Pathology is an area that has witnessed the most transformative changes due to the advent of new technology, especially in precision medicine. While this has helped pathologists to constantly update their knowledge and toolkit, it has also raised the diagnostic burden in labs across the world. For instance, newly emerged molecular pathology helps pathologists study a set of markers on each patient and predict which therapy will be most beneficial for each of them. Telepathology service enables any pathologist in any corner of the world to beam images to a specialist. Furthermore, the images can be shared across the globe on different platforms to educate and evaluate pathologists and medical students. They can also be analyzed through algorithms of artificial intelligence to provide more accurate and reproducible diagnostic reports. At the same time, this has also increased the diagnostic burden. Pathologists must work diligently to diagnose several slides within hours of it being prepared as treating physicians seek quick answers. When one person tends to diagnose many slides in record time, it raises not only the work burden, but also chances of a mistake, especially at a time when the number of pathologists is dwindling across the world. But overall, we are going through an interesting period as these developments have led to positive changes in pathology education, training and practice, ultimately benefiting the patients, says Dr Shivayogi Bhusnurmath, a world authority on pathology education and training and Dean of Academic Affairs & Chair and Course Director for Pathology at St. George’s University. Winner of the 2020 Excellence in International Pathology Education Award, Dr Bhusnurmath is our guest in this month’s Straight Talk
Technology is making bigger advancements and changing the paradigm of diagnostics and investigations. Are these changes creating more challenges or opportunities for pathologists?
Advancements in technology can be a mixed blessing. For example, technology is helping us to move more towards personalized medicine. As an example, five women that have developed breast cancer that look similar under the microscope with routine stains may not respond uniformly to a standard line of treatment. Molecular pathology helps pathologists study a set of markers on each patient and predict which therapy will be most beneficial for each of them. Thus, each patient receives personalized treatment for a cancer that looks similar under the microscope, with beneficial results. Previously, standard lines of treatment may have helped one while not helping the other four patients.
On the other hand, each of these tests is expensive as they may have to be run in specialised laboratories which have standardised the tests, running them every day with positive and negative controls. (Most departments cannot afford to run these tests by themselves because of sample numbers and costs.) The referral leads to delays in diagnosis and increased costs. Pathologists are reimbursed on the code- based diagnosis and may not be satisfied with the amount because the tests have actually cost more to run.
Pathologists must also constantly update their knowledge because of developments in the field. The increasing number of lab tests available for fields like bleeding or clotting diseases make it difficult for the treating physician to advise on the appropriate pharmaceuticals to use and how much. Clinicians who may not be very diligent in using cost-effective lab tests may end up ordering a plethora of tests just because they are available on the system. The results may confuse the treatment options and raise the cost of treatment, with the potential of leading to adverse effects on the patient when abnormal lab tests are treated instead of the disease itself.
Has the dwindling number of pathologists actually led to an increase of diagnostic burden in the labs across the world?
Indeed, it has. Pathologists must work diligently to diagnose every slide within hours of it being prepared as treating physicians seek quick answers. When one tends to diagnose many slides in record time, there is a potential for mistakes. The evidence on which a pathologist makes a diagnosis is permanently stored in the slide. It could be reviewed by anyone at a later time to look for diagnostic errors. Hence there is a lot of pressure on the pathologists to deliver results not only quickly, but also accurately.
Can digital pathology play an important role in providing the much-needed flexibility for the over-burdened pathologists? How do med-schools take this as an opportunity?
Digital pathology has become a big educational and diagnostic tool in recent times. The telepathology service enables any pathologist in any corner of the world to beam the images to a specialist pathologist, like a skin pathologist, and get an expert opinion quickly and is of great benefit to the patient. Furthermore, the images can be shared across the globe on different platforms
to educate and evaluate pathologists and medical students. The images can be analyzed through algorithms of artificial intelligence to provide more accurate and reproducible diagnostic reports. Online images and virtual microscopy have expanded the horizons of pathology education for medical students as well as pathology residents. The COVID-19 pandemic has led to the evolution of virtual sessions which have opened up a new horizon on global education using digital images. The future seems to be focusing on artificial intelligence in digital pathology to reduce costs, reduce the load on pathologists, and achieve a more accurate diagnosis.
Has the current trend of early-stage cancer detection added to the complexity of pathology?
This is again a mixed bag. It has indeed increased the workload on pathologists and radiologists. The ultimate benefits are however questioned by some experts. Some cite the tortoise, rabbit, and the eagle context. Not all cancers grow at equal speed. Based on the molecular damage to the DNA, some grow very slowly and move with the speed of the turtle. Some grow very rapidly and spread or fly to other parts of the body like the eagle and the third category are in between, like the rabbit which runs fast but cannot fly to distant parts.
Interestingly, most cancers detected early by aggressive measures tend to grow very slowly and it is debatable whether the early detection really helps in prolonging the lifespan or quality of life of the patient. The patient might have lived the same life span even if the cancer was not detected early. Experts often quote examples of early prostate cancer and breast cancer detected by mammography. Although caught early, the diagnosis of cancer itself and the surgical and or chemotherapy instituted after the diagnosis of early cancer may decrease the quality of life and increase the anxiety of the patient and the family. Some cancers which fly like eagles very fast and fly over the fence, may not benefit from aggressive early screening measures because they would have manifested soon after anyway with symptoms. The early cancer detection in such patients may not materially affect the longevity or quality of life because it spreads rapidly and may not respond to therapy well. On the other hand, there is the other school of thought that we might really benefit a certain segment of patients by early detection of cancer by providing robust early treatment and preventing its eventual spread.
The latest estimates show that residents do not seem to be too inclined towards pathology as the majority prefer other specialties. Is this the case with med-schools across the world including St. George?
The pathology forums in North America keep discussing ways to motivate medical students to take pathology as a career. Historically only a small fraction of a graduating medical school class opt to focus on pathology. However, at St. George’s University, we have many students graduating and pursuing degrees in pathology. Over the past five years, St. George’s University has had more than 70 graduates securing first-year US residencies in pathology.
What is your assessment of the quality of pathology education in India and how does it compare with that of St George’s University?
The pathology training in India has variable quality based on the institution, its facilities, and the quality and numbers of its faculty. There is variability in the standards of exit exams because they are determined by individual universities. There are attempts in recent years by the central agency to oversee medical education to standardize the learning objectives and exams in medical schools. The pathology labs also exhibit wide variation in their quality control and the reliability of test results. Unlike the US, where lab accreditation by CAP- College of American pathology is mandatory, there is no such mandate in India. The bulk of the training of a pathologist emphasizes surgical pathology, while the pathology practice in real life is mostly clinical pathology. The pathology taught to medical students in India tends to be a duplication of textbook material with very little emphasis on the application of pathology knowledge to clinical reasoning and applications. The students tend to memorize facts and pass the exams which tend to test rote memory rather than clinical problem-solving. At St. George’s University, the pathology taught to students totally emphasizes clinical analysis, interpretation and problem solving using the basic principles of pathology as the basis of medicine. These concepts are further reinforced in the final two years that focus on clinical sciences, with training available at more than 70 leading hospitals and health systems in the United States, and the United Kingdom. Our approach to clinical training gives students an opportunity to learn medicine in a broad network of hospital settings throughout the US and the UK, with core rotations, sub-internships, primary care, and elective rotations. Clinical training emphasizes responsibility, maturity, and compassion in the development of professional excellence
As the winner of the 2020 Excellence in International Pathology Education Award, what is your perspective on the emerging trends in pathology education globally?
Pathology education is definitely going digital. There is an attempt to provide educational resources to any student who is interested by shared faculty and image resources nationally and globally. These shared resources can benefit any trainee irrespective of his or her location and their institutional facilities. YouTube is providing access to any number of educational videos. Delivering CMEs online has made them more accessible and less expensive while still remaining interactive. Telepathology has provided expert consultations to far off places where no local expertise is available. These are the common themes we discussed at the International Academy of Pathology (IAP) meeting last week. I am an executive committee member of the IAP and we publish the IAP bulletin through our pathology department at SGU. I have been invited to give an oration on this very topic in February 2021 at an international conference in Cochin in India. I presume the trend is similar in other disciplines too.