The Drive to Share, Discuss and Mingle - Understanding the Social Network Pathologist

Using the power of social media for professional work isn’t new to pathology. By today, social media channels have become one of the speediest and easiest to use online tools in the disruption of healthcare communication. 

Despite an initial reservation, by 2017 pathologist around the world have discovered especially Twitter and Facebook as effective platforms to exchange thoughts on the latest technical or regulatory developments in pathology, discuss interesting cases and images with colleagues, and communicate with patients in dedicated support groups. The number of the pathologists engaging in social media - let’s call them ‘social network pathologists’ - continues to grow swiftly. On Twitter alone, there were over 19,000 Tweets on #Pathology in the month of September 2017¹, leading influencers in the field have thousands of followers and even a formal ontology on Twitter hashtags for pathology subspecialties ²emerged.

Looking around the web, we find numerous practical how-to guides³ for the use of social media as medical doctor and pathologist, including tips of how to prevent pitfalls to HIPAA’s regulations⁴. But what are the real drivers for pathologists to publicly share, present and discuss their work and to mingle in these virtual groups?

Is it the need for more expert discussion and exchange, which healthcare IT solutions cannot satisfy? Is it the community spirit or a self-branding and advocating-opportunity for one’s institution or personal career? Or is it a mix of all these reasons? Let’s try to get to the bottom of the most apparent benefits of social media for pathologists and understand what motivates them to ‘read, like and tweet’.

SOCIAL NETWORK PATHOLOGIST DRIVER #1: CLOSING THE COMMUNICATION GAP

Social media provides us with simple means to communicate and share viewpoints, ideas and experiences with others - anywhere, instantly and at zero costs. It is therefore not at all surprising, that a field of medicine, that embraces the interpretation of images at its core, jumped on this channel to close the communication gap between stakeholders inside and outside their lab or hospital. Software providers in the field of digital pathology focus on work-flow solutions that are dedicated to collecting Protected Health Information. Public availability, which is a must to foster inter-institutional exchange, is mainly forbidden by design⁶. As a result, interaction with treating physicians, specialists and colleagues working in other institutes and even with patients shifted to tools that are available to everybody. 

By using social media apps such as Facebook and Twitter, pathologists can instantly and efficiently share their case images (encoded/de-identified for privacy), give and ask for opinions on photomicrographs, and comment on others’ posts - anytime, anywhere, from any device and even outside of their daily routine work after hours. Usage is free of charge, no budget decisions need to be taken, no IT department to be involved. 

While the interaction between pathologists on social media usually also includes exchange on new regulations, medical trends, educational videos and content links, the focus seems to rest on sharing and discussing interesting, rare and ambiguous histology images with experts around the world. Although annotations to posted histology images, replies to questions and content shared on social media can and will never be basis to a diagnosis, pathologist widely welcome the value of such comments for supporting and confirming the diagnosis of human disease. 

Pathologists' drivers to use social media - a summary. Copyright: microDimensions

Not only for regions, where pathologist expertise is widely scattered, exchanging additional opinions about a case can make a difference to the quality of patient treatment. With the urge to make diagnosis more precise, especially general pathologists consult with colleagues qualified in subspecialties. However, direct communication with their personal network is cumbersome and subject to both technical and availability constraints. By posting a snapshot taken with their smartphone from the microscope or even a screenshot of a dedicated area of the whole slide image on Twitter, pathologists can open up the possibility to receive additional opinions from virtually all experts of the field worldwide at a glance.  

Social network pathologist driver #2: Explore and build pathological knowledge

Digitizing medical and pathological knowledge and thereby giving broad access as a resource can only be an advantage: Building online libraries of medical publications was one step on the digital journey. An additional potential to explore and build pathological knowledge unfolds in what is aggregated and made publicly available on social media: images with comments and annotations, rare cases and photomicrographs suitable for training. Especially in developing countries, or in fact anywhere where educational resources are scarce, and books are too expensive, pathologists value the knowledge available free of charge and instantly via social media channel.

Residents join social groups or follow long-standing experts (‘influencers of subspecialty’) to expand their knowledge, use it as educational training field, learn and absorb. At the same time, pathologists constantly come across more complex or rare cases outside their particular expertise. Leveraging the extensive public networks, they can get easy and fast confirmation of their initial assessment, or at least be guided into a previously unseen direction. 

SOCIAL NETWORK PATHOLOGIST DRIVER #3: BEING PART OF THE COMMUNITY!

Engaging in social media networks and groups makes us feel part of a community. Whenever pathologists collaborate with experts of the same profession via social media, they contribute or take benefit from the community knowledge. This fosters a unique feeling of belonging and playing a role in the huge complex healthcare system.  One of the ultimate goals of social networks is, to extend the own professional network, eventually turning an initial virtual ‘like’, ‘follow’ or ‘reply’ into a real physical, beneficial interaction. Just lately, I have overheard a conversation between two young pathologists who delightfully met for the first time at the European Congress of Pathology in Amsterdam after starting and intensifying their Facebook friendship. Think of the opportunities that open up:  joint publication projects, long-term second-opinion collaboration, or international career opportunities.

Live tweets on pathology events and conferences are a welcome form of exchange - not only to learn what went on in a parallel conference session. They are not only fostering the community of participants, voice opinions about the event and keep memories alive. Social media is also used to continue discussion initiated in sessions or poster presentations, letting the entire pathology community join in. And in fact, the United States and Canadian Academy of Pathology (USCAP) 2015 annual meeting gathered over 660 tweeting participants resulting in more than impressive 6,500 live tweets about the event⁶.

SOCIAL NETWORK PATHOLOGIST DRIVER #4: A TENDENCY TO CLUSTER AND THE MERITS OF GROUP COLLABORATION

More and more of the group collaboration is turning to social media, in particular to Facebook groups, as they “provided a no-cost way for pathologists and others across the world to interact online with many colleagues”⁷. Here, various topics including histology findings can be discussed in a closed, hence locally unlimited real-time setting. 

The objectives to form, join and contribute to a group are manifold. Some groups form around specific subspecialties, giving space to focused exchange in that field. There are groups of regional and international organizations and associations that can attract over ten thousands of members. Then, there are smaller, often temporary groups that are means of communication during the preparation of papers or publications. In education, residents can turn to groups to ask their study questions or discuss their educational success online with their fellow students from other universities.

At this point I would also like to mention the smallest group format on social media: private chat possibilities, which most social media channels provide. Tools such as private message (PM) in Facebook or Direct Message in Twitter enable pathologists to continue public or group-wide discussions in a very private environment. It is common, that a post turns into a lively one-to-one discussion between the posting pathologist and a commenter - or even between commenters. This hints us to the next driver for pathologists using social media: building the own professional network and career.

Social network pathologist driver #5: Self-branding, institute-advocacy and other career kicks

As a private person we engage in social media to inform our networks about what we are currently doing and especially what we are doing well. The social channels’ power to present and self-market ourselves and our employers is priceless. Every post a pathologist makes has the potential to identify him or her as recognized expert in a subfield and suitable to give a qualified second opinion, eligible to teaching opportunities or candidate to give speeches - turning a contribution to the healthcare community into career kicks for the social network pathologist.

Unlike large hospitals, not many private pathological institutes have dedicated manpower to run marketing initiatives for their organizations. When it comes to international reputation building, communication of the latest research results or simply promoting vacancies, the social media engagement of their pathology staff can be a real asset and a win-win situation for both employee and employer.

As a positive side effect, communicating about pathology work publicly contributes to the image of the pathologist profession as such, its role for a more precise and profound health care and it also helps to break down stereotypes - check out #ILookLikeAPathologist on Twitter.  
 

Summary

No social network pathologist’s motivation is driven by only one of the above named goals. Usually their interaction on social channels combines all of them and even mixes with private interest posts and tweets. What unifies them - however - couldn’t be a more noble intention: to understand disease and help people to heal people.

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¹ real-time analytics data for past 30 days on 29 September 2017: https://www.symplur.com/healthcare-hashtags/ontology/pathology/

² https://www.symplur.com/healthcare-hashtags/ontology/pathology/

³ E.g. Jerad M Gardner, MD: http://pathinfo.wikia.com/wiki/Social_Media_Guide_for_Physicians, http://pathinfo.wikia.com/wiki/Social_Media_Guide_for_Pathologists

⁴ E.g.: http://blog.intakeq.com/5-ways-to-stay-hipaa-compliant-when-using-social-media, May 2017

⁵ As an alternative, all stakeholders would need to work with the same DP system, which is not very realistic; and standardized exchange protocols are not yet established.

⁶ Modern Pathology (2017): #InSituPathologists: how the #USCAP2015 meeting went viral on Twitter and founded the social media movement for the United States and Canadian Academy of Pathology, http://www.nature.com/modpathol/journal/v30/n2/full/modpathol2016223a.html

⁷ Gonzalez et al: Facebook Discussion Groups Provide a Robust Worldwide Platform for Free Pathology Education, Arch Pathol Lab Med 141, pp. 690-695, May 2017

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Further Reading on Social Media in Pathology

• If You Are Not on Social Media, Here’s What You’re Missing! #DoTheThing http://archivesofpathology.org/doi/pdf/10.5858/arpa.2016-0612-SA?code=coap-site
• Social Media Guide for Pathologists: http://pathinfo.wikia.com/wiki/Social_Media_Guide_for_Pathologists
• Pathology Image-Sharing on Social Media: Recommendations for Protecting Privacy While Motivating Education: http://journalofethics.ama-assn.org/2016/08/stas1-1608.html
• #InSituPathologists: how the #USCAP2015 meeting went viral on Twitter and founded the social media movement for the United States and Canadian Academy of Pathology: http://www.nature.com/modpathol/journal/v30/n2/full/modpathol2016223a.html
• Fine social aspiration: Twitter as a voice for cytopathology: http://onlinelibrary.wiley.com/doi/10.1002/dc.23713/epdf

Expert Consultation - Sketching the Ideal System for Pathology Online Collaboration

Since decades, pathologists extensively consult with fellow pathologists to collect expert opinions on difficult cases. This is due to the fact that pathology is dealing with an area of diagnostics that is extremely variable. General pathologists are able to diagnose virtually any disease, but in rare or complex cases it is common practice to consult a (pathology) expert. It is also true, that many pathology labs have developed particular expertise in certain subspecialties and receive consult cases predominantly for these specific indications. 

Coming from the digital pathology (DP) domain I was certain, when learning about this extensive network of pathology consultation, that most if not all pathology labs use tele-pathology to ask for (remote) expert opinions. For me, the many advantages were obvious when comparing to the alternative, the traditional, non-tele way: Shipping blocks or slides takes much longer and has risks (of losing or damaging the material) - and time plus risk reduction are two important matters for any lab. 

I had to learn, however, that only few pathologists are as excited as me about performing tele-pathology for expert consultation, due to various reasons:

Sharing Blocks or Slides? 

Traditionally, pathologists either share a glass slide or the tissue block when asking for remote consultation. Since the glass slide is the fundamental source of evidence for the diagnosis, pathologists are quite reluctant to send it, so sending the block is, if possible, the preferred way. Sending the block has the advantage that the consulting pathology lab can apply its own stains. But generating duplicate sections also reduces the amount of valuable tissue and is only possible if there is enough material within the tissue block in the first place (which is usually not the case for e.g. lung biopsies). If the block rather than the slide is requested, however, tele-pathology solutions cannot be used. 

A Word about Costs

To perform tele-consultation a lab has to massively invest into a DP solution. Considering the entirety of hardware, software, and effort of staff to establish and introduce the solution, costs can easily exceed 1 million USD, which takes some years to amortize. Especially the small and mid-size labs, where the demand for (remote) expert opinion is largest, cannot afford the spending for a fully fledged DP solution. However, more and more labs are taking the step to go digital, especially after the first DP system was approved by the FDA for primary diagnosis earlier this year. But for tele-consultation, this is only half the battle. The other end needs to run a DP system, or at least a software for viewing, commenting, and annotating virtual slides, too. Most DP scanner vendors provide such a software for free, but they are usually limited to one specific virtual slide format. Experts who consult for various labs running different DP solutions need to switch between various applications, which adds extra burdens to pathologist and IT staff.
 

Upload Times and Storage - the Eternal Barrier?

Once both, local and remote DP systems are up and running there is the need to transfer virtual slides. One would think that sharing images is easily done via the web. Not so in the world of digital pathology: A virtual slide contains much data and is - depending on the format - often distributed throughout several files. Uploading such files or file sets is time-consuming and moaning sounds from the IT department can surely be expected.

At this point I asked the question if the ever increasing speed of internet connections would overcome this challenge in the future. Assuming the average size of a virtual slide scanned on 40x resolution is 850 Megabytes¹ and an upload speed of 10 MBits/second, the transfer of one virtual slides takes a bit more than 10 minutes. For tele-consultation of a complicated case one would usually transfer about 5 virtual slides, keeping the transfer time below 1 hour, which is quite long whatsoever. If the resolution of the scans are kept to 20x, however, the transfer time can be cut down to 15 minutes for the entire case, so: is bandwidth and upload times, together with storage costs decreasing year over year, really still a barrier?

Compliance and Security

Transferring pathology data via the web requires several safety criteria to be met. Even though many pathologists I talked to use non-HIPAA compliant file sharing apps together with email correspondence or even share their images within social networks, a professional tele-consultation system should guarantee Protected Health Information (PHI) to be secured. Even though a histology image per se is not considered PHI, the metadata stored within a virtual slide or the pathologist’s descriptions that are necessary information for the consulting expert quickly make it PHI. Using non-HIPAA compliant sharing systems require the pathologist to carefully decide what information is shared and what information is kept private, a fact why tele-consultation is often discarded. 

User Experience

Finally, one of the most important limiting factors why tele-pathology for expert consulting is only hesitantly adopted by the pathology community, is the ease to use these systems: Pathologists have virtually no extra-time and cannot afford to invest hours in learning complicated user interfaces. More importantly, the sharing of a case with a colleague should not require many steps and involve various people: If a pathologist cannot share a case with a colleague with only a few clicks from their work desk, tele-consultation will not happen. One of the easiest ways to do tele-consultation is to use screen-sharing tools where the asking pathologist shares a screen (displaying the case and its virtual slides) and the consulting pathologist can remotely control the shared screen. These tools are, once installed, very intuitive and easy to use, and they just require one end to be equipped with a DP solution. But they lack one fundamental functionality, which is the possibility for asynchronous communication: Screen sharing requires both pathologists to sit in front of their workstation at the same time, which is simply impossible for many consultation use cases. 

Despite all these reasons, there are many pathologists already using tele-pathology for consultation, even across national borders. But the majority of consultation cases are still done the traditional way, by sending blocks and glass slides via postal mail. 
 

'I have a Dream'

So what would a tele-consultation system look like that has the potential to a broad acceptance and usage?

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It must be easy to access: Given a device connected to the internet you should be able to immediately run the system. That is, no installation, no or very simple interfaces to other software systems of the lab, no storage requirements, and ideally running on mobile and stationary devices alike. 

It must be easy to use: Sharing of virtual slides and communication must be accompanied by an extremely easy set-up that only focuses on this particular use case: upload, annotate, invite, and comment with a few clicks. 

It must be easy to afford: Optimally, such a system should be provided for free or for a minimum fee to account for the very limited reimbursement levels of pathologists’ work in many countries. 

It must be fast: As discussed, the transfer of virtual slides is taking time. If this time cannot be spent, there should be other options for online collaboration: Support the sharing of smaller fields of view, or live streams of camera microscopes to speed things up if need be. 

It must be secure: Data safety, security, and secure communication channels should allow pathologists to share any information they are willing to. If a system is compliant to the HIPAA, US pathologists would be able to share even PHI. In other countries, where laws are less clear or requirements for data security are higher, these systems should adapt, or at least provide tools for a thorough anonymization of patient data before sharing cases. 

It must be truly vendor neutral: Support of all data formats is a must - no assumption can be made on the underlying hardware that produces the images or a possible standardization of virtual slide formats in the future. Moreover, labs in non-industrial countries cannot afford a DP solution but create digital images with their camera microscopes. For them, tele-consultation should be made possible, too. 

Is This It?

Sounds quite doable, no rocket science to be mastered. So do neither software nor hardware providers see a business case behind it? True for some, but surely not all. Or have I forgotten a fundamental requirement? 

Some might bring in the issue of the image quality that differs between slide scanners. This was quite a problem a few years ago, but nowadays most slide scanners produce good and consistent image quality within a reasonable amount of time.

Many will argue that such a system must be optimally integrated into the pathology workflow and software eco-system, which ultimately boils down to interfacing with existing laboratory/hospital information systems (L/HIS) as well as image management systems (IMS). And this is, from a technical perspective, challenging indeed: There are more than a hundred different LIS providers operating in developed countries and, due to lack of standardization, there are at least as many IMS as there are scanner providers. Creating interfaces to the existing IT infrastructure and deploying these systems into pathology labs takes time, costs money, and involves more stakeholders into the process, e.g. lab managers and IT staff. This inevitably increases the costs for such a solution while decreasing flexibility and versatility. At this point, it is important to balance the benefits of a full integration with the costs: Is it really necessary for tele-consultation to directly access all the information stored in the LIS? Or is the effort it takes to copy the relevant information from the LIS into the tele-pathology system acceptable if this system can be available (almost) for free? 

In either case, the patient benefits from a consultation solution based on tele-pathology: The quality of the diagnosis is likely to increase while turnaround times will decrease. And that’s the good news.

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¹ We have averaged the size of > 15 000 virtual slides with formats from most slide scanner manufacturers, a resolution of 40x, and commonly used compression methods.