Digital Pathology Blog

The public health events of the past few years changed our society as most of us knew it. Downtown commercial office space in our cities remains widely available. Even the sprawling suburban campuses around those large cities designed to entice workers to work closer to home for work-life balance are now being sold at a fraction of what those properties were valued at just several years ago. As a railfan, I know that ridership on commuter trains remains significantly below pre-March 2020 levels.

From baby boomers to millennials, folks are working remotely. This is not entirely new to some verticals, but for many industries and markets, it is. A 4-day office work week with a remote Friday or Monday was well-established in the past. After 9/11, many large companies with operations in large urban areas established virtual private networks should the need for them arise in our future. Insurance, retail, sales and marketing, financial houses, consultants and the like had many of the necessary components in place in March 2020 for this transition.

This line, of course, was made popular in a scene from The Phantom Menace: Episode 1. A deadly fish is chasing Qui-Gon and others underwater, and that fish gets taken down by a bigger fish. As fishermen, we often use this line after catching a good sized fish, but not a huge fish. You get your bait, jig, crankbait or other contraption you have come up with back in the water to catch a bigger fish.

Over the past three decades, this has been a constant theme in healthcare and laboratory medicine. Mergers and acquisitions are commonplace, and while the big fish have swallowed up the little fish decades ago, there is always a bigger fish.

As a first-year pathology resident, one of both the most daunting and exhilarating experiences of your training was presenting at tumor boards. The preparation to do so as a junior resident, meticulously reviewing every slide and picking the best ones to show the pertinent findings, was in and of itself a laborious task. Reviewing them again with your attending to confirm the slide(s) you chose showed the pertinent features also took time. Thinking about what to read in the report during the course of the tumor board was another task, planning for when the moderator says, “Can we review the pathology?” and what your spiel was going to be.

My maternal grandfather was a glazier. He was orphaned at a young age and raised in an orphanage on the West side of Chicago with 2 brothers. One of those brothers died during adolescence. My grandfather and his oldest brother fought in World War II and became part of America’s Greatest Generation. He and his brother started Chicago Glass which became the largest glazier company in the city. For over 30 years, my grandfather hung glass on some of the tallest buildings in the world at the time. Sears Tower, John Hancock, Lake Point Tower, Standard Oil, you name it, he worked on it. Buildings downtown had to be “glassed in” by November 15 if the electricians, plumbers, elevator, drywall and carpet guys were to have a chance to work through the winter for spring occupancy on a residential or commercial high rise. In the winters, my grandfather drove a cab between “indoor” jobs such as hanging mirrors, repairing windows or building storm windows. He would drive me around in his large Checker cab and point out what buildings he worked on and what he did, what worked and what didn’t, if he got injured, or one of his men did, and when they “glassed” it in.

A radiologist, an internist, a surgeon and a pathologist go duck hunting. The radiologist is up first and a flock of ducks fly overhead. He raises his shotgun but does not shoot. The surgeon asked him why he didn’t shoot to which the radiologist replied, “They had the outline of ducks, their contrast looked like ducks, but I wasn’t sure they were ducks.” The internist is up next. When the next flock flies overhead, he raises his shotgun in the air but does not shoot. The surgeon, getting irate at what is happening, asked the internist why he did not shoot to which the internist replied, “They looked like ducks and quacked like ducks, but I wasn’t sure they were ducks.”

There is a joke among surgeons and oncologists -- the pathologist at a tumor board is like the guy whose funeral that you are attending; you can't do it without him, but you don't want him saying too much. 

Nearly 2 years ago, our tumor boards went "virtual". Like billions around the world, we scrambled to get Zoom, GoToMeeting, WebEx and other applications up and running to hear each other’s voices and share screens to show radiology and pathology images. We anticipated that by the Summer or Fall we would be back to "normal".

Recently I received a call from an oncologist. After giving me the patient’s name, she asked “What does the gene panel show?”

I responded we didn’t have the patient’s biopsy yet, that he was scheduled to undergo a CT-guided needle core biopsy, and we would process it overnight and review tomorrow as we normally do.

The oncologist acknowledged the patient was undergoing the biopsy in the afternoon, and we hadn’t even yet done an immediate fine needle aspiration rapid on-site assessment prior to the core biopsy.

Surgical pathology is increasingly becoming more based in molecular diagnoses rather than morphologic diagnoses. For 150 years, morphology has been an accurate predictor of clinical behavior with standardized criteria for both histological grading and pathologic staging of tumors. While there are certainly “gray areas” in morphology and classification of disease, a traditional approach of classifying tumors based on location, gross pathologic findings and histologic findings combined with immunohistochemistry, over the past 30 years, has served our patients well in terms of classifying tumors for appropriate therapy and management.

My grandfather, who was self-employed, made a living as a glazier and drove a cab in the winter when he couldn’t hang 10-foot panes of glass 100 stories above the city if it was too windy. The jobs required him to be aware of his surroundings constantly, whether high above the city putting glass on a skyscraper or running the one-way streets around the downtown Loop.

Telepathology, the ability to view remote pathology images, and more specifically, the technology to allow this to happen, has been available for more than 50 years.