Optics and Tech

To follow up on my previous post, I want to try and imagine the pathology workplace of the future. When the frozen section was invented in the 1890s, doctors hardly could have imagined the workplace of today (2019) 130 years later. In the last century, many advances were made in the field of pathology, aided by the increased availability and means of communication and exchange of ideas (telephone, radio, television, and most recently, computers and the internet became widespread). A century before that, dyes originally invented for the textile industry were applied to biological specimens. About one to two centuries before that, the microscope was invented.

Now, I would like to discuss the possibilities and logistics regarding what I believe to be an eventual and inevitable transition from traditional microscope viewing of physical slides to what I shall loosely call 'digital pathology'.

First of all - I want to note that pathologists have a central role in shaping how we want the 'workplace of the future' to be.  

Secondly, I believe that this is a process which must evolve organically given new developments in technology which are happening on a daily basis in our time. 

Third, there are crucial mistakes to be avoided if digital pathology is to 'get off the ground' so to speak.  

Additionally, I do know that there are opponents (read, older pathologists) who often harbor mistrust of new technology (i.e. computers) because they are set in their ways. The pathology workplace of the future should be so foolproof (read, solid) that a late-career pathology could walk into this fictional futuristic workplace and be impressed and amazed at its capabilities, and excited about the future of pathology and the possibility of working in one of these places.

While radiologists get a bad reputation for being in 'the dark room' perhaps we as pathologists have something to learn from them, as both are highly visual specialties. By reducing the amount of bright light exposure, radiologists have attempted to create a workplace in which a certain type of eyestrain is reduced (but not due to squinting), the details of the surroundings are obscured and their visual attention is focused on what is being assessed. In a similar manner, pathologists desire (or should I say, require) an immersive experience when we are looking at tissue through our microscopes. This, I believe is why pathologists tell me, books cannot compare to looking under the scope. What is seen is much larger when looking under the microscope compared to a picture in a book, moreover there are fewer distractions. A similar phenomenon is when one holds his or her cell phone close to the face, in effect 'blowing-up' the screen.

The fairly recent invention of VR headsets could be a game-changer in this regard. Or take augmented reality implements (such as google glass). I envision something akin to wearable sunglasses, with digital slides projected on the lens, with built in eye movement tracking in order to navigate a slide. Additionally, there will be no keyboards or controls, a pathologist will use simple hand gestures/movements which are read by sensors in the 'room' which serve as 'shortcuts' to navigate back and forth between slides (or if preferable, voice commands). Alternatively, imagine just thinking about magnifying a certain region of a slide and it happening instantaneously -- this requires nascent technology which I will elaborate on further.

Other key considerations which radiologists have heartily adopted, and pathologists should also, have to do with ergonomics and equipment. For example, on my recent visit to the radiology department, I was impressed by their adjustable table heights and comfortable chairs. An simple adjustment many pathologists can make without any fancy equipment is to obtain an adjustable microscope stand (but one might need an adjustable eyepiece as well depending). Comfort improves concentration and makes already heavy work feel lighter somehow. Importantly, they have also invested in state-of-the-art viewing equipment. Even for teleradiologists, to read at home, they must have a monitor (or monitors) which meet a certain specification in terms of quality. This is analogous to microscopes, which can be very costly, but when the inevitable transition to 'digital pathology' occurs the 'viewing station' may become very different.

Another innovation which radiology has gotten down pat, is the use of a universal file type which enables the easy sharing of information between different hospitals/medical centers. For example, one can obtain the images which were acquired in one location, and easily transfer/read the very same image in a different location because of the very fact that the filetype is the same. A simplified example of this is extensions in computer programs. For example .doc means document and can be opened by any program which can read document files. In the same manner, pathologists should decide and insist on standardization of digital slide filetype which would enable universal sharing of such information (although I wonder and hope the companies commercializing slide scanning have already decided upon this).

The final point which I would like to make is with regard to the speed of formulation of reports, and in a very real sense has to do with communication, and this is again is where the imagination part comes in. It has been shown that the human brain thinks much faster than it speaks. Additionally, I think we can all agree that one in general speaks faster than one types (hence dictation), one types faster than one writes with the hand (hence typing and writing), and that one reads, writes, speaks, and thinks faster and with more accuracy the more one uses each faculty. Regarding the conveyance of information and the formulation of reports, I wonder if in the future pathologists will be able to think up/down a report (this may require the invention of a new word).

Returning to my point of elaboration, which I referred to earlier, research is currently being done on the conscious control of objects, whether real or virtual, using brain waves. This is also called many different names, however I will use the term which I find most fitting, a mind-machine interface. It could be imagined that in the future, mind-machine interfaces will become commonplace, and eventually applied to pathology workflows.

The pathology workplace of the future may require the use of a real life, state-of-the-art 'thinking cap' which includes a built-in viewing station and neural net/hat (similar to an EEG monitor) conjoined, which would allow a pathologist of the future to complete reports much faster than before. Old pathologists will tell you, once pathology transitioned from hand-written reports to typing and eventually dictating, how turn-around times (TAT) decreased and subsequently the expectation of clinicians for same-day/the-day-after results became commonplace. If thought to text conversion is accomplished within our lifetime and applied to pathology, I believe pathologists will become ever more efficient at their jobs. Not one, but all of these in combination, and with the incorporation of yet-to-be invented technologies, all are innovations which would revolutionize pathology as we know it today.

If one makes an another analogy to radiology, one could say radiation exposure is the main limitation in conducting scans of the human body; nevertheless, advances in imaging technology (MRI, low-radiation CT) have allowed less radiating (though more costly) scans to be acquired. Radiology differs from pathology, however, in that a patient is a potentially unlimited source of scans. Moreover, the demand for scans and imaging results has on-the-whole been increasing (part of this is due to greed, and the other, negligence on the part of radiologists to serve as gatekeepers of healthcare resources). Because of these practices, modern radiology is now the practice of normology, in which one sees much more normal than 'bad' as a radiologist. The bottleneck in pathology is that it as a practice requires precious human tissue. Because I do not see resections going away anytime soon, I anticipate pathologists in the future having more time for research and academic pursuits, mentorship, safety/infection control, hobbies or perhaps even an improved lifestyle which would be pretty nice.

A very important cause which I believe all pathologists (who care) must fight for, if these changes do occur, is recognition of our speciality as being the foundation of medicine and the bridge between basic scientific research and other specialties of medicine (see the tree of medicine). And in addition, pathologists must prevent of the creation of 'mills' in which pathologists are made to work tirelessly to enrich others, from outside or within medicine itself. Technology has the power to unite people, under a common cause/interests in order to enact change.

P. S. A disturbing scenario involves the monitoring (Orwell's 1984) or de-privatization of thoughts (a.k.a. mind reading). A very dark episode (no. 1) of the anime Kino no Tabi tells the story of a town in which people automatically know each others thoughts. Would brain-computer interface technology develop to the point in which this could be enabled? Food for thought.