Moving Pathology Education Online: A Burst of Glass and Light

Just a few weeks before the first documented case of COVID-19 was reported, a group of us were discussing a futuristic vision of pathology education – one that incorporated online resources and social media connectivity to enhance and enrich the scope of training for graduate students, residents, fellows, and practicing physicians. Our discussion, excited and animated, revolved around the need for alignment between digital pathology educational resources and the slow, but deliberate, expansion of expand routine clinical practice beyond the tethers of the physical optical microscope.

We knew that a trend toward digitization of pathology data was clearly emerging in the educational and clinical arenas. But, in the same breath, we acknowledged that too many aspects remained ensconced in the realm of glass and optics. Although glass and light have allowed physicians like us to peer into the microscopic world of human diseases for the past century or more, data portability and artificial intelligence cannot begin to be explored without broad digitization of the analog data currently imprisoned in glass slides. We envisioned a new educational model that would prepare trainees for a time when microscopic images are digitized and made available for onscreen visualization as they emerge from production lines behind the cloak of histology labs. At that moment, deliberating in a small office within arm’s reach of one another, we could not have imagined how a novel virus would bring our vision into existence in short order.

A forward leap
As COVID-19 spread through the United States and lockdown orders permeated the land, the routine clinical training activities that were our institution’s crown jewel all but came to a standstill. This was quite impactful in the hallways of the pathology department. Crowding around a multi-headed microscope to review patient cases was a thing of the past. Aggregating in a dark room, with 20 or 30 colleagues hovering around a speaker clicking through a slide presentation – gone. Taking center stage to present pathology findings in multidisciplinary tumor boards – also gone. Newly implemented social distancing measures made the mundane elements at the core of pathology education impossible. An eerie silence fell on the hallways and meeting rooms. All, that is, except the stopwatch inevitably ticking down toward the end of our fellows’ academic year. That countdown meant abbreviated training and lost opportunities that, for most, would never come again.

The notion of shutting down our educational activities indefinitely due to COVID-19 weighed down on our team. We knew that such an option was unsustainable – and our need for an alternative set us on the path to the most innovative educational initiative in our department’s 79-year history. It was time for telepathology to take center stage in our training.

Digital platforms were already making inroads into pathology clinical operations at our institution – including digital microscopy archiving of glass slides, second opinion consultations, and remote access for intraoperative consultations or adequacy assessment for fine needle aspiration procedures. In addition, an earnest effort to develop an integrated digital pathology service had been progressing slowly and carefully at our institution for five years – but was quickly accelerated to support novel telemedicine-based care delivery. Without a blueprint, our team took early steps to build what might now be one of the leading pathology educational platforms in the world for on hematolymphoid cancers.

An opportunity for growth
Before COVID-19, our trainees benefited from a variety of educational activities that included didactic lectures, over-the-microscope seminars reviewing difficult cases, participation in various clinical diagnostic modalities from microscopy to flow cytometry, subspecialty tumor boards, quality improvement meetings, and more. Now, faced with pandemic restrictions, how could we replicate our trainees’ 15 hours a week of hands-on education?

Scrambling to mitigate the disruption caused by COVID-19, we started with the easiest option to implement – a didactic lecture delivered via WebEx. It was a resonant (but choppy) start, with a limited guest list that included departmental faculty, fellows, and faculty members from neighboring hospitals. Wearing masks and keeping our distance, we joked a few days later about the noises we heard in the background, the learning curve involved in managing a new cockpit of controls, and the oddness of lecturing while staring at a screen rather than interacting with a live audience. But it was a start – and those wobbly first steps opened our eyes to the potential of digital learning. Could we turn the calamity of COVID-19 into an opportunity to elevate our educational and clinical training activities?

We decided that such an opportunity needed the following core elements: i) open access to educational content, ii) leverage of social media platforms, iii) leverage of whole-slide imaging technologies, and iv) real-time clinical care and quality improvement discussions with restricted access to in-house personnel.

Within days, we had fully transitioned to online meeting software for our daily educational sessions. To continue our conference series – which involves unknown cases that attendees diagnose based on microscopic examination and on-the-spot drills – we developed a workflow to digitize cases on whole-slide scanners and post them online for study ahead of the virtual meeting (allowing our attendees much-needed flexibility). Finally, we used Twitter to announce our educational sessions ahead of time and share links to view the virtual slides. The process was new, exciting, and refreshing against a backdrop of unprecedented worldwide disruption. It also launched our journey into online pathology education – incarnating the very essence of our discussion only a few weeks earlier.

Within a week of their debut, our virtual conferences had attracted more than 240 attendees from 79 institutions spanning 32 states within the US and 17 countries covering nearly every continent. Within a month, we had more than 2,360 people attending our virtual educational offerings, and by three months, we were well over 10,000 – a far cry from the eight hematopathology fellows (plus a few visitors) who had attended the in-person lectures!

What was holding us back? Did we really need a pandemic to push us into the future of pathology education? And, now that many people are returning to in-person work and education, can we maintain our momentum? Only time will tell – but we think telepathology training may be the way of the future.