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Next-Generation Pathology is Close to Being Reality

March 6, 2014

DIGITAL REVIEW, GENOMIC MEDICINE AMONG CHANGES

Reprinted with permission from the Journal of Business
David C. Hoak, M.D.

David C. Hoak, M.D.

When I was young, my father would take me to the lab on weekends. He would look at smears of blood under the microscope, place samples on circular blood plates to allow bacteria to grow, and type out biopsy and pap test reports by himself on a typewriter with two fingers.

In the 1950s, he performed two to four autopsies a week.  He was a pathologist, a solo practitioner serving two hospitals, six miles apart. Today, I practice with 36 pathologists at Incyte Diagnostics, a group practice spanning Washington and northern Idaho.  I still use a microscope every day, but all of my reports are computerized, and I rarely perform an autopsy.

As a second-generation pathologist nearing the end of my career, I look to the past to predict the future of pathology.

Digital pathology:  Today’s microscope probably will become part of an exhibit at the Smithsonian or an ornament on display in someone’s study. Microscopic slides will be scanned by a computer and viewed and interpreted on a computer screen or a tablet.  A pathologist anywhere in the world will be able to examine a scanned slide from any patient in the world over an ultra-high speed Internet connection. Geographic borders will evaporate, and pathology will become a global practice. Pathologists will seek opinions from the world’s experts in real time, no longer delayed by the air shipment of slides. Computers will quantify more accurately tissue biopsy analysis in the future.

Genomic medicine:  In 2003, the Human Genome Project completed the first analysis of a complete human genome, the entire genetic information encoded in DNA sequences, consisting of approximately 3.3 billion base pairs. Since then, there has been an explosion of knowledge about the genetic basis of disease. The first human genome cost $3 billion. In 2014, with next-generation sequencing (NGS), the cost to a lab to sequence a patient’s genome will be $1,000. In the not-too-distant future, every patient will have the opportunity to have his or her complete genome sequenced, so it can be determined what diseases the patient may be susceptible to. If the patient has cancer, his or her cancer cells will be sequenced to look for genetic mutations that are susceptible to targeted therapies. NGS will generate enormous amounts of complex data. Pathologists, geneticists, genetic counselors, and other trained professionals will be needed to interpret this vast amount of data for treating physicians and patients.

Informatics: Medicine in the near future will be entirely computerized. Digital pathology, next-generation sequencing, and clinical lab tests will generate enormous amounts of information. The health care industry will need subspecialist pathologists who know how to retrieve and analyze data from all the known clinical databases. The need is growing so rapidly that clinical informatics is now a recognized subspecialty, and pathologists are expected to comprise half of these subspecialists.

Real-time lab testing on a patient: Patients will wear a “lab on a chip.” Certain chemicals, such as glucose and electrolytes, will be measured, continuously. The results will be sent to the patient’s smart phone and to the patient’s electronic medical record with alerts pushed to their physician when the results reach critical levels.

Collaboration: Pathologists have a reputation of “hiding in the lab,” especially since pathologists don’t see patients directly. With the development of accountable care organizations and medical homes, physicians, nurses, social workers, therapists, and pathologists will need to work as a team to coordinate a patient’s care. Pathologists will need to help develop laboratory test algorithms and test utilization committees.

In hospitals, pathologists will be expected to be increasingly more active participants in leadership roles as medical laboratory directors. This will include committees and presentations to staff. In addition, pathologists might be expected to be active participants in an organization’s social media presence.

Workforce shortage: In 2015, the number of pathologists retiring will exceed the number of newly trained pathologists. With the general population increasing and an aging population, there will be a shortage of 6,000 pathologists in the U.S. by 2030. The average age of a clinical laboratory scientist, which is a professional staff member who works in a clinical laboratory performing testing, is more than 54. There is already a shortage of clinical laboratory scientists, but with retirement and population increases, the shortage could become severe. Laboratory staff will have to find ways to perform testing more efficiently because the laboratory provides 60 percent to 70 percent of the actionable information in a patient’s medical record.

Patient-centered pathology: Patients are much more informed and engaged in their health care because of the Internet these days. It has been reported that over 60 percent of Americans turn to the Internet to answer questions about their health. For many, the Internet has replaced other trustworthy sources of health information. Pathologists have a responsibility to provide accurate and actionable information for patients and their families dealing with cancer. This will allay any undue anxiety that might be generated by excessive online searches coined “cyberchondria” that have resulted in misinformation.

Incyte pathologists already have developed and implemented many resources that enable patients to find out information directly from a board-certified pathologist. Our website includes an “Ask The Pathologist” page, which was the vision of Incyte pathologists who clearly want to help patients be more engaged and informed. Helping patients understand their illness helps them gain control over their fears.

In the future, pathologists may be consulting directly with patients and explaining digital slides of their tumor over the Internet. Like next-generation sequencing, next-generation pathology is nearly upon us, and it’s exciting.

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