Neuropathology fellow Josh Klonoski estimates that 30 percent of his learning happens at the microscope with an attending pathologist. He and his peers are reaching out to first- and second-year residents who have less experience and need camaraderie.
In mid-March, when hospitals began postponing elective surgeries, physical distancing became the protocol, and people began working remotely, directors of pathology training programs around the country scrambled to adapt so that residents and fellows could still receive the hands-on, collaborative instruction around a microscope they needed.
“We immediately started working out virtual ways of doing things,” said Kristi Smock, MD, who supervises the U of U Health Pathology Residency Program in the University of Utah Department of Pathology, for which ARUP Laboratories is one of the primary rotation sites.
The morning didactic conferences, during which all 20 ARUP trainees would typically be in a room together, discussing slides and cases or listening to a lecture, were transitioned to a virtual platform. Learning opportunities for the 14 anatomic and clinical pathology fellows that the institution sponsors have also been affected.
Slide reviews, which generally involve an attending pathologist and one or more trainees, who gather around a multihead microscope, were no longer safe or practical. Many institutions began switching to a virtual format, enabling pathologists with cameras on their microscopes to share and discuss slides virtually.
“Reviewing slides is a critical part of the training in AP [anatomic pathology] and is generally very hands-on,” said Smock. University of Utah neuropathology fellow Josh Klonoski, MD, PhD, agreed, estimating that about 30 percent of his learning happens at the microscope with an attending pathologist. Those on cytopathology and surgical pathology rotations were especially hard hit because slide review is a critical part of the education.
“The COVID-19 pandemic completely disrupted this apprenticeship model by forcing these close in-person interactions to switch to teleconferencing and post-sign-out feedback,” said Roseann Wu, MD, MPH, associate program director of the pathology residency program at the Hospital of the University of Pennsylvania (Penn Medicine). “Many trainees and faculty mourn that microscopic education has been compromised, since that one-on-one slide review and discussion just isn’t quite the same through a computer monitor and telephone.”
Dr. Roseann Wu
“It’s a great time for independent learners to take charge of their education, delve into research, and self-identify areas of weakness that they want to spend time on.”
Penn’s program discontinued one-on-one, in-person, slide reviews and began using email to exchange feedback on case reports, while those who could began sharing slides virtually using HIPAA-compliant systems.
With no end to the pandemic in sight, programs are adapting. Some are setting up larger multihead microscopes, with plexiglass dividers between eyepieces, and requiring participants to wear masks. Some are projecting slides onto a screen so that people can sit a safe distance apart and still view and discuss the slides in person. Other programs, such as ARUP’s, have a completely virtual approach to sign-outs that involve microscope cameras and teleconferencing software such as Zoom or Microsoft Teams.
Wu pointed out that while virtual discussion does allow for real-time exchanges, it interferes with nonverbal communication; for instance, an instructor may not pick up on a resident’s expression of confusion. Sometimes slow internet connections can create lag times in viewing slides, and the histologic and cytologic details are not as crisp, so subtle nuances can get lost in virtual projections.
Physical Distancing Catalyzes New Rotation Protocols
When the pandemic first hit, many programs minimized the number of people on-site, sending many fellows and residents home for online learning. Clinical volumes also decreased, limiting the patient-care activities that typically provide learning opportunities. There were fewer autopsy rotations, and generally, trainees were not allowed to be near bodies that had been infected with COVID-19.
At the University of Southern California (USC), the pathology residency program maintained physical distancing by rotating surgical pathology residents between on-site duties and web-based education from home. Faculty redesigned their chemistry rotation curriculum so that it could all be accomplished via teleconferencing. Other clinical pathology rotations transitioned to remote learning where possible, although trainees on the microbiology rotation were encouraged to participate in the COVID-19 response.
“It’s been a valuable experience for residents to see how the lab has responded during a pandemic,” said Rosemary She, MD, associate program director of USC’s pathology residency program. Residents witnessed supply chain issues for specimen collection kits and polymerase chain reaction (PCR) test kits, learned about the complexity of regulatory issues surrounding clinical testing and how they changed for SARS-CoV-2, and helped respond to the demand for rapid validation of new instruments and reagents. They saw the importance of universal precautions in laboratory testing. They learned the important role labs play in public health and epidemiology and witnessed the economic impact of COVID-19 on hospitals and labs. “All of these lessons will be valuable for when they face the next pandemic,” She said.
At the University of Utah, instead of residents focusing on one specialty area in each two-week rotation period, they began focusing on four areas at the same time. For surgical pathology residents, those areas were head and neck, breast, bone and soft tissue, and gynecologic and genitourinary. “Because you are less focused, it’s harder to learn proficiently in one area,” said Klonoski. “It turns out to be a longer learning curve because you are so spread out.”
In most programs, residents and fellows on cytopathology service, which includes rapid on-site evaluation (ROSE) and fine-needle aspiration (FNA) procedures, remained on-site but had new protocols to follow. For example, at Penn, the cytopathology trainees (a resident and a fellow) typically would remain in the room with the pathologist or proceduralist and the patient for an on-site evaluation or FNA biopsy. However, due to physical distancing requirements, the number of people in the room is limited now to one trainee with the faculty. If the room has telecytology capabilities, then the attending might view the case remotely while the resident and fellow receive and prepare the specimen for on-site evaluation.
Residents and Fellows Must Continue Their Education
To qualify for pathology certification, fellows and residents must meet certain medical education and experiential patient-care requirements. When case numbers dropped dramatically and many residents were sent home to be educated via online means, gaining the hands-on experience to meet those criteria became challenging.
“Even if you had a neuropathology fellowship that lasted 10 years, you wouldn’t see everything that’s in the books. Now consider, our fellowship is generally two years; you’re just not going to see every type of cancer during your fellowship,” said Klonoski. “If you wipe out half or a quarter of your fellowship, it has a significant impact on what you see and deal with.” Klonoski also laments all the canceled national and international conferences, which typically he and his colleagues would attend to network and find jobs.
“The people who are really hurting the most are the first- and second-year residents,” said Klonoski, who is finishing the first year of his neuropathology fellowship and will return to complete his fourth year of residency as a co-chief resident. He and his peers have been checking on these residents, who are at an earlier point on the learning curve and need the camaraderie. “All those things we took for granted before, we’ll really appreciate once we’re all back,” he said, adding that he suspects normalcy won’t return for another 9 to 12 months.
While hands-on experience has taken a hit, virtual access to education and to the expertise of renowned pathologists has exploded. Early on in the pandemic, many professional organizations, such as the American Society for Clinical Pathology and the College of American Pathologists, began offering their resources for free or at deeply discounted prices.
“It’s a great time for independent learners to take charge of their education, delve into research, and self-identify areas of weakness that they want to spend time on,” said Wu.
As patient-care activities begin to resume and pathology programs around the country adapt to new ways of providing education, some changes that have been set in motion seem to be here to stay. Many programs that had considered setting up digital-slide reviews and workflows now plan on it.
Faculty members who were unfamiliar with virtual learning and other new technologies are now using these tools. And trainees are learning to use online resources better and are paying more attention to online communication.
Many programs may rely more heavily on the convenience of offering virtual lectures and didactic conferences. As She said, “Attendance at our conferences is good, likely because no one has to battle L.A. traffic to make it to the 8 a.m. meeting.”
“Something good always comes out of something bad,” said ARUP’s Smock. “We were forced to figure out new ways of doing things and have found that some of these approaches are useful. We may never completely go back to the old way.”
This period has presented unbelievable opportunities for residents to learn about crisis management and to gain leadership and lab management skills, pointed out Wu. “This pandemic has really pushed all of us to become more adaptive, flexible, and comfortable with rapid change in all sorts of ways.”