Response to Survey on Digital Pathology Adoption

I received some feedback, e-mails, questions, comment and death threats about my recent posting entitled  "94% of Pathologists Agree Digital Pathology Will Become Common Practice"

One in particular I have extracted from a LinkedIn message board in response to my feed to the group. If you are a member of this particular group you may have seen this.  If not, to protect the innocent, I will leave the respondents name anonymous. His comments are in plain text with my opinion in italics and/or bold. 

"This is a very interesting, yet misleading headline.
This is not one-size-fits all.
I think that when one reads this headline, it is our impression that digital pathology will replace the standard microscope and H&E slides. Not a chance, in my opinion, in the next few years. I have replied on this topic many times before. This is NOT, however, stating that digital pathology will not be adopted."

— Of course the title is misleading.  And interesting. Not as misleading as "Dewey Defeats Truman", "Mission Accomplished" or "New Coke Better Than Old Coke" but I appreciate you calling my little blog post title a "Headline" nonetheless.  Trying to promote content here so I used this title as opposed to "6% of those surveyed say chances of digital pathology adoption equal to Cubs chances of winning the World Series (NEVER)".  After Steve Bartman I may lose some friends on da North Side. Anyways, you read the piece and commented so the headline had some attraction which is what a blogger needs – catch those 2 or 3 minutes out of your day to read what I write among all the other things you want and have to do including reading legitimate news sources.

If the headline read "Digital Pathology to Replace Microscope in 10 years" that might be misleading and completely inaccurate, in my opinion.  I actually think it will become part of common practice but not replace common practice.  Perhaps 20 or 40% of work will integrate or involve digital pathology but not selling my stock in wax, glass or microscope companies just yet so I think we can agree on this.

"One has to look at the APPLICATION of digital pathology. Let's look first at routine pathology. Digital is a LONG way off. Why?….here are some thoughts.
1. It can't compete with routine H&E for in expense. Digitizing slides just adds expense.
2. Digital can't replace the routine H&E. The slide still has to be produced. (unlike radiology which eliminated the need for film)
3. The "look and feel" of a slide still has not been replicated by digital.
4. It's still more reliable to store a physical glass slide for 10 years than a digital file.
5. I still can look at an H&E slide with a microscope that uses a mirror for illumination, and it won't take any power to run a computer (the ULTIMATE green solution)."

— I agree with many points made here.  Scanning adds costs.  A nickel H&E may result in a 90 cent image that has to be acquired, labelled, archived, stored, backed up and eventually perhaps disposed of.  Have made this argument before – unlike radiology which starts with digital CT and MR images that initially were printed on pieces of plastic for viewing on light boxes and "hot lamps" analagous to those used by Roentgen himself, pathology, tissue, histology is well founded in physical analogs as mentioned above in terms of wax, glass and stain after the tissue have been collected, heated, cooled, baked, fried and stained.  The cost issue I think does go out the window a bit if we speak to the points you make below about looking at something 1000 miles away.  This helps costs:benefit ratio business case argument.  More below on this.

— "Look and feel" best used by interior decorators, not physicians.  As far as imaging is concerned, Kodak use to make film, lots of film and now they don't and they are still bankrupt.  I still try to shoot some hobby photos with film.  Takes weeks to get it ordered and longer to get it developed.  Have to send to Atlanta.  Nearest place from Charlotte to send film to be developed.  Doesn't anyone use 110 or 35 mm anymore? Anyways, look and feel overrated and this will be improved.  I like the grainy nature too of good old black and white film and a long f/stop but I can do some much more with digital.

— And this is the analogy (no pun intended), like radiology, we are going to see so many more deliverables with digital, just as radiology has with 3D imaging and the like that we can do with 2-dimensional pink and blue stained images (or bichrome IHCs).  

— "Slide storage" and "reliable" are not usually words I put in the same sentence.  Take the case from last week the patient wants sent to a medical school pathology department and the slides "are not in file".  Or the slides are in the file room, but misfiled.  Or the slides are not filed.  Granted, most of the time it works.  Digital would be no less reliable, perhaps more secure and perhaps most importantly, not only stored, but sharable, to your points below.  Rent and expense of slide file room versus 100 TB of server space in terms of costs over 3 or 5 years?  With wind and solar energy running the factories and powering our homes and businesses, costs of either would be very low.

"Now….for specialty uses….Digital beats glass…

1. Send an image a 1000 miles away for a consultation.
2. Send an image of an IHC or FISH for analysis from a 1000 miles away.
3. any permutation of the above."

 –  Could not agree more. One of the two most tangible ROIs for digital pathology, today, remain, tele-pathology, tele-consultation, tele-IHC, virtual consultation, virtual IHC, tele-peer review, tele-whatever, remote screen share, image host, same slide, same time.  No substitute for this in medicine and pathology.  And with Pathology 2.0 – the power of the cloud to harness collective intelligence.  The other tangible use case/application for digital pathology is image analysis.  FDA cleared algorithms and CPT codes for reimbursement.

"There are also some other applications that simply cannot be done on an old H&E slide that is easy with digital (if there are any companies out there interested…let me know). At this point, they will remain un-published."

— When the times comes I welcome you to publish your thoughts here.

"Let me know where you think I am going wrong. I would like to hear your thoughts…"

— Thanks for the thoughtful comments and dialogue.