The Virtual Pathology Lab

There are many hurdles in the world of digital pathology, but I believe three in particular stand in our way. In this piece, I hope to show how I’ve tackled each of these through my online lab resource, and illustrate how the advantages of digital pathology are often the solutions to its greatest challenges. This can be seen as somewhat of a guide – highlighting how anyone, no matter the budget, can make practical resources for pathologists and patients.

The first challenge: to bring the non-expert into the world of a pathologist

The average person has no idea what goes on in a real laboratory – in this case a diagnostic pathology laboratory. How would they? Why should they? Well, let me tell you why.

For one, it is interesting! Plus, it gives you a chance to see what goes on behind the curtain. It would be a fascinating opportunity to see a real digital slide move right and left, zoom in and out. People may never get into a pathologist’s lab, but they can easily access it here and it may be an exciting experience. Not to mention they will get to see what happens between the piece of them that was cut out and the strange words on the report that comes back; they may come to appreciate the skill and techniques that the pathologist brings to making that critical report and have increased respect for the pathologist’s role in the patient’s healthcare.

With regard to keeping patients interested, the best way, I believe, is via a story – and you can find a number on my virtual lab. In The Sin of Occupying False Premises, they see the back-and-forth between the pathology residents and the different possible diagnoses. In Can You Find the Mucin That’s Loose in the Tumor? they see a resident arrive late for the discussion about staining, conduct his own stain and come up with an improper conclusion. In Where’s Patho? they see that there is more to diagnosis than just a peek at the screen. These scenarios are short, but each gives a real life look at what goes on before the report comes back. The pathologist becomes more real, a professional to whom one can relate, doing a job one can respect from knowledge, not just from their credentials alone.

My first piece of advice is that it’s important to bring the public into the world of the pathology lab, whether through education or entertainment.

The second challenge: to sharpen the skills of professional – but early career – pathologists

The stories I detail above have an even greater impact for pathology professionals. In The Sin of Occupying False Premises, for example, they see what misdiagnoses can occur if one does not pay attention to the notes from the clinician who submitted the biopsy. In Can you Find the Mucin That’s Loose in the Tumor? they are reminded of the need to keep up with the latest literature. Other stories provide a good review of the pros and cons of different staining techniques. The tales told in International Cases make the point that one needs to watch out for look-alikes (is it a worm or tumor?) and a disease in a foreign country that we may not be familiar with in the US but should be – as Did Lou Gehrig Eat Shark Fin Soup? shows.

Although these stories are useful pathology teaching tools, the greatest resource for professionals can be found in the access to whole-slide images. In undergraduate medical school, the textbook shows a static image – framed, idealized. In my virtual lab, the links are to digital slides of the whole “biopsy” slice (as available online), where the question is not only “what is it?” but “where is it?” The challenge that pathologists’ face is that much of a real slide is actually normal tissue. They must know normal versus abnormal. They must be able to scan the whole slide and to find the region of interest, to decide which level of magnification is appropriate to make the relevant observation.

My second piece of advice is that it’s important to train students and residents with real slides, using medical backstories that teach important professional lessons in an enjoyable way.

Third challenge: to do all of the above for free

Generally speaking, preparing new platforms and formats for medical education, especially in the digital realm, is highly expensive. Funding is needed for an IT department to develop software and purchase  hardware. Funding is even needed to make it available online, to present it to the outside world. I have developed a way to save all that money. I used the Twinery site software (www.twinery.org) to create my virtual lab stories. The programming knowledge needed is minimal. Page by page, the steps in the story emerged, including embedded links to outside locations. The end result was an HTML file on my desktop. No charge.

Then, I used a second site that hosted the HTML onto the web and made it available to the world. The site is Neocities (https://neocities.org). Again, no charge necessary. These two can form the basis for medical education in many disciplines at zero cost.

The key to this approach is the use of links. The slides presented here are not part of my collection, and so I have no need for a dedicated server to host them. Rather, these are all publicly available digital slides – whether my own set hosted by Pathomation, or digital slides built into journal articles or available collections. Speaking of journal articles, the same applies to them. There might be dialogue in one of my stories that says “Check out this article,” and with one click the reader has the actual journal in hand. The behind-the-scenes prerequisite (especially for the slides) is that the target is immediately available – so no passwords, and no multiple steps to get to what you want. So, as quickly as one could look down a scope or pull up an image, the reader is able to access any material that is used in the story. Verisimilitude!

My last piece of advice is that even if you have a small budget, your impact can still be big.