Whole Slide Digital Images in Residency Education: Sliced Bread or Iced Dread? Lewis A. Hassell, MD University of Oklahoma Health Sciences Center Pathology Visions October 2010

Pathology Residencies Approximately 40% of resident candidates come from schools using digital slides exclusively to teach pathology topics Approximately 65% of residency programs use digital slides in some way Almost all programs have access to digital slide collections in some manner (41% have scanners; 10-15% use scanning services) Survey of ADASP Oct 2010

How are residency programs currently using WSI? Teaching Conferences (50%) Extradepartmental conferences (e.g. tumor boards) Digital slide box of teaching cases (40%) Unknown slide challenges (30%)

Resident evaluations The majority of histopathology slide evaluations on the ABP exams involve use of WSI The RISE offers only minimal use of WSI A small minority of programs use WSI in any way for internal evaluation of resident progress Resident-level traffic on self-evaluation sites using WSI is unknown

Pathology Resident Capabilities: Are we at the end of the beginning, or just the beginning? ACGME requirements are organized around areas of “competency” ABP eligibility requirements include many “time-based” and “number-based” requisites or thresholds

ACGME Competencies Patient Care Medical Knowledge Professionalism Practice-based learning Communication skills Systems-based practice How can WSI impact residency education in these competencies with regard to a) acquiring the competency, and b) assessing the competency?

Patient Care Competency Residents… learn how to examine a slide completely Can find and correctly identify critical diagnostic features Can interpret a broad spectrum of special stains and IHC Learn how to apply advanced tools- image analysis, CAD, etc. appropriately Learn to interact with patients in explaining pathologic findings

Patient Care Competency Residents learn how to examine a slide completely Learn how to find and correctly identify critical diagnostic features Learn how to interpret a broad spectrum of special stains and IHC Learn how to apply advanced tools- image analysis, CAD, etc. appropriately Learn to interact with patients in explaining pathologic findings Slide-search mapping and tracking tools Annotation, “hot box,” photo- documentation and other tools (Chaser et al. ) WSI transmitted via internet expand library of available stains Coming Structured patient encounters (Hunt et al.) using iPad and digital slide photos or WSI

Medical Knowledge Residents are proficient in microscopic diagnosis of a very broad spectrum of pathologic entities Able to properly stage and evaluate prognostic and theragnostic variables

Medical Knowledge Residents are proficient in microscopic diagnosis of a very broad spectrum of pathologic entities Able to properly stage and evaluate prognostic and theragnostic variables WSI-based sequential assessments (UI tool) Virtual Slide Boxes &Teaching Collections Sign-out simulation using digital slides in workflow Competency evaluations using standardized WSI

Sample UIowa Competency

Professionalism Residents exhibit habits of thoroughness in case evaluation… Develop patterns of preparation for patient and professional encounters… Demonstrate integrity and respect for patients and colleagues.

Professionalism Residents exhibit habits of thoroughness in case evaluation Develop patterns of preparation for patient and professional encounters Demonstrate integrity and respect for patients and colleagues Slide examination tracking tools to monitor time spent, magnifications, completeness of examination Preparation for “unknown” conferences documented vs. “call it from the screen”

Communication Skills Residents are able to communicate findings clearly and succinctly to colleagues in reports and conferences Able to explain findings directly to patients Consistently provide all needed information for further medical care

Communication Skills Residents are able to communicate findings clearly and succinctly to colleagues in reports and conferences Able to explain findings directly to patients Consistently provide all needed information for further medical care WSI use in tumor boards Extracted images included in reporting

Practice-based Learning Residents use current case material to guide study and expand knowledge Able to identify gaps in their abilities and knowledge from QA data trends

Practice-based Learning Residents use current case material to guide study and expand knowledge Able to identify gaps in their abilities and knowledge from QA data trends WSI workflow allows insertion of “reinforcer” cases to coordinate with didactic processes Real-time feedback from QA WSI cases Recognized areas of low kappa values can be included periodically to improve uniformity

Systems-based Practice Learn to consult colleagues appropriately Residents recognize the impact of their work on health systems and society

Systems-based Practice Learn to consult colleagues appropriately Residents recognize the impact of their work on health systems and society WSI lower the threshold for broad consultation with experts and peers that are trackable Adjustments in criteria and follow-up can be evaluated as a part of real-time QA using WSI

Current Challenges for Resident Education Low level of penetration of WSI into daily work routines– few role models Clunky interfaces and jury-rigged workstations Time pressures favor most efficient method of examination

Additional Challenges Pseudo-interactive vs. truly interactive connection with peers over the slide -Virtual reality vs. reality -Value of informal scope sessions in learning for trainees

“Are we there yet?” challenge Infrastructure build-out– Are we really ready to live in this house yet?

Disruptive or Adaptive? WSI have the potential to disrupt many currently “time-based” and “site-based” activities in residency, leading to displacement of existing models of training and credentialing as well as practice Institutional and organizational responses may be to seek to co-opt, subvert or suppress the technology, rather than to adopt and adapt…

Summary WSI may not yet be the best thing since sliced bread when it comes to Pathology Residency Education, as on many fronts the loaf is still either awaiting the leavening to penetrate the whole loaf, or at best half-baked. But….

Summary But it is not “iced dread” either—unless we view the offer of tremendous potential to entirely or significantly disrupt existing models of education as a threat. But here, the lesson from industry should be instructive—adapt or become irrelevant.

Acknowledgements Michael Talbert, MD Kar Ming Fung, MD, PhD Brad Chaser, MD Linda Freeman

Questions?