Digital Pathology Podcast
Digital Pathology Podcast
96: Achieving Work-Life Balance in Medicine as a Pathologist with Digital Pathology w/ Todd Randolph, MD
How can you work remotely as a doctor? Clearly some specialties, give more possibilities to do that than others and pathology is one of them.
In this episode, I talk to Dr. Todd Randolph, a pathologist living the remote pathologist lifestyle.
Dr. Randolph shares his journey into digital pathology, including his background, the evolution of his practice, and the transition to remote work.
We discuss the benefits and challenges of digital pathology, including the importance of pathology and business experience, as well as insights into AI in pathology.
Dr. Randolph also provides advice for those looking to pursue a career in digital pathology and emphasizes the importance of taking initiative and staying informed about the field.
TIMESTAMPS
00:00 Introduction to the Guest: Dr. Todd Randolph
01:05 Todd's Pathology Journey
02:04 Specialization in Pathology
03:55 Transition to Digital Pathology
05:01 Working with Lumea
11:44 Daily Life as a Remote Pathologist
13:36 Challenges and Benefits of Digital Pathology
20:37 Starting a Career in Digital Pathology
24:45 Early Days of Digital Pathology
26:17 Challenges in Digital Pathology Systems
27:46 Exploring Different Digital Pathology Systems
29:03 Impact of Digital Pathology on Work-Life Balance
32:50 Advice for Aspiring Digital Pathologists
41:11 The Role of AI in Digital Pathology
50:40 Regulatory Considerations for AI Tools
54:11 Final Thoughts and Encouragement
THIS EPISODE’S RESOURCES
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Aleks: Welcome, my digital pathology trailblazers. Today, my guest is Dr. Todd Randolph. And Todd is a pathologist who is living that dream remote pathologist lifestyle. I just hosted a webinar and I had several people commenting, Hey, how can I work digitally? So Todd is actually doing this. And if he wanted, he probably could work with the tablet on the beach or in the mountains.
I just saw mountains, through his window. Could we not all work like that? We are both smiling now because, there's a bit of a catch to this. It did not happen overnight, quite in contrary, it took quite some years to get there and, not only pathology experience, but also business experience and some heavy digital pathology trailblazing, to enjoy this way of practicing pathology.
So with that short intro, I welcome you, Todd, Dr. Todd Randolph to the show. How are you today?
Todd: I'm good. How are you, Alex?
Aleks: [00:01:00] I'm good. I'm excited to have you on the show.
Todd: Yeah, no, thanks for the invite. It's great to be here.
Aleks: Yeah, let's start with you. I want you to tell the digital pathology trailblazers, who you are and, what's your background.
And also what did you do before you started practicing a hundred percent digital.
Todd: Absolutely, so yeah, like most pathologists in the, in the, you know, mid nineties era, I, joined a group, which was relatively small initially where I practice primarily surgical pathology and atomic pathology with a little bit of CP. I may be CP boarded.
And then I was, , that group grows or grew significantly. that's become almost a 20 person group over a 20 year span. And I was active in that group, developed some, some specialization. We sub [00:02:00] specialized in the late 90s, early 2000s. So I mean, again, it's specialized in GU.
Specialization in Pathology
Aleks: Where this specialization in pathology, is this like a new thing? No, right?
Todd: Not, not really. Yeah. But in that era, it was, it was a bit, I don't think they actually had a GU fellowship.
Aleks: Ah, okay.
Todd: In the late 90s.
Aleks: I'm asking because it's totally not the case for the rest of the world. You don't have such strictly specialized pathologists. But here in the US, I was like always exposed to, Oh, I do skin.
I do dermatopathology, GI…
Todd: Right…
Aleks: I do soft tissue. And I'm like, what about the rest?
Todd: Yes…
Aleks: And I was, and I kind of took it for granted that this is the level of specialization all over the place. It's not. And now you're saying that it actually, not all the specialties were available in the nineties. Cool. Thank you.
Todd: Yeah. As far as the, you know, fellowship, you know, specific training, for them, weren't available and it was driven, we can go off topic for a second. It [00:03:00] was driven a lot by the healthcare system, the large healthcare system. begin to have some specialty conferences as supposed to just a general tumor board, you know, which is kind of the classic thing, work of this presents.
So they began to some specialize into, chest and then a soft tissue and neuro, GU, which is on that I did. So that kind of drove our practice to begin some specialization within the group, but we still practice all this practice general pathology. As well, but all the referral cases and things like that, compared to the conferences we go to this person.
So that's kind of where this specialization quote, unquote, you know, you got to arise in our setting. I've seen other larger practices with large medical systems are probably similar to that, have similar experiences, but. So, anyway, so, so back on track. so.
Transition to Digital Pathology
So yeah, for, for, for 20 years and, and obviously [00:04:00] after doing something, you know, relatively consistently kind of the same way over, over 20 years, I was beginning to look for at least a different career path or maybe, a way to practice. The same type of tissue type of pathology, but differently, practice it differently. So I began to kind of look for that, , maybe you're 18, 17 or 18 or so, and then stumbled upon an opportunity in around 2016, where I was able to, to kind of make the leap right, to, to industry and, and I did kind of in parallel, I began to work for a biotech company as their medical director.
So much more on the clinical pathology side. And then, and then also, just to, and this kind of goes back to how your introduction happened to be [00:05:00] lucky enough to be in Utah at that point in time.
Working with Lumea
And that was the very early days of, of Lumea and, and I, I'm not sure how much your audience knows Lumea and Matt Leavitt.
Aleks: You can, you can say like how it enabled you. I don't think I had anybody from Lumea on the podcast to strictly talk about the company. So feel free to explain like how this enabled you.
Todd: Okay. Yeah, sure, sure, sure. So, so it was Matt Leavitt's idea. What…
Aleks: Yeah, I had him. But he was…
Todd: You had Matt on, okay.
Aleks: Yeah, I had Matt on the podcast, but he was talking about different things including Lu mea.
Todd: Gotcha. So Matt was, , essentially the founder, of Lumea as well. And his, his idea was to digitize pathology, right. He saw, he saw the, the need for pathology to become, a little more [00:06:00] efficient. How was practiced?
And then also, I think, you're well ahead of his time where artificial intelligence would ultimately be introduced…
Aleks: I'm laughing because in the podcast, he's, he's telling the story and I'm going to link to this podcast. He's telling the story where he decided, oh, he's going to go digital. He bought a scanner and it was so slow…
Todd: Yes, yes…
Aleks: That it was just such a mistake at that time…
Todd: So it was rather, it was rather clumsy initially, like all things new are, right? But, but I did, I had met him and then when my situation changed, when I left my group where I practiced for nearly 20 years, started with the biotech company, then I started to work with him, with Lumea. So that was, that was kind of the early days, very early days in Lumea, where they still had a laboratory.
And Lumea, like I said, was a company where for maths, it was to digitize the knowledge, right? So, [00:07:00] so that was my initial experience and I worked fairly closely with Lumea in the early days and then, and then was still doing the biotech and then kind of back and forth through, through that process and then, and then started signing out digitally with him, probably like 2017, 2018.
Mm-Hmm. and once Lumea was, you know, to scale and was fast enough as she alluded to and organized enough. and I was primarily doing, almost exclusively probably doing prostates at that point in time. Their system at that point was really optimized.
Aleks: Were you not missing other pathology?
Todd: Not at that point, no, I wasn't.
I wasn't actually. Yeah. and, and we could go into that. I think as we talk about digital pathology in general. So you're still, I still have a number of colleagues, right, that are on the platform with whom I [00:08:00] interact. So it is a different interaction, but I think you could, you could certainly do a hybrid model of digital pathology and on site pathology as well, kind of get the benefits of both worlds.
That's kind of where your personality was or where your practice was. So, so ultimately, the, the biotech, medical directorate position kind of changed a bit. I'm still affiliated with that company, but not as much. And the digital opportunities expanded, probably right, right before covid.
Aleks: On the diagnostic side?
Todd: …2020. Yeah. Yeah. So, so that's where I kind of made the decision. All right, I'm going to veer more and more to the digital pathology. And, and it was, you know, using the resources, as you mentioned before, it can be kind of capital, capital intensive, right? Initially, where, where you may have had [00:09:00] that, initially, and then that's a whole other story.
What happened, what's happening, which we may have and, and. And how the practice of pathology kind of moved beyond that, as…
Aleks: Yeah, Matt kind of goes through the story a little bit because he, he like, he started Lumea, then he started practicing pathology, but then Lumea was more software, and then there was some kind of conflict of interest, so he stepped out, started a pathology practice, then again he stepped out and…
Todd: Yeah.
Aleks: Yeah. So she has an interesting journey.
Todd: Yeah. So…
Aleks: Evolution
Todd: Right, So, so that's kind of where I am now. When Matt said he stepped out, that's kind of where they, where, where Lumea became and is, basically a technology company. And they, they have a, digital platform, that, [00:10:00] is very efficient, very optimized for digital pathology.
Our full biopsy link, so that's what I use and that's the company, the practice that moved outside of Lumea is called, is called PathMed. And I contracted with them, to read digitally, to read, remotely.
Aleks: But you have your own practice, right?
Todd: And then, yeah, there is another, there is another practice…
Aleks: Because it cannot be too simple. That would be just too straightforward.
Todd: Yeah, yeah, another, another, yeah, exactly. There's another practice, primarily GI specimens. That's not related to, that's unrelated to, to the, to the spinoff of Lumea, where they have, you know, self-standing laboratory, scanner on site, but we are using the, you know, BXlink or Lumea's, software, Lumea's structure [00:11:00] system.
So that's, so that's the one where I have most experience as opposed to having a separate viewer. And an LIS where you have to kind of go potentially between a box like has a boat together. It's a long, long introduction, but, but that's kind of where I am now, and, and that's kind of my, my daily practice is covering…
Aleks: So like legally, do you have your own pathology practice or are you like self employed? How, how do you practice?
Todd: So, so I'm set up as a, since I'm strictly a contractor, I'm set up as 1099.
Aleks: Okay. So you're a contractor pathologist for several companies that enabled their pathologists to read digitally.
Todd: Yes, exactly.
Daily Life as a Remote Pathologist
Aleks: And we were both smiling during the introduction because you currently are living what many would consider the dream life for a pathologist [00:12:00] with the ability to work remotely, sign up cases from home and maintain a flexible schedule. Can you describe what a typical day looks like for you in this role?
And, and also how it compares to your role before when you had to be on site, like to do a little bit compare contrast classical on site versus fully digital right now.
Todd: Right, right. So, so the digital is good. Like you said, it does give you more flexibility, what you typically have with a, with an eight to five type position.
So my typical day would be. You know, just kind of getting getting started on cases, right? Kind of signing up, signing in, logging in, to, to a, you know, dashboard similar to what you would have with a regular land refurbishment system. And then I would just work through, work through the cases for that, for that day. But you know, you can take breaks if you need to, [00:13:00] run errands if you need to. So it does give you that flexibility, provided the internet is working that day. And it's fast enough that day too, you know, that is, that is one of, one of the limitations.
Aleks: So is this a cloud based system or is it something that you like have to predownload ahead of time?
Todd: Yeah, no, it's a cloud based. Yeah. It's cloud based.
Aleks: Ok, and there are, you know, different versions. I'm just asking out of curiosity.
Todd: Right. Yeah.
Aleks: And another, like, logistical question is, do you do primary diagnosis or do you do second opinions?
Todd: Both. Okay.
Aleks: Okay.
Todd: Yeah. Mostly primary, right? Mostly primary diagnosis.
Challenges and Benefits of Digital Pathology
So, so yeah, I mean, that contrast, you know, without the, like you said, there's, there is. there's one element where you don't have, interaction with colleagues, at least directly with colleagues, but there are several, [00:14:00] other pathologists who are on the platform who work within the same companies that I work, who are either employees or contractors who I've met, you know, in person, live.
So I, I know that when you develop, you know, social relationships. It essentially. I can either call them on my cell phone and say, “Hey, take a look at this case.” I can shoot them a text with the case number, , and then I can share the case with them. We can talk about it. So it's as if you're sitting across the scope with them or at a multi headed scope, but it's just all virtual.
So, so that's, that's different, right? As opposed to having a conversation with somebody…
Aleks: Do you like it better or worse? Like what, what are your feelings about this way of interacting?
Todd: Oh, I, I, I think it depends on the personality of the pathologist. This, as far as the, you know, the technical quality of the, of the image, looking through a microscope [00:15:00] versus looking through, you know, looking at it on a monitor or a screen or whatever.
Yeah. Images are equivalent that digital is at least a better, than what you're typically get under the microscope. so, so in that regard, I think it just depends upon what, you know, what, what you're most comfortable with, what you'd like and as far as a person overaction, one advantage of having a digital platform is that you have, you know, tremendous expertise available where you wouldn't necessarily have that.
And to that degree, in a hospital setting. Like I said, you may be the only dermatopathologist, but you would like the opinion of the other dermatopathologist and if there is another dermatopathologist…
Aleks: And you're the only one in the hospital.
Todd: Yeah, you're the only one, but you could ask somebody else too.
Yeah. But you know, you do. You're not going to lunch with a colleague, right. You don't have that interaction, figure out the [00:16:00] day or what's happened or half this challenge about, you're not interacting with the clinicians as certainly as probably as frequently as we would in a hospital setting. The variety of practice is probably less with what I'm doing because of the nature of my current practice where I'm socially specialized, at least primarily, so that would be maybe quite a bit different between that and a general practice, you know, I don't go to tor boards, for example, anymore. I, I don't have a call, but yet there's a little, take that to that, there's, cases are always available, so it's hard to kind of turn it off, that's what I found as a challenge, right?
That's different, whereas if you're in a, in a work setting, you tend to leave whenever in the late afternoon or the evening and you go to your home [00:17:00], wherever your next place is. and you stop you have to stop because you don't have the…
Aleks: Yeah you have like not not only a mental but also a physical transition…
Todd: Yes.
Aleks: And that kind of helps you switch tasks better with I mean, I know for my just the, the, the, digital content creation, activities that I'm doing.
This is constantly available on my phone and, you know, I get messages…
Todd: Right.
Aleks: About things and I try to respond to people. Because I know that they have questions that they need answers to. It doesn't mean that I have to do it right there and then, but because I can, I do it. And maybe I should not do it all the time.
Todd: And that probably comes from the territory of anybody who works remotely, right?
Aleks: Yeah, I guess it's like a new era, new digital age challenge that you have to navigate your mental health in a different way.
Todd: Right, exactly. Exactly. So, so [00:18:00] that, that for sure is a difference between, historical pathology and, and, you know, digital primarily remote, pathology, yeah.
Aleks: So from your perspective now, I think like a lot of things that, that are not available digital, like you say, variety of cases, it kind of comes with specialization. I don't think it would be different if you were on site. And you would still be, like in this specialist capacity. For me that the digital consultation, they are so much like less intrusive than It felt when I was starting and I had to like go with a slide to a colleague who was doing something under microscope was busy when they're in their work.
I was like very early in my career. So everything was looking funky. And I'm like, is it embarrassing to go with this? Let me like go through everything [00:19:00] and then collect stuff. But then you have a pile of slides and you also don't want to take a chunk of time of people. And now what I, tend to do, I mean, I, I've seen more slides since I started.
So, there is a little bit of the experience component. But also, the digital accessibility of colleagues. You don't have to bother the same colleague that's next door all the time.
Todd: Right. Yeah, that's good…
Aleks: They can also answer on their own time…
Todd: Right.
Aleks: Rather than me, like, interrupting and knocking on the door.
Todd: Interrupting and demanding at that point. So this can be triaged a little bit. Yeah. Yeah. That makes, that makes sense. So I think those are the, I think we covered the major points as far as, you know, the difference between, you know, historical on site, versus, you know, I think, and your point about if you were, if you were specifically in more of a academic setting.
The type of tissue specimens would not be different. That was different from what I'm currently doing [00:20:00] primarily. Albeit, I still see some general pathology in a different setting, , but, but certainly not as, as much as what I did my first four years of practicing.
Aleks: So obviously it took some time before you got to practicing like that. So is there anything that you think, oh, would not serve you when you were a younger pathologist, if this was an, a possibility, and we're going to talk about like what hurdles you had to go through and how you arranged this digital world for yourself. But do you think that there is a, like a disadvantage for…
Starting a Career in Digital Pathology
…people entering the pathology, practice, pathology profession to start digitally.
Todd: I think in general, there probably would be a little bit of a disadvantage to be 100 percent [00:21:00] digital starting out. And I think that would be, you know, again, dependent upon the personality of the pathologist, the colleagues and the comfort level that you have showing cases, learning from them. And there's probably there's that long, fair amount that actually you do pick up, which is casual conversations about a case. That you may not have if you just get a result back from somebody after looking at it digitally if you're sitting across the strip with them. You know, I guess think about when when you're both sitting there and then you're looking at a sliding at the lens.
And then you look up and you chat about something. And you, you would probably lose that, if you were just sharing cases, digitally.
Aleks: Like through a system.
Todd: Not, not in real time. Kind of like you said. They could send it to [00:22:00] them and they could triage and look at it when they, when they would like. And they get the answer back to me.
But you lose that casual conversation, that learning experience. I don't think digital pathology lends itself to that type of interaction, which is, you know, critical in the early days, as you mentioned, showing things around, building your confidence. So, so I think in that regards, that would be maybe a bit of a disadvantage to start out doing, doing that. And I think, you know, you need, you need those general skills as well. I guess it depends upon where your career path is, but, but I think to be able to do frozen sections, right. And present it to the boards and things like that. If you really want to have, be able to participate in that type of setting.
But if you always see yourself as being, you know, I'm just going to be a, you know, person [00:23:00] working off site. So specialize, that's what I'm going to do that. That's the best idea, starting out. So, but that's kind of where right now I think digital technology is in that, in that regard. So, so that's kind of like the answer to your question.
But yeah, I think there are disadvantages to, to strictly restarting your career digitally. Yeah. I think it is.
Aleks: Like, you kind of lose the, and I mean, to everything that you said, I kind of agree. And I also disagree. Because the, the, the environment that you have, like, studying in med school, vet school, doing your residency with your colleagues, basically when you go remote, this disappears.
And if you thrive in this environment, and this is environment, kind of on purpose, designed in a way to stimulate, learning and stimulate, learning from each other, not only from the lectures, right? So this disappeared. Can you recreate [00:24:00] this digitally? I think you can. But will you be able to take advantage of this digitally as well as people in the normal setting?
Depends on the personality, and probably you might need to put some more effort into that if this is important to you. I think like through osmosis with people, it's going to be faster and easier. It's still possible digitally, but you need to put effort into like, we do, where I work, we do digital rounds.
And I basically like communicate and send screenshots without like, formal, way of requesting second opinion just to colleagues I trust and I know already from on site so it's not like fully digital strange people that I never met and I was on site before and then I moved to digital.
Early Days of Digital Pathology
But yeah, so you've been practicing digital pathology full time since 2018, which actually [00:25:00] makes you a true pioneer, and the digital pathology trailblazer, because I can, I kind of think like the tipping point was during COVID, which was, you've been doing this for two years already.
So do you have some insights of those early days working at digitally? And what were the challenges? How did you face the transition to a remote setup? And, and like, what did you do to have a good quality of work and let me just tell you one thing that I remember from my early days in digital pathology, which was like 2016 where I needed to do annotations on slides and the act of annotating this tor would take me like five seconds.
The image would take 30 seconds to open. I was going crazy.
Todd: Right.
Aleks: I was like, Oh, my goodness, as much as I believe in this technology, please, I cannot do anything in 30 [00:26:00] seconds. Like I cannot use this time. And the task only takes five seconds.
Todd: Yeah. So I think the, you know, the initial challenges, you know, obviously bandwidth is important.
All right. Earlier to have, and then, and then not only, you know, where you're located, but also the, the, I guess the outflow capability of…
Aleks: Yeah, they send the images…
Todd: …where, you know, where that, where that's originating.
Challenges in Digital Pathology Systems
Right. So, so that, there may have been some bumps in the road for, for that time it was Lumea cause they had a laboratory within the Lumea organization, but that was pretty well ironed out between that 2016 to 2018 period of time for them.
At least they, they worked through that process. Yeah. so, for me, the latency wasn't, you know, usually isn't that big of a deal, and I don't remember it being a big issue, when I first started as, as well. [00:27:00] So, so I think, you know, just some of the challenges with the, you know, it was a new laboratory information system, so I think that's kind of where you would potentially run into, there were, there were some, you know, obviously, bugs along the way, because it was, a new system, much better now than what it was initially.
But yeah, I think, I think those are probably the major things it wasn't things have pretty well been ironed out, by the time I started, but I think it started, you know, try to really force it back, , kind of reminders that man had the first year. Right. And they had our value has been as high as what they are now.
Yeah, and you know, but I think the volume basically increased as the technology has improved and allow that volume to increase along the way.
Exploring Different Digital Pathology Systems
Aleks: Yeah and you know there are differences, you can either have systems that are like cloud native and everything happens [00:28:00] in the cloud is in this like really directly dependent on your bandwidth. In the moment, regardless, like how you optimize viewing those images, like, like Google maps or whatever, that not all the tiles are loading and there are systems where you have to download stuff ahead of time, which also have their challenges.
I think that the size and the data transfer is still, like, it's not as bad, but it's not as seamless as I'd like, I would like it to be.
Todd: I see, yeah. And you don't have personal experience using, the Lumea Biopsy Link system?
Aleks: No, no. Yeah, okay.
Todd: Be interesting to see what you would think of that, since you've used other systems.
Aleks: I'm planning. I actually was talking to, to them and maybe I'm going to go to the conference later in the year to the Lumea, to the digital, no, [00:29:00], there’s no data…digital diagnostics conference.
Todd: Oh, the one in Park City in the, in the fall?
Aleks: Yes, yes.
Todd: Yeah, yeah, I agree.
Aleks: So if anybody is, , going there, let me know on LinkedIn and I might be there as well.
Impact of Digital Pathology on Work-Life Balance
So, digital pathology obviously offers a level of flexibility that's quite unique in the medical field. I think only the image based specialties can actually benefit from that, the radiologists are a little bit ahead of us and now pathologists. So did this, impact your work life balance? Like, what do I refer to, like, would you design your life the way you have it regardless?
Or did digital pathology actually enable this? And I kind of am asking this from a personal perspective. My husband [00:30:00] is a clinical pathologist. And at some point, he also switched to the industry, because he wanted to. Try something different and, you know, live a different life. And this kind of directly translated into a different work life balance.
You kind of had it with the biotech, I assume. But now you have digital pathology. Were you missing digital pathology? Like how did it influence your lifestyle?
Todd: Yeah, good question. So, so I think it did enable, a relocation for me, you know, initially, we could set up my practice with kind of tethered to a large hospital system, hospital practice, where, where I was active with call, active with, with two more of some presentations and some administrative.
So it required to me for me to be active. And that's very, very important. I mean, at least within a commuting, [00:31:00] you know, reasonable pre-distance to those facilities, right? Whereas now, that's not, that's not a requirement. So it does give, give a pathologist more flexibility. You don't have to be within, you know, close to the laboratory or as close to the laboratory is what you would, initially, or, you know, historically.
So, so in that regards, it has enabled me, , to, to kind of relocate into a setting that, that is a little more interesting to me, that allows me to pursue my, my out, outside of pathology interest.
Aleks: What do you do outside of pathology?
Todd: I enjoy the outdoors. So I do a lot of, a lot of, well. Not as much as what I would like, but the plan is to also do a lot of outdoor activities, so hiking, biking, primarily [00:32:00] in skiing, and things like that.
So I'll do it in the mountains preferably. So live in the mountains.
Aleks: Is that a beautiful mountain out of your window.
Todd: We're a little early there.
Aleks: So you, you kind of say digital pathology enabled me to enabled you to live the life a little bit more the way you want. Do you think, because it wasn't like, oh, you just raised your hand and you could do digital pathology.
You have a unique like employment situation. You're a contractor pathologist. And it's not that like, all the hospitals out there are looking for contractor pathologists. You needed to build, , to establish connections, build relationship. And so. I am hearing voices from the pathology world that people would like to be able to work like that.
Advice for Aspiring Digital Pathologists
So, is there any advice [00:33:00] that you would give pathologists who are, who would like to do a similar thing?
Todd: Right, yeah, yeah, yeah. I think, I think on your, like I said, on your own would be, would be, would be a challenge. And, and for me, it was just, you know, you know, it starts kind of lined up. He's early on meeting Matt, working with working with Lumea and establishing that comfort level and having a, you know, a laboratory that was focused on digital technology, right?
Which kind of enable you to do that. And if you were starting on your own, I kind of see it as, you know, two, two different, two different ways that that would, that would work. You would certainly need to join with other people, to try to create, you know, whatever that mass is that that's required. But if you're, if you're already practicing as a, as a group, with a, maybe a larger health care [00:34:00] system, the advantage of digital pathology would be, would be lifestyle, , and potentially recruiting as there are fewer pathologists out there.
There would have to be one thing to that. We always struggled with my group. we were largely centralized laboratory and, and it was difficult to, transport glass slides to the remote further out locations, right? It was always on the courier. As far as when you would get your case when you complain about, you know, having 30 seconds to load, but sometimes you would be waiting hours for Casey.
So, so if you could, you know, convince the administration or maybe do a joint venture where you would digitize the, maybe the majority of those slides and not have to rely on couriers, have better turnaround times in that, but that way you would share with that infrastructure, the infrastructure. Cost that requirement for digital pathology and allow you as part [00:35:00] of the group, more of a traditional practice, right?
Where you might be able to do a hybrid situation where, where you would do some work remotely, either in the facility, or you could be in a smaller hospital and then do the rest in a different location the second part of your day or have that flexibility where, when, or where you would, you would practice, digital pathology.
So, so that would be one, one way to do that, to introduce digital pathology. I think another way, if you're a little more entrepreneurial, would be like I said, you could set up a, subspecialty group or approach a subspecialty clinical practice and, and kind of, I guess, go with the kind of a joint venture, if you're, if you're more interested in a, in a large multi specialty clinic or something like that, where they would say, Hey, you know, you can establish a laboratory.
And I can be your one of your pathologist or your pathologist and like that, and this is how we can work [00:36:00] together. And, and, you know, if one group isn't big enough, then you might be able to find a couple groups to work together, but that would be you as a pathologist kind of driving that. And it would be kind of taking that opportunity back from maybe more, some of the larger commercial laboratories that you may have.
As you know, I started, I saw that in my career where you tend to loss that. but now, you know, that opportunity may be changing back to local pathologist where, where you can compete. At a digital level, because you would have access to that kind of clinic and say, hey, let's work together. Yeah. to try to build that practice.
So that would be one way. And then I think another way would be to like I said, the advantage of digital pathology is that it gives you access to experts. So if you were with a group of pathologists, kind of say, okay, [00:37:00] let's try to set up a slide processing facility, a scanning facility. It's impeccable. We can bring in clients and offer, you know, so specialty service, from bringing in specimens from a variety of locations.
And then we're offering that service and, and, you know, we may be working with several dermatopathologists that may not be that close by, but yet we can offer a tremendous service, again, competing with some of the commercial labs that maybe you couldn't do that before, because you couldn't have people on site, you don't have enough work in one spot, but if you centralize it, then you would have, you do have enough work, if you digitize it, so those would be kind of the three ways that, None of them are particularly easy, I think there are, right, there are benefits for, for, for, you know, if you go with the model, it's just the biologist setting this up, or I'm working with my clinician colleagues [00:38:00] in their multi specialty clinic, or as my large health system, hey, these are advantages in going digital for all of us.
So did that answer your question? I think that's kind of alarming.
Aleks: Yes. Yes. And you, you like emphasize a very important point. None of them will be easy. All of them are going to be pathologist driven. It's like, you know, you, you kind of like had this type of career and it kind of tells me. Well, you have to make this type of career for yourself and, you know, maybe you're lucky and you can join an institution that already is digitized, which is fantastic, but less than 10 percent are, or probably even less than that.
And then it's like figuring out, trying to find an anchor. I kind of had a similar, well, I don't know if it's a similar story, but basically, Also very much [00:39:00] like. Actively driven by me, the first job that I had in the digital pathology space, maybe we can call it by accident. It was, you know, I went to the, interview and they needed a pathologist to oversee image analysis efforts in that company.
It was an image analysis company and I joined the company and I started liking this. But this experience and me liking it did not really result, in me just like being able to raise my hand and say, “Hey, take me to this other startup or take me to this digital thing.” Actually, when I, started the blog and the podcast and I incorporated the Digital Pathology Place as a company, and that was a time in my career where I didn't know if I will ever have anything to do with digital pathology.
I was switching totally to preclinical veterinary pathology work. I was lucky to join a group that was already interested [00:40:00] in this technology, but I didn't know if I will have anything to do with it. And I still wanted to, to anchor myself in this, in this environment. So I just started publishing online about it.
And that led to two different conversations, different relationships. And, if I wanted to stay in this field right now, it probably would be easier for me, with what I have already experienced and done in this space than somebody who is just starting and, and asking, Hey, where can I do digital? and I try to like let people know, “Hey, this is a company that wants a digital pathologist. This is another one.” But with just such a fraction of institutions being digital at the moment, and then even another fraction of this actively recruiting for this kind of a role. It's still, kind of a niche way and a marginal way of practicing pathology as much [00:41:00] as I love it. And you know, you with your showing that it took you some effort to be able to do that.
And you know, affinity towards this, that was not really driven by, “Oh, I want to have a nice lifestyle.” But Yeah, there was, yeah, it kind of came after that.
The Role of AI in Digital Pathology
Todd: And I think one thing that, that we were, you mentioned, you know, image analysis, and we haven't really talked about, you know…
Aleks: Yeah, I wanted to ask you at some point, but I didn't want to interrupt you. Do you do AI for, on, on the biopsy?
Todd: Yeah. Yeah. So, so I have some experience, got a little bit experience with, , with Several algorithms, primarily, well, I think exclusively at this point in time, you need prostates with, with, with prostate pathology. And, and I think, you know, I think there's two ways to look at that.
One is, you know, again, getting more [00:42:00] in the early days of what that, what that looks like. And, and I think the, the company we're doing my contract in is trying to, trying to establish, you know, the benefits of the, current version, of, of those algorithms. And I, I think there will be some benefit or there is benefit in, in using that.
But I think as that, as that technology matures, and I think it will mature and, and the efficiencies that you will, I think, realize in the pathologist and the practicing pathologist using that, as the numbers of pathologists decrease, right? I don't remember that time, time again. And then also, you know, the potential diagnostic algorithms where the, where the AI sees, quote unquote, sees more than what we currently see as pathologists.
And how [00:43:00] we as a pathologist, or I as a pathologist, work along with AI to potentially render a better diagnosis, right? An improved diagnosis from what I currently can do, be it, you know, historical glass slides with light images versus digitally. Once we establish that, and I think that will be established, then, then you'll have a driver for, because, because that will become, you know, the standard.
Aleks: Yeah.
Todd: Had to be digital, because it will, a lot of us are, are afraid of digital. I don't say that might replace us, but I think it's really good. To augment how we practice, make us more efficient and, and allow us to make better diagnoses, you know, interact with AI. And then once it becomes quote unquote standard of care, then everybody's going to be forced to do it, right?
Be it a small system or a large system, hospital system, whatever, because it'll be better patient care [00:44:00] ultimately. That's kind of a ways out, but I think that's another potential driver for you know, converting to digital pathology, be it a small, large group or hospital system or whatever. I think that'll happen.
I don't know if I'll still be practicing at that point, but I'm not easy, you know, just because how quickly things mature. But I could see that as being a driver for addition. Yeah. To digital path based on my experience. Yeah.
Aleks: Very much. You mentioned standard of care when this like becomes. So clearly better.
Todd: Right. Just an enabler. Yeah, right. Yeah, for sure.
Aleks: Like clearly a lot better because now we are like in the space. And for, for the prostate AI, so specifically, this is the, this is, an algorithm that points out the malignant areas in the [00:45:00]…
Todd: Right. Typically that's, that's what they are.
Aleks: So it's basically, this is like, it highlights where to look.
So, you know, then you just look there and if it is there, it's there. If it's not, then, you know, you might look somewhere else. but it's, we're still in this like, Oh, increased efficiency, maybe increased accuracy. But like how much increased and when does it start to matter for, the decision makers to decide that this is the way to go.
So, yeah, I guess, so when you say when there's going to be something in addition to this efficiency and, increased accuracy, what do you think about? Do you have something specific in mind? Like, do you think of like predicting molecular, properties?
Todd: Yes, exactly. Exactly. Something that, that might, you know, augment [00:46:00] molecular, I don't think it's going to replace it by any means, but, but if there's a way…
Aleks: To speed up the…
Todd: Either through, either through quantitation of tumor content or a particular, you know, install recognize kind of what we do with the RPR right now, you know, is there a different way to think about therapies based on what the AI may see and what we may confirm as pathologists. that, that we don't know.
Yeah, right. And essentially that's just, that's kind of, just kind of discovery and learning, right? Using algorithms and, looking at clinical outcomes and what would be different. Yeah, so that's, that's a lot of fun stuff. I think there are probably companies out there that are, that are doing it. They only do that.
I don't think that's a five-three. I think, I think that's, I think that's, I think that's there, right? Based on what I've seen. [00:47:00]
Aleks: Yes, I think it's there. But then when you say, oh, AI is there and we're gonna do AI in pathology, it kind of, I don't know. I have noticed that this is like a trigger statement where people are, what do you mean AI is there?
Because when you say AI is there, we both now understand because we just had this conversation. We mean this particular algorithm that highlights this type of cells in a prostate biopsy or in a prostate resection, right. And in the context of this conversation, this is what AI for us means, and yeah, it's there.
I mean, people use it, there are practices that use it, right?
Todd: Right, right.
Aleks: But this is like a narrow, very narrow application out of so many narrow applications. So, my impression or my feeling about it is, it's like with all the medical devices, it's going to be one medical [00:48:00] device at a time, one algorithm at a time.
Although there are efforts to like building and models that can detect multiple cancer types in multiple organs. I don't think we're that far away from this. I would need to do some more reading up on this, but it kind of contradicts to the blanket statement AI is there, which is the case, but it's this narrow application of AI.
And I think without the context, what it actually is, have I seen it? How comfortable do I feel with it? Like, is it actually helping me or not? Without this context, It is more polarizing than it should be. I don't know, what's your impression about that?
Todd: You know, if it's a tool that the pathologist can ultimately, you know, [00:49:00] that you have to be a pathologist to use it correctly, and we improve patient care and patient outcomes with that, with that interpretation tool, then it's an advantage for us, right?
As a profession, as well as for the patient. So it's a win win for everybody. Let's just say the applications now are very narrow, but I think, I think it will become more, more broad.
Aleks: You mean more broad in terms of there's going to be more narrow applications or more broad in terms there's going to be like one thing that detects every one narrow applications, you're right.
Todd: Yeah, yeah. I would think, you know, is there, is there a way…
Aleks: So you can like chain them and tools that are more powerful.
Todd: Yeah, exactly.
Aleks: I think so, too,
Todd: Right, right now are all tubular had known us a lot, you know, kind of in our minds. Maybe they maybe they are, but maybe there's something that's there that with the assistance of AI.
We might say, oh yeah, I see that, I agree with that, I don't agree with that, you know, is that, is that likely to occur? Or, you know, is there [00:50:00] something there in this one that's not there? That's probably too much for our minds, at least my mind, to process as a pathologist on a case by case basis. But, you know, if something's there processing that image differently, looking at it, you know, what will we get differently?
And then I'm there kind of orchestrating that, all that information. that would be, that would be fun, right? That people ask to try that.
Aleks: Yeah, it would be amazing. But there also needs to be, like you say, it's too much for my mind. It's totally too much for my mind as well. And the research that is out there is mind blowing, but I cannot personally verify, Hey, is it good or not? So I think like, I very much appreciate the regulatory oversight over this.
Regulatory Considerations for AI Tools
And you know what I learned recently? That there are a lot of AI tools, so, so you don't need an FDA clearance for any, of these devices or, [00:51:00] algorithms to actually be used in a lab if you do your, CLIA validation in the lab.
And, but to me it was like, there is some kind of regulatory approval or regulatory framework that you need to work within, or at least you should have had the publication. It is not the case. Okay. I recently saw a publication like public evidence of AI, I'm going to link to this publication in the show notes as well, but basically a publication analyzing, how many AI tools are out there.
And it was over a hundred tools, all over the world. I learned that the restrictions in Europe, now the regulation changed, but the IVD restrict, framework did not really require an external, authority to review, this validation data. And then there are a lot of AI tools [00:52:00] that have been approved, by a regulatory body before any data was published on the validation of this, or some that are not approved or were approved without any validation.
I was kind of a little bit shocked, and it did kind of, put my mind on alert. I was kind of looking through the FDA clearance framework, and this is not the case for everyone creating AI tools for healthcare. So, yeah, I guess it's like, some food for thought for all of us.
Todd: Yeah, no, I think, I think, exactly.
I think, I think once they're used, I'm assuming that they will be used for either, you know, to facilitate primary diagnosis or to affect patient outcomes as, you know, as opposed to just a research R&D type application that, that [00:53:00] you'll need some type of, certifying body, for us, you know, the cap or clear or something like that would happen or for so, you know, if it's actually, like, a patient outcome, it's like an FDU type level or something like that.
But I think, I think that would be You know, that's kind of like the clinical validation of something as opposed to just a, you know, analytical validation.
Aleks: Exactly, exactly. So yeah, that's what I meant that not all of them have undergone the clinical validation. Yeah, right. Yeah. As opposed to the analytical.
Todd: And what that validation needs to look, you know, to look like, who sets those guidelines and guardrails for all that. that will for sure have, have to happen. And that'd be a cool career, right? For somebody to go in, to go into that, to kind of, pioneer that work through that delay. And I think that's, you know, probably where some academics [00:54:00] are, are, are working on that.
And, you know, might be part of that to come from the, from clinical commercial world. But I think those career types will probably be driven from, from an academic setting. So, but no, I agree with you.
Aleks: Yeah. Yeah.
Final Thoughts and Encouragement
So, so before we, leave here, before we finish this episode, I don't want to, people who are interested in this field and who, want to work remotely who want to do digital pathology in one form or another to walk away and say “Hi.” They both have started doing it already before and they have plenty of connections and like what am I supposed to do so like my advice is always like start learning about it and there are, you know, different avenues of learning.
I choose the, like, online, , information, online informational content, including the content that comes from various digital pathology [00:55:00] companies and commercial entities, and that are spreading the word, about their development. So that's kind of like what I always recommend. And then you start…
Start seeing opportunities that you didn't know actually were opportunities before you started being interested in this? Do you have any words of wisdom for people who are interested, but there's not that many open, digital open positions yet?
Todd: Yeah. You know, I don't know if I have anything to add to that.
I think, I think as we said earlier, you know, it's, it, it, you can look at the point. and I think that that's probably going to be driven from you, as a, as a pathologist, but just to, to learn, you know, how, what technical skills, and understanding do you need to have, you know, talking, we didn't really talking about scanners or imaging their connections, interfaces, and things like that, you know, is that, [00:56:00] do you need to bring that to the table, or at least understand that, before you have a conversation, with, with a hospital administration, for example, or for you to go out and potentially think about doing it with a group of, another group of pathologists or a separate pathologist, you know, if you want to be the driver for that, then there probably is some technical and, and, and I'm, I'm probably not the person to ask for that because that was, I was lucky enough right not to have to do that.
Aleks: Yeah, I consider myself lucky as well, but, you know, there's always luck and there's always the preparation part or like the, what do you then, and have to back up this luck. So definitely listen to this podcast, because if I'm going to be hearing about anything, I'm going to be letting you know, and I want this technology to spread for the good of humanity and patients and pathologists.
Yeah, I definitely drank the Kool Aid, [00:57:00] but that's okay. I think it's a good technology. Thank you so much, Todd, for joining me today.
Todd: You're welcome. You're welcome. Nice meeting, meeting you and spending more time with you.
Aleks: You have a wonderful day. Okay. Take care. Bye bye.
Thank you for staying till the end. This means you are a real digital pathology trailblazer.
And you know what? Don't get discouraged. like in any discipline, , especially in such a, like pathology is niche. And then digital pathology is really like a fraction of pathology, but it doesn't mean that we're not supposed to look for opportunities in this area. So, as I said in the podcast, my advice is always get informed.
And so if you did not grab the book yet, please do. I'm going to leave the link in the description below. This is going to give you an amazing intro to digital pathology and you take it from there wherever you want to take it. And I talk to you in the next episode.