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A Journey to Pathology 3.0: From 'bricks'​ to 'clicks'​. The Tao of Distributed Work.

As discussed in one of the previous posts, #pathology (#histopathology) services have accumulated strategic debt. This debt is stretching our ability to address the current gap between demand and capacity. It will also challenge our human, technological, and financial capabilities to endorse #computationalpathology and 'multi-omics' systematically and at scale. Hence, it is not surprising that in addition to the chronic shortage of 'invisible doctors', conversations about the future of pathology revolve around the challenges of mainstreaming #genomics and #digitalpathology.

 Quite understandably conversations about digital pathology often focus on technology and its applicability in the ecosystem of the current clinical, organisational, operational and financial constraints. Yet, the journey ahead is not about spending time and money on 'digitising' our existing processes and systems. We should learn that much from the visit to the museum of incredibly expensive and ambitious healthcare technology projects. Successful and effective 'digitisation' of outdated, suboptimal and redundant processes only creates outdated, suboptimal and redundant processes.

Instead,  we should focus on leveraging technology and science on developing service models and processes that can address the key challenges of the future. For pathologists, these will always be clinical challenges. As in any walk of knowledge work, that of pathologists will remain "ever-changing and dynamic" and dependent on the evolving knowledge base and skills. With that in mind, we should think of digital pathology as a platform or more effective teamwork, communication, training and professional development, sharing resources, balancing of workload, process improvement and, as they evolve, deploying clinical-grade computational pathology 'power-tools'.

With that in mind, I'll start exploring the concept of "distributed work".

The ability to deliver work in a distributed manner is underpinning the concept of a "distributed histopathology service enabled by a digital pathology platform". The best operational definition of a distributed histopathology service that I can think of at the moment comes from the following perspective. Any histopathologist or team of histopathologists need to be able to seamlessly view, report, comment, share, consult, hand over, supervise, present, teach/train and request additional information or additional work on any case from within their clinical network, irrespective of the site where the work originated, their physical location or the physical location of other colleagues.

Since the onset of the #pandemic, we have seen many business and societal adjustments that were previously thought of as logistically impossible implemented quickly and with reasonable ease. It has become quite acceptable that the knowledge work may be delivered from a home office, from non-residential co-working facilities and with episodic attendance at primary corporate premisses. In the #healthcare sector, a range of #telehealth and other innovative approaches are also gaining ground. This is quite likely to become a permanent fixture for some industries and employers. We may even need to ask ourselves forscenarios where it is possible, would it be ethical to revert to old commuting, high-carbon footprint practices.

For pathologists, neither remote work nor work from home is particularly new. I do not have information on the number of jiffy-bags with histopathology slides in wide circulation, about paid or unpaid, clinical or academic work delivered on microscopes in home offices, on kitchen tables, or the root-causes and governance arrangements around these practices. I am sure that every pathologist of a certain generation will understand what I am talking about. There is a common understanding about the impracticality, waste, costs and the scalability ceiling of the 'jiffy-bag economy'. There are also a few examples where digital pathology-enabled solutions have been tested and accredited. Besides, many pathologists have at least some pre-pandemic experience with remote participation in the Multidisciplinary Team Meetings within their organisation or wider geography.

The pandemic brought new levels of enthusiasm, and forward-thinking organisations and networks are actively looking into institutionalisation and scaling-up of remote work and work from home. In my opinion, both remote work and working from home should be considered only as special cases of distributed work. We should ensure that the evolving framework remains flexible, inclusive and easy to review and develop, in sync with our experience with the new environment and technology. 

Although the idea of distributed work is gaining traction, I am also aware of potential concerns within the profession. Each of them, and the new ones that emerge, will be topics of the future articles; the issues risen so far are listed here:

First, is the state of the existing IT and cybersecurity infrastructure permissive for this journey? How to mobilise and synchronise cross-organisational resources and capabilities to deliver transformation? How much will it really cost? Each one of us doing this long enough has got a bloody nose in the minefields of hidden and unexpected IT costs and steep fees.

Second, there is anxiety about the physical decoupling of laboratory processing and reporting. Do all histopathologists need to be permanently collocated with the laboratory processing operations? Tissue processing laboratories are led and service is delivered by exceptionally well trained and competent scientific staff? How much specimen dissection/grossing will require pathologists' hands-on input, taking into account excellent dissection training for scientists and opportunities for video-assisted supervision? Given the current fragmentation of laboratory services across acute hospital sites, with workload ranges from ~100 to 2,000+ slides per day, can we ignore the opportunity to leverage the economy of scale, utilise the existing estates and other resources prudently and standardise processes and equipment? If the incumbent services do not, will new market entrants do so? Will small and fragmented laboratories be fit for the expanding and potentially demanding future preanalytical requirements of omics? Is there a practical ceiling for scaling up processing labs? We know that due to a significant amount of manual work, histopathology operations may not scale up as smoothly as, for example, biochemistry. How can one combine meaningfully scheduled presence on-site and the contemporary mediums of communications to safeguard and even improve productive teamwork between medical and scientific staff?

Third, how is the evolution of traditionally very local interactions between pathologists and frontline clinicians going to look like? Will large distributed networks lead to 'depersonalisation' of these relationships, for some, many or all pathologists? The colleagues in the profession know what it takes to establish them and how fundamental they are. With this in mind, do we need to have concerns about the quality of patient care? Is this a clinical issue, a matter of the organisational culture, or combination of both? How to address it during the transformation? We know of quite a few examples where supraregional ventures across significant geography proved to be attractive solutions for niche specialties and domains of interest; does "the will and the way" proverb apply here?

Finally, what will be the impacts of distributed work on teams of pathologists? Conversations with colleagues brought to the surface a few potential issues; my previous article, for example, discusses the opportunity to quantify some aspects of performance. We have learned to work, interact, bond, develop knowledge base and skills, exchange and cross-fertilise ideas, and learn about our teams' activities and dynamic by being within earshot from each other. Although not even the most zealous 'postindustrial' pathologists suggest that we should abolish departmental premises or face-to-face interaction, we still have a lot to do to describe how that future may look like from the perspective of the teams and its members. As professionals, we are at the beginning of this journey. We have started to explore and scale up a routine clinical work using digital pathology tools. We were just about getting in the position to start having meaningful conversations about distributed work and commence active experimentation when the pandemic shifted us up a gear.

However, as leaders, we've been doing, and are about to do what leaders have always done – developing effective teams that can adapt and effectively respond to the changes in the environment. 

I've recently heard the interview with one exceptional leader from a different industry. Now, you may have never heard about Matt Mullenweg and Automattic, the $3bn company that he has founded. However, over 30% of sites on the Internet run on their flagship product, WordPress. Automattic, incorporated in 2005, employs over 1,200 staff globally, has never had an office-based workforce. They master the art of distributed work, and they claim that there is a method for developing teams and organisations to take full advantage of this approach.

I am by no means trying to extrapolate the philosophy or operating model of a hyper-lean software giant to overstretched, under-resourced and understaffed pathology services aspiring to sail through their creative transformation in high winds. Nevertheless, I've paraphrased here Matt's ideas as a thinking point about the approach to developing teams that can competently endorse a distributed histopathology service on a digital pathology platform. 

According to Matt, distributed teams can function at five levels:

1.       Level 1: Non-deliberate action

Most organisations were at this level before the pandemic. They have not made proactive arrangements to support distributed or remote work. If for some reasons, they need to stay home for a day, the employees would be able to keep the ball rolling, although most of the work would need to wait until back in the office.

2.      Level 2: Recreating the Office Online

Most traditional organisations are now at this level. The teams have access to corporate software and data through channels with business-level security and online communication tools. Nevertheless, instead of redesigning their activity to take advantage of the new medium, the teams default online to the ways they used to work in the physical office. Matt's few examples sounded very familiar. Pavlovian adherence to real-time emailing, frequent interruptions, videoconferences with 10+ participants, even for the meetings where only a couple would do.

3.       Level 3: Adapting to the medium

The advantages of distributed work start emerging through exploiting communication channels. Real-time documentation of online meetings may be the first step. For distributed teams functioning at this level, precise written communication across defined electronic channels significantly reduces the number of meetings, their length and number of participants required. Time is released for productive activities or for improving the work-life balance of team members.

4.      Level 4: Asynchronous Communication

According to Matt, companies that can practice asynchronous communication can abandon the factory floor mentality and no longer equate presence with productivity or time with output. There are significant benefits of adopting the principle that, save for the appropriately flagged urgent activities, other things seldom require an immediate response. For example, giving knowledge workers time to think, create and get into more productive and low-stress 'flow state'. It also helps people making better decisions by giving them time to think between questions and responses. It may help to mobilise brainpower of less extroverted team members or those whose first language differs from that of the majority. As long as there is a functional overlap between team members' days and transparent allocation of responsibilities and expectations, this level of distributed work can enable significant flexibility.

5.       Level 5: 'Nirvana’

With tongue in cheek, Matt described it as the aspirational level where the distributed team works better than any face-to-face team ever could.


Before we go…


I would like to remind you that our guest speaker at our next #dPath20 Webinar on Thursday 25th June, 13:00-14:000, will be Juan Antonio Retamero!

Juan is one of the most experienced digital pathology leaders and transformation experts in the World. This is a unique opportunity to hear Juan's perspective on the Journey from Granada University Hospitals and other organisations where his expertise made a difference. We expect a useful, practical, insightful, and entertaining Webinar. This Webinar will be supported by the media team from Bradford University and moderated by Samar Betmouni and me. The aim of #dPath20 is to learn about the implementation of #digitalpathology from those "who have walked the digital pathology walk" and are willing to share with us their insights, data, and tips and help us move faster and more effectively

Please book your place by following the registration link. Feel free to share the information about #dPath20 with colleagues across the World. The journey from 'bricks' to 'clicks' is the global journey of our profession and we would like to build a vibrant professional community willing to crowdsource ideas and solutions.

Also, if you are the practising pathologist and are using teleconferencing to attend Multidisciplinary Team Meetings or Tumour Boards, please do not miss the opportunity to participate in the Twitter survey designed by Dr Tim Bracey. Tim is a Histopathologist and one of the most enthusiastic advocates of digital pathology that I have had the privilege to meet. Your answers will help us all to feel the pulse of the profession better and formulate our transitional strategies. Thank you in advance.

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