In this newest episode of PathPulse, Jake Brown interviews our esteemed guest Dr. Lewis Hassell. Dr. Hassell is a pathologist and Director of Anatomic Pathology at The University of Oklahoma Health Sciences Center. He leads the Open Pathology Education Network (OPEN), which provides digital education to pathologists in underserved regions, with pilot programs launched in Vietnam. Dr. Hassell has a strong focus on resident education and the use of digital pathology for both training and global care. He completed his residency in Clinical and Anatomic Pathology at Massachusetts General Hospital and a fellowship in Nuclear Medicine at UCSF. He is board-certified in Cytopathology and Anatomic/Clinical Pathology.
Tune in to listen to his insights and hear about his work in digital pathology to help solve some of the access to care issues that we face, both domestically as well as internationally, largely focused on the supply and quality of pathologists.
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Transcript
Welcome to PathPulse: Pathology Innovators in Action, your go-to podcast for practical and implemented digital pathology insights.
Jake Brown: All right. Welcome to the PathPulse: Pathology Innovators in Action podcast. We’re thrilled and excited to announce that we’ve rebranded from Ask a Pathologist podcast, and we’re trying to focus more on showcasing pioneers, innovators, and trailblazers who are transforming digital pathology from theory and hypothetical into actual daily implementation and use. In today’s episode, we will be exploring the potential of digital pathology to help solve some of the access to care issues that we are facing both domestically as well as internationally and how lots of those issues actually are hinging on the supply and quality of pathologists.
So, our guest today is Dr. Lewis Hassell. We’re very excited to have him with us, and he is particularly suited very well to talk about this topic, as he’s been a member of the Digital Pathology Association since 2009 and is quite the pioneering educator in digital pathology. We welcome you, Dr. Hassel. Would you mind telling us for a minute a little bit about your background in pathology and your interest in the topic?
Lewis Hassell: Well, Jake, it’s really good to be with you, and I appreciate this opportunity to talk about where digital pathology has brought us and where it can further take us. So, I began my life post-training working in the private practice field.
Actually, for a considerable length of time was in a rural practice, kind of in a rural state in the Northeast. We had 16 to 18 hospitals of varying size, mostly small, that needed pathology services. We were trying to distribute the efforts of a dozen pathologists or so over a very large geographic area. And sometimes, that meant driving through snow storms and driving over icy roads to go down and do service for one patient. Although we were happy to give that service, it often seemed like an enormous effort that was not always indicated because, truth be known, sometimes the surgeon just wanted you there to hold their hand rather than to provide the best care for the patient.
So, you’d be driving off down through the snowstorm going, “dumb frozen section, dumb frozen section”, and so forth. But it underscored the point that there was certainly room within the domestic space for some of the innovations and technological advances that could allow us to extend high-quality care to patients even in remote locations. Now, I also have in my background a considerable amount of work in developing areas of the world. I have a particular passion for and love for the people and culture of Vietnam. And that’s an area where, you know, I first visited hospitals there in 1989, and it was like going back to the early 1900s in some respects with regards to the equipment and so forth that they had to deal with. You know, we’re talking about microscopes using mirrors to focus the light and things of that sort that just would belong in a museum.
And that oftentimes means not that the people are unhappy or that they have tragedy in their lives, but it certainly means that their lives may not be as long as they could be or that they may not get treatment for certain things that are entirely treatable because they lack both the technical and the intellectual expertise to be able to make the right diagnosis.
Some years ago, the CAP coined the phrase that the cure can begin once the diagnosis is made, and that’s where pathologists are at that critical nexus of making the diagnosis, and that’s true whether it’s looking at a piece of tissue, a biopsy sample, or whether we’re just looking at a blood specimen. Pathologists are involved with, you know, regulating and running and evaluating, making sure that the quality in all aspects of laboratory testing are optimal for accurate, reproducible, and reliable results. So that’s kind of the backdrop for where I am now and for kind of my passion as we’re seeking to see what we can do to raise the bar and to accelerate the expansion or the spread of pathology services to areas that are underserved or, in many cases, completely unserved throughout the world.
Jake Brown: Yeah, yeah, that’s that’s a fantastic backdrop, and it’s also like, I have all these questions, all these things I want to talk about, and so my brains like, okay, where do I start?
I want to ask all these questions. But if you’re okay with it, I’d love to just jump right in and I’ve got a question-
Lewis Hassell: Let’s do it.
Jake Brown: I’ve got a question for you that I think is just blaring in my mind, and the question is around something that you said as you started to describe your background in your history a little bit, which was with the experiences that you had driving through the snow and having these opportunities where like, you know there, there could be a better way to do this.. When did you first have the chance to do digital pathology in a way that made life better? and then once you had that experience, how long was it before you were able to take those experiences and translate that into your experiences with Vietnam?
Early Work and Experience in Digital Pathology
Lewis Hassell: Yeah, so that’s still a work in progress.
But, you know, I will…
There are a couple of aspects or a couple of types of digital pathology.
So, at its very most basic sense, you know, any time you acquire a digital image of pathologic materials, you’re essentially doing digital pathology.
Now, it’s not always, you know, the recipient who’s driving what is photographed or what is digitized and so forth. But for a long time, you know, digitization has been possible. Since the early 90s, we’ve had good quality digital cameras that could attach to your microscope and generate a, you know, digital image of a fixed area.
And so, from that standpoint, I began seeing consultations from colleagues overseas using those kinds of fixed images, you know, very early in the 1990s.
And you know, sometimes you could make sense of them and sometimes they were set up to, you know, go down the wrong pathway.
And that’s where the need to, you know, to have full slide digitization and other sorts of improvements allowing the recipient greater leverage and greater ability to see and examine the whole context of a slide rather than depending on what the sender has chosen.
And so that underscores the fact that there are kind of two sides to this.
There’s the acquisition aspect of it, which requires a level of expertise and understanding.
And then there’s the interpretation side of that. The distance in between can be large or great, across the hall or around the world. But if you lack, it’s difficult to compensate entirely for missing IQ points on one end or the other. So, you do have to have some level of training to be able to acquire a good image and you have to have some level of training to be able to interpret a good image. And the value of that, of course, is that by being able to share, collectively, our IQ points go up.
I mean, if I may be a mediocre person, but I can acquire a good image, but if I’m linked up and connected to somebody who’s the world expert, then suddenly I’m a whole lot smarter, and we can render a whole lot better care. And so that’s really what digital pathology allows us to do, is to make that connection for people across broad areas and broad distances that, in effect, raise everyone’s IQ, raise everyone’s level of expertise, or at least their access to expertise that will get the right answer.
That’s been an ongoing process. Fixed images in the 1990s, and in the 2000s, we began to do whole slide digital imaging. That wasn’t widely applied or widely available. Those scanners were expensive. When our department acquired its first scanner, it wasn’t using our budget. It was a combination of several departments’ research and clinical budgets to obtain that scanner and pay for it and the various storage devices and software required.
So, at that stage, it was still a work in progress. Now we’re much further down the road now.
And there are relatively inexpensive ways to acquire digital images now and either stitch them together as composite whole slides or to scan the whole slide as a single function. So many times, those kinds of functions can be done with cameras that are actually, truth be told under $1,000 in some cases, and scanners that are, you know, 10 or $20,000 that can fit on your desktop. Now they’re not high throughput processes, there’s a lot of manual effort there, but it does bridge that gap of gaining access to that expertise. So now that when I get a consult from Hamnoy, you know, very often they scanned it with one of those methodologies, and I can look at the scan, and I can look at the stains that they’ve sent, and so forth, and provide a much better answer, a much more educated answer, as to what sort of considerations that may prevail for the patient, and what, if anything, needs to be done further.
Jake Brown: Yeah. Yeah.
That makes a lot of sense, and I love that description and that timeline going back to the 90s when you first experienced it with fixed images and kind of the history of how that’s gone. I guess I didn’t realize that the 90s is when that started, but it makes sense. You say, like, oh yeah, that makes sense, that they would have started seeing stuff then.
Lewis Hassell: Well, that was back when you had a little card to put in the camera, and you’d pull the card out, and then you’d plug it into another device and so forth.
So, the pathways of history and the technologies of the past are intriguing, and the pathology is full of them, just like the old 8-track tapes that people used to carry around in their cars. I mean, there are people now who still have the little flash cards and so forth with their floppy disks with images stored on them or CD-ROMs and so forth. We progressively move forward, but the key step is that digitization that allows us the manipulation of the image and management and extraction of data from that image.
And what we’re discovering now is that there’s a lot more data in those images than we even thought before. It’s more than just the three colors and shapes and sizes. There’s really molecular information in that data that now more and more people are able to extract just from the image pixel data alone. Let’s talk a little bit about the education side of things because that’s really my passion.
And any time you’re starting to think about how can we improve the IQ points or the expertise on one end or the other of this process, you have to think about how we educate people.
Digital Pathology as a Teaching Resource
Truth be told, the COVID pandemic was an enormous emotional and physical and intellectual trial for everyone in the world, but coming from that have been a number of very, very significant advances in our perceptions of how to educate and train and how to share information and what can be accomplished. So, you know, we began quite early on in our department to use digital slides as a teaching resource.
A trainee may come in and they may look at your cases on a given day and so forth, but they may not see all the great cases that you have.
And so previously, you’d have to pull out a slide box and give them a box of glass slides to go look at those kinds of cases that you had accumulated over your career.
Well, now you have those digitized and you can post them on a central location and not just one resident, but all of your residents from now till eternity can look at those and gain the expertise from that. And then, now you have the development of more libraries of materials so that not just one institution or one pathologist can share their best cases and their most stellar examples of certain things. That way, anybody can share that, and almost anybody can access that if they have, you know, a little bit of bandwidth on an Internet-connected device.
So that change of making digital slide materials, digital education materials much more broadly available coupled with the, you know, the ready access to high-quality teaching materials that people began to develop during COVID for asynchronous teaching. And we have the genesis or the seedbed to create a training regimen, a training program that can be literally accessed and applied anywhere in the world. And that’s such a dramatic change for the usual paradigm, because the paradigm in pathology education was kind of knee-to-knee, face-to-face, across a microscope with the expert, with the attending, the mature seasoned pathologist, one-on-one, or maybe, you know, five- or ten-on-one or something at the most. But it was all in-person, live, based on the wisdom of that person teaching.
But now with Skype and Zoom and all these other modalities, you can do those sessions live, yes, and stream them to dozens of countries or whatever, do whatever you wanna share with.
But you can also stream them live and record them so that they then become available asynchronously to people who aren’t in your time zone or who are in the middle of the night when you’re doing that process. And so that just leverages the expertise to enable anyone who has the language skills and the connectivity ability to access truly world-class education in a way that can help them to advance their career.
And so then what you need is the organization, the structure, and the sanction to be able to help those people, you know, grab their bootstraps, grab onto these training materials and follow a course that will lead them to a better endpoint. So here’s my vision. Here’s what I think is possible. We have lots of countries where there are not enough training programs that are established. We have lots of places where there are no training programs. Say, take Laos, for example, or take, you know, areas of Africa, sub-Saharan Africa. You know, the total number of training positions in sub-Saharan Africa per year is less than, you know, 500. And at that rate, training, you know, 500 people a year, it’s literally going to take them over 100 years to bring up a population of trained pathologists to manage the expect a number of cancer cases that they’ll have by 2030. So they’re never going to catch up with the current paradigm of training. And that is, I think that’s a disgrace. I mean, I think that’s just horrible.
But if we can use digital materials and use remote learning technologies and remote assessment technologies and so forth, and couple that with the appropriate sanction from the governing bodies and medical societies and so forth, to produce a quality product, a quality trained trainee using these sorts of things that would be available anywhere and at essentially no cost. You suddenly got a new paradigm that says we can have as many pathologists as we want, or as we can get people to follow the training program.
Digital Pathology for Mentoring and Training
And we can do it fairly quickly. So that’s kind of become my passion, is to get that program organized, out there, available, publicized, and validated so that we know that we can do what we’re doing and that we’re able to accomplish what we set to do and then make it happen. So one of our pilot projects was working with a hospital, an oncology hospital in Da Nang, and interestingly, our gynecologic oncology colleagues have seen the same issue in gynecologic oncology. There aren’t enough trained gynecologic oncologists to treat the women’s cancers that are out there.
So, they have been setting up virtual tumor boards and virtual training programs to mentor and train people in lots of different sites.
That often involves the need for getting the pathology to rise to the level of the care that’s being offered. We took one of their sites in Da Nang, and we launched a training program using our organized materials to train their pathologists and bring them up to speed to support and sustain the gynecologic oncology tumor board. Now, when we started, this is a tumor board that was supported by gynecologic oncologists from the Mayo Clinic from the University of North Carolina, from major universities in Japan, Singapore, and elsewhere, a really world-class support system on the gynecologic oncology site.
And we brought together, similarly, some support groups from Yale and University of Oklahoma and elsewhere to support the pathologists.
And our experience was that, you know, when we would initially present or when cases would be initially presented before we really began our training program, they would have, you know, one or two, usually two cases per tumor board that were presented. And they present the radiology and the pathology and discuss the treatment and so forth. And almost without fail, every tumor board had one and sometimes two of their cases that needed either further testing or a revision of the diagnosis or some sort of pathological change so that they could make a good treatment decision.
That’s very frustrating for the gynecologist who wanted to go in and treat, and their drugs are going to be different depending on whether it’s one thing or it’s another. But by the end of our training program, we saw that number of proportion of cases that needed diagnostic revision or change at tumor board just drop dramatically. And for the last six months, and even beyond the conclusion of our pilot project, there were no cases that needed to be revised. The diagnosis was accurate, it was actionable, and so forth. And our pathologists that we had trained, they went from a score on our assessment of about 65% of cases, which is barely passing for a first or second year resident in the U.S. to over 95% accuracy with their diagnoses on challenging and live day-to-day cases. So, functioning at a very high level. So that’s what we think we can do with people who have had some training. Now, we’re now at the stage where we want to validate that that same level of acceleration of learning and accomplishment can happen with naive trainees. People who are just out of medical school who have had no pathology training and so forth. Can we do the same for them in terms of raising their level of qualification? So we’re out beating the bushes for grant funding.
We’re working on our training modules in other domains like breast and GU and head and neck pathology, pediatric pathology and so forth so that we can really get an idea, is this going to work?
Because if it does, it really can change the lives and the outcomes for millions of patients.
Jake Brown: Yeah. Yeah.
It was making me think as you were talking, there’s a couple of points that I thought were pretty interesting. The first one being that that statistic you shared, from 65% to over 95%, that’s a very significant increase in proficiency. Just to clarify, I want to make sure I get this right. That was specific to OB-GYN -trained pathology, subspecialty-trained pathology, or at least the focus on –
Lewis Hassell: Our population were people who had had a couple of years of training and a year or two of experience in pathology as well. So they were not dummies. They were people who were out there working in the world already, but whose level of expertise and understanding of the GYN domain was about the level of a second, first or second-year trainee in the U.S.
Jake Brown: Yeah, and then can you say one more time where this pilot was?
Lewis Hassell: So we were partnering with the Da Nang Oncology Hospital and our international collaboration was with the International Gynecologic Cancer Society, which is the one who sponsors the training program at that institution.
It’s been a very successful pilot project. They have trained, I think, three or four gynecologic oncologists there through a combination of regular mentoring, some on-site mentoring, and then some short-term off-site mentoring as well. We try to do somewhat similar. We haven’t had much off-site training or mentoring for the pathologist, but we’ve had regular mentoring with the pathologists that are there and seeing great progress.
Pilot Trials with Digital Pathology to Accelerate Training: Work Smarter Not Harder
Jake Brown: Yeah, that’s really, really cool. The second thought that I had that I wanted to ask as a follow-up is, with that pilot being so successful, and also with OB-GYN getting such a bump in proficiency with what you were just describing, are there any other… either subspecialties or areas of pathology in general, where you’ve seen similar improvements with other pilots that you’ve looked at?
Lewis Hassell: So we have not got that data on other areas yet because we did have a successful pilot project in urine cytology, but we don’t have quite the same outcome data from that project, but we are in the process now of completing and uploading our training modules for breast pathology. We have a module for head and neck pathology that’s moving forward and in development, as well as modules in pediatric pathology, GU pathology, and now cytopathology is beginning to move forward as well. So we think that by…
At the beginning of this next year, we’ll have enough broad-spectrum materials that we’ll be able to have a very robust pilot trial using a comparison of pathologists who are in a training program and starting out, pathologists who are not in a training program and starting out, and pathologists who are in other settings who will use these materials and will have the same kind of pre- and post-evaluation progress that will hopefully let us know if this is going to work. What we’re using are online materials. These are materials that are digital slide-based. There are recorded videos. There are other kinds of case materials and online materials that people study.
Then we try to couple those with, at least we did in the Vietnam pilot, some regular monthly mentoring sessions with the exchange of case information and presentation and discussion about issues going forward. We feel that a combination of self-study, self-paced virtual materials, and then some motivating regular live mentoring will encourage and facilitate greater progress for the trainees that come through our program.
Jake Brown: Yeah, it makes me wonder too with that success from that pilot you had. Do you have regulatory bodies, do you have governments reaching out asking for this? Are they aware of it?
Lewis Hassell: Yeah, so we have had some conversations with the pathology secretariat in West Africa who are interested in the potential for this kind of material to be used as an adjunct or even potentially a requirement for their candidates who are going to take their licensing exams. Because we don’t really have a full spectrum training program start to finish yet, we haven’t been real eager to jump into kind of regulatory licensure approval kinds of questions, credentialing kind of questions.
But we feel that if we have something that’s created and we can demonstrate progressive improvement and competency and so forth, that that will be fairly easy to obtain and so forth. It’s still a lot of issues down the middle, a lot of problems to solve yet ahead for this to really make a dramatic impact on the workforce. But we’re trying to do the first steps first, and then we believe that as we do that, that those subsequent steps will be easier, and we’ll have the right kind of framework to say let’s go with this or this is what we can do. Now we wouldn’t need that for people to use this in established training programs. And so where you have local programs.
We also think that there’s a good chance that this could allow them to expand or enhance their training to include this component so that they could take more candidates. And that would be potentially another way to augment the supply, is if the existing programs could expand their number of seats at the table, because previously these have been kind of limited by space and materials. But if we suddenly give them this, you know, regimented list of things and can say this will help accelerate, accelerate competency, it may be that, you know, one of two things happens.
Either they expand the number who are training at a given time, or they may be able to use them sequentially and say, okay, first do this virtual training.
And then come and do some live training, and if you’re confident, then we’ll just push you out the door a year sooner or whatever. And so, either way, you get an accelerated pace of capable trained people. The United States has, we’ve had this sort of ambivalent direction in terms of our training. On the one hand, there are certain what we call time-based requirements.
So you have to have had this number of hours, this number of days, this number of autopsies, and so forth.
And that’s kind of the approach of most of the medical boards, is looking at these time-based standards coupled with a certification from program directors and so forth.
But, on the other hand, we have the Graduate Education Committee, which has taken the competency side of the equation without the time-based requirement.
And they, of course, see that many times the time-based determines whether, you know, the pace at which they reach competency. But my own experience in working with residents and trainees on a very limited scale is that when you expose them to well-organized, self-study digital materials, that their progression, their competency, is accelerated dramatically.
So, the standard program in our process was, you know, the first-year residents would spend some time on GI service and they would rotate and they would see the cases that came through the door. It was kind of a random cases and so forth and you sat down with the attendant and they explained things and you looked at them and you got your level of education.
And my experience with that was that it often took six months to maybe eight months for a first-year resident to feel really capable and competent with one of the most basic elements of GI pathology, which was GI polyps. But on the other hand, if we gave them a sequence of tutorial digitized slides and had them work through that before they came on the service that they could be at that same performance level within two weeks.
And so you’ve just cut out an enormous amount of time, accelerated their progression to competency dramatically by using these standardized and organized digital slide examples. And that was with exposure to maybe five or ten different cases of each particular polyp type with a good explanation of what was involved and why. And after they’d examined those systematically, they knew it, and they could do just as well as a third or fourth-year resident on the same material.
So, I think that we can see a dramatic acceleration in a lot of areas myself. Now, getting everybody to buy into that, that may be a much….. I don’t write the regulations and give the exams and so forth. But I’m trying to persuade enough people that this is the way to go. And certainly, the residents who do that, they feel much better about themselves and their learning is much more efficient. If they spend more time, they’re not back studying on some of the basics. They’re going on to more advanced topics, and they’re going to accelerate their capabilities. And because I want them to become my peers and to be teaching me and so forth. And the faster they can do that, the better.
Jake Brown: Yeah, it makes me think of the cliche phrase, but work smarter, not harder. And it seems right, but organizing your material in a way to take something from six to eight months to two weeks is just.
It seems like it’s a no-brainer, it probably is, but there’s also so much data and there’s so many important things to learn that being able to organize it in a way that is efficient to make all the changes.
Lewis Hassell: Pathology is a vast field and it’s always expanding and the things that we need to know now that are so much greater than when I was being trained. And so we do have to work smarter and train smarter and we have these tools that enable us to do it. And COVID has forced us to use them and to learn how to use them. And I see more and more people who are discovering this and just excited about the prospect.
Jake Brown: Yeah. Well, I could keep talking like this for a long time with you, multiple hours. Hey, maybe we need to do that in the future a couple hours, let’s just hash it out, all the things we want to talk about. But I do know that we’re running out of time here, but I did want to, maybe in closing, just ask two questions and get your final thoughts.
With your experience, what you’ve experienced thus far, and everything that you’ve been doing with digital pathology, it’s no secret that digital pathology faces hurdles. And that there are certain instances where it makes a lot of sense, there’s somewhere it doesn’t, and there’s pushback and back and forth on which is better, and this tells me that, no, it makes me faster. There’s the whole topic of artificial intelligence that we could go down, that’s a whole rabbit hole in itself. But from your perspective, Dr. Hassell, what is the biggest hurdle that you would like to see overcome quickly to get your experiences and getting education modules and organized material to the people that need it most? What’s the biggest hurdle that needs to be overcome for that? And then if you could end by just giving us a glimpse into your vision. Where do you see this being someday and how it’s impacting the world as a whole and also in every human being’s personal life as they navigate some of these issues where they might have cancer?
What is the Biggest Hurdle to Digital Pathology?
Lewis Hassell: Yeah, I’ve written a little bit about some of the barriers and written editorials on the regulatory and other things that have been involved with that in the United States. You know, I don’t think that so much the barriers are… economic or structural. I think the major barriers have been more those of, how should I say this, mindset, if you will, and it’s a mindset both on the users as well as on the providers. So from the providers’ standpoint there’s been a lot of siloing that have been barriers.
So file types, for example, you know, I make a scanner, I’m going to save my scan as this file type, somebody else makes a different file type and scanner and so forth, and there the twain shall meet.
That has been a barrier because people wanted to protect their intellectual property. They wanted to profit from their inventions, which is a natural inclination, rather than seeing it like the fax machine, where the more we have this, the more we’re all going to be able to share. The value of having one scanner someplace is pretty paltry, but having many scanners that can freely share and many images out there that can be freely viewed and freely shared is an enormous benefit to everyone involved. Then on the recipient side of things, just the user side of things, just the willingness to see the potential for this to change their lives and to see the positive benefits that can accrue from this, which really we didn’t see or weren’t willing to see until COVID forced us to think about having to work remotely or work asynchronously and so forth.
But I think more people now are seeing that, and hopefully, eventually, the siloing side of things on the other side will abate.
The Future of Pathology
Now if I look forward 10 or 20 years, I’m really hopeful that the combination of enhanced training and enhanced utilization of AI will make us equal to the task, will make it possible for every patient, anywhere, who develops a potential malignancy or a potential pathologic issue, can readily get access to the best quality diagnostic information, and likewise, then the best care. And I think there are reasons to have hope for that. When I first started going to Vietnam, it was virtually impossible to call Vietnam from the United States, and it was prohibitively expensive if you did.
Even faxes were costly and not widely available.
And yet now, I can talk on video chat with any of a dozen people very easily in a conference call or in a single call and have it not cost me anything.
That is a dramatic change in cost and structure and availability. If we could do the same with the availability of pathology expertise and pathology images over the next 20 years, we’ll have given mankind a great, great gift. Our society and the barriers between people, the access to quality healthcare, to the drugs that are being invented to fight some of these disesases and other solutions that we’ll have will be truly the blessing that they’re intended to be. That’s what I hope for, certainly, before I have any of those diseases at hand.
Thanks so much, Jake. It’s been a great pleasure to talk to you and to see how things are going forward with this. Let’s get together in a year or so and see where things have come.
Jake Brown: I would love that. Thank you for your time, your amazing mind doing amazing things for the world, and we really appreciate you taking some time out of your busy schedule to chat with us.
Thank you
Lewis Hassell: All right. Bye.
Thanks for listening to PathPulse: Pathology Innovators in Action. Tune in next time for more inspiring conversations with digital pathology experts.
