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Closing the Knowledge Gap in Medicine Through Digitization

By Dr Jonhan Ho

Passing information to the next generation is critically important.

Ten years ago, when my son was born, I had an epiphany.  The first moment I met him, my life flashed forward.  As he took his first breath, I became a father. Suddenly, I had a vision that 18 years had gone by and I saw him wave goodbye, turn around, step off the front porch of our home, and leave for college.

He hadn't even taken his second breath, and I already started to miss him.  Then my pulse began to quicken as I had a shocking realization -- that I only had 18 years to teach him everything he needed to know before he struck out on his own. Eighteen years to teach him how to learn new things, what love for a dog is like, how to be a good big brother, what to say when you let someone go, how to stay true to oneself, and how to pick yourself back up.

Since then, I've become obsessed with how to best pass on knowledge to the next generation.

We have a knowledge gap in medicine.

Passing on knowledge in medicine is a similar problem.  How do we pass on maximum clinical knowledge and experience in four short years?  Moreover, how do we pass on newly emerging knowledge to doctors who are not at the cutting edge most efficiently?

The purpose of residency and fellowship is to gain enough experience and knowledge so that when one graduates, they have a minimum level of competency to practice. Attendings have more experience than trainees, naturally. However, doctors who discover new diseases also have knowledge that other doctors don't.  The wider these gaps are, the more opportunity there is for missed diagnoses and over- or under-treatment.

One way to shrink the knowledge gap would be to hold back the front runners.  Obviously, this would be a horrible idea. The other way would be to pull up those who might be lagging. By raising the lowest common denominator, we can improve the care of patients everywhere.  

Schools are measured by many variables, but chief among them is the teacher to student ratio.  Medicine has its roots in the apprenticeship model, with the ideal ratio being 1:1. In this scenario, the trainee can ask specific questions to fill holes in knowledge, and mentors can probe to see where gaps exist. The two work together, gaining clinical experience through seeing patients with varied presentations. Learning is personalized.

However, the best mentors in the world are essentially capped at how many apprentices they can take on at any one point in time. We try to scale teaching by increasing the number of apprentices.  We start with small group sessions, then move to large classes, then onward to massive lecture halls, and finally to conferences where thousands of bleary-eyed attendees are seated in the same chair hour after hour being talked at by rotating lecturers.

What if we could democratize teaching?  What if we could democratize clinical experience?

This ability would change society as we know it.  The best teachers could be available to everyone.  The best cases could be seen by everyone, and we all would be better doctors for it.

There is an extra layer of complexity that needs solving, though. In pathology, trainees spend a month at a time in different rotations.  Throughout their 4 year residency, a resident typically only spends 1-2 months in dermatopathology.

The first week they might spend getting to know our workflow, the second week they might spend learning what normal skin looks like under the microscope, the third week they usually get familiar with the "bread and butter" diagnoses, and in the fourth week they start hitting their stride, and begin to gain a little confidence in their diagnostic skills.  Then, their rotation ends and they stop and move on to a different rotation. They stop at precisely the time at which their learning curve begins to accelerate.  Residency today is like having to leave a party when it just starts getting good, over and over again. It is senseless.

Why can't we build on that foundation over four years, one bus stop wait at a time?  Why can't we trickle knowledge out in little bites throughout the rest of the residency to reinforce learning?

If I were a resident again, I would wish for the ability to learn from the greatest pathologists in the world.  I would try each of them out to see which one I liked best.  Maybe one is more inspiring than another. Maybe someone is researching a topic -- like digital pathology -- that I find more interesting or even mind blowing.

I might have several favorite pathologists I'd like to learn from, one who is great at melanocytic lesions, another who is an expert on skin rashes, and still another who has a particular knack for identifying microorganisms.  Undoubtedly they would not all exist at one institution, no matter how heralded that institution might be.

I would wish for the ability to see the best cases from anywhere in the world.  Instead of waiting for the occasional good case to come across my hospital microscope, I would want good cases to come to me.

I would want whole slide images instead of static images because it is so important to learn how to find important features, not just know what the characteristic features are. You can't make a diagnosis if you don't know where to look.

I would want these little nuggets of knowledge dripped out to me like snacks that I can quickly consume while waiting for the pasta to boil or during my drive to the hospital.  Even better, after I finished training and was out on my own, I would want to keep my skills sharp by still having access to my favorite experts and have interesting cases pop up in front of me.

What a wonderful world this would be, and what a fantasy! Except it is no longer fantasy.  Today's digital pathology systems are fully capable of delivering this dream.

Slides can be scanned quickly and inexpensively and shared immediately.  De-identification of slides is no longer arduous. Image quality is outstanding, and oftentimes surpasses glass.

I will give you an example to illustrate this thought. I have recently acquired the lifetime collections of Dr. Sid Barsky, an academic dermatopathologist who lovingly curated a teaching collection of thousands of slides, many of which are greater than 50 years old. Many of those slides have hand-written labels hand-written. Some coverslips have dried out. Some stains have faded. This only makes me even more amazed at how much better the digital scans look when compared to the original glass. Eosinophils do pop out on the screen while they are a real chore to find through the oculars.

When I post Dr. Barsky's old cases, I feel like I help him reach thousands of pathologists, young and old, across the world.  I like to think that he is doing the thing he loved most, even after he has passed -- teaching individual pathologists and dermatologists dermatopathology in an intimate way.

I have seen the evolution of digital pathology user interfaces grow from "kludgy" styles with clunky buttons to beautifully designed user experiences that auto-orient skin slides to be right side up.  Today, I regularly scan and post tough cases to get opinions from trusted colleagues all over the world. I've collaborated with legendary dermatopathologists on lectures and research projects. I show teaching cases publicly and privately to residents and pathologists across institutions so that they may gain clinical experience. We put on worldwide digital dermatopathology grand rounds so that we can all see each other's interesting and challenging cases.

What I most enjoy, however, is sharing fun cases with people who I know will also get joy from seeing them.

I've always thought seeing cases is like breaking bread together for pathologists.  Seeing these cases brings back memories of fun conversations we had around the scope during residency, hard times we went through with other cases like this one, and how we felt the first time we made a tough diagnosis. In addition to making each one of us better pathologists, sharing cases brings us all closer, strengthening the ties that bind our tribe.

With digital pathology, there is no technical reason whatsoever for any pathologist not to be able to connect with other pathologists, or see any case they want to examine.      

We are at the beginning of this new paradigm of knowledge sharing and streaming.  It makes me happy that the next generation will see it as normal. I look forward to all the connections it helps us all make with each other.

This is a guest post by Dr. Jonhan Ho, MD, MS, Director of the Dermatopathology Unit at UPMC and founder and CEO of KiKo, Knowledge In, Knowledge Out, a knowledge sharing platform for pathologists and other physicians.

Tags: knowledge, training, education

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