 2020, the CAP Virtual Pathology Lecturer was Michael Feely, a gastrointestinal and liver pathologist whose topic was “Infectious Diseases of the GI Tract.” He shared that gastroenterologists often note numerous white nodules in the colonic mucosa of patients infected with Strongyloides. Sometimes, he cautioned, the biopsy may only show a small portion of the worm – difficult to recognize in a background of intense eosinophilia – and deeper levels can better clarify the pathology. Adam Booth immediately recalled a colon biopsy from three years prior, featuring intense eosinophils, that had been signed out descriptively. With his pathology attending, they retrieved the case and learned that the patient had an unexplained multi-year history of chronic diarrhea and eosinophilia. Deeper sections into the tissue block revealed a single fragment of Strongyloides (see Figure 4). Booth shared the updated information with the gastroenterologist, who immediately contacted the patient, ordered Strongyloides antibody serum IgG, and prescribed ivermectin.

7. Social media is a powerful catalyst

There’s no doubt that social media was a key factor in successfully launching the CAP Virtual Pathology Lecture Series. With the launch coming only days after the idea first arose, there was no time to work through the usual channels of committees and advertisements. Instead, the pathology Twitter community stepped up. By June 21, 2020, the Twitter phrase “#CAPVirtualPath” had garnered more than 76 million potential Twitter impressions from over 23,000 tweets – numbers we don’t think any other pathology initiative has reached.

Social media not only helped launch the series, but also became an integral part of the experience. Nearly one-third of survey respondents participated in Twitter-based discussions surrounding the lecture series. Learners “live-tweeted” key teaching points and images during the lecture so that the information and discussion could disseminate beyond the classroom. “[Twitter discussions] added so much to the experience,” one anonymous respondent said. “Not only did the presenters often add valuable insight to the conversation, but the reviews and summaries helped build takeaway points to better understand the material.”

To help everyone access the social media discussion around the lectures, the CAP hosted a Twitter workshop giving basic tips for navigating social media for pathologists. And learners weren’t the only people dipping their toes into social media for the first time. Several of the faculty also joined social media to contribute to the online discussions. Andrew Bellizzi, GI pathologist at the University of Iowa and Chair of the CAP Immunohistochemical Committee, joined Twitter prior to his first lecture. Within 48 hours, he had more than 1,000 followers. Within three days of his first lecture, the paper he discussed (6) had jumped from four abstract views to 1,153 (see Figure 5).

8. Adapt to a changing world

“The art of life lies in a constant readjustment to our surroundings.” – Kakuzo Okakura

COVID-19 changed all of our lives in every way. Would the CAP Virtual Pathology Lecture Series have existed in a pre-pandemic world filled with bustling service schedules, unrestricted travel, and scheduled didactics? It seems unlikely. Regardless, out of these dark times, something valuable was created. It started with CAP members voicing their concerns about the ongoing educational crisis. Next, their educational needs were connected to a supply of talented educators who were no longer traveling and wanted to help build the new normal. This lecture series grew organically into a social community through a series of happy accidents, organizers open to new ideas, and engaged learners eager to share. More than 9,500 learners across the globe shaped its presence on social media – and it is still evolving.

“As training slowly returns to ‘normal,’ we recognize that the new normal will be different,” says Donald Karcher, Chair of the CAP Council on Education. “As a result, we’re currently working on making the CAP Virtual Lecture Series a permanent resource for the pathology community.”

But even pandemics are not forever. Now, the world is easing travel restrictions, learners are returning to medical centers, clinicians are ramping up services, and pathology services are bustling again. What role will the lecture series play in a post-lockdown world? At this point, it continues on a biweekly basis. The leadership team will become a larger and more formal committee. Although the details of the CAP Virtual Pathology Lecture Series are evolving in step with the needs of today’s learners, the lessons it has imparted will stay with us as we build our new normal.

Acknowledgments
A project of this size and scope is only possible when a large group of talented people believe in the purpose and pour their hearts and talents into its success. Thank you to the CAP for always seeing the value of training the next generation of pathology leaders. During the SARS-COV-2 pandemic, thank you for not only seeing the need for a new mode of education, but also delivering it to us within days of the idea’s inception. Thank you to Teresa Burgin for sharing your idea with all of us, creating this magical team, being the anchor for our work, and working nights, weekends, and holidays to see it spring to life. Thank you to Ken Molay for lending your voice and people skills to transform a mistake into magic. Thank you to the new committee of staff and pathologists who are working together to transition the CAP Virtual Pathology Lecture Series into a more permanent fixture: Kim Kruger, Teresa Burgin, Kathy Fox, Kristen Johnson, Denise Mack, Abby Thomsen, Crystal Wells, Robert M. Najarian, Ashley Holloman, Adam L. Booth, Kamran M. Mirza, Michael A. Arnold, and Christina A. Arnold. Thank you to all the educators who came together with almost no notice to share knowledge and wisdom with the world. And the biggest thanks to all the learners who tried something new and returned again and again and again (and again!) to show your support and enthusiasm for learning in this community we are building together.