Dermatopathology Training Research Articles

Pathologist Characteristics Associated With Rendering Higher-Grade Diagnoses for Melanocytic Lesions

The incidence of melanoma diagnoses has been increasing in recent decades, and controlled studies have indicated high histopathologic discordance across the intermediate range of melanocytic lesions. The respective causes for these phenomena remain incompletely understood. To identify pathologist characteristics associated with tendencies to diagnose melanocytic lesions as higher grade vs lower grade or to diagnose invasive melanoma vs any less severe diagnosis. This exploratory study used data from 2 nationwide studies (the Melanoma Pathology [M-Path] study, conducted from July 2013 to May 2016, and the Reducing Errors in Melanocytic Interpretations [REMI] study, conducted from August 2018 to March 2021) in which participating pathologists who interpreted melanocytic lesions in their clinical practices interpreted study cases in glass slide format. Each pathologist was randomly assigned to interpret a set of study cases from a repository of skin biopsy samples of melanocytic lesions; each case was independently interpreted by multiple pathologists. Data were analyzed from July 2022 to February 2023. The association of pathologist characteristics with diagnosis of a study case as higher grade (including severely dysplastic and melanoma in situ) vs lower grade (including mild to moderately dysplastic nevi) and diagnosis of invasive melanoma vs any less severe diagnosis was assessed using logistic regression. Characteristics included demographics (age, gender, and geographic region), years of experience, academic affiliation, caseload of melanocytic lesions in their practice, specialty training, and history of malpractice suits. A total of 338 pathologists were included: 113 general pathologists and 74 dermatopathologists from M-Path and 151 dermatopathologists from REMI. The predominant factor associated with rendering more severe diagnoses was specialist training in dermatopathology (board certification and/or fellowship training). Pathologists with this training were more likely to render higher-grade diagnoses (odds ratio [OR], 2.63; 95% CI, 2.10-3.30; P < .001) and to diagnose invasive melanoma (OR, 1.95; 95% CI, 1.53-2.49; P < .001) than pathologists without this training interpreting the same case. Nonmitogenic pT1a diagnoses (stage pT1a melanomas with no mitotic activity) accounted for the observed difference in diagnosis of invasive melanoma; when these lesions, which carry a low risk of metastasis, were grouped with the less severe diagnoses, there was no observed association (OR, 0.95; 95% CI, 0.74-1.23; P = .71). Among dermatopathologists, those with a higher caseload of melanocytic lesions in their practice were more likely to assign higher-grade diagnoses (OR for trend, 1.27; 95% CI, 1.04-1.56; P = .02). The findings suggest that specialty training in dermatopathology is associated with a greater tendency to diagnose atypical melanocytic proliferations as pT1a melanomas. These low-risk melanomas constitute a growing proportion of melanomas diagnosed in the US.

P30 Declining staff numbers and increasing workload: is there a solution?

Abstract Within the UK, there is a rapidly rising incidence of malignancies, including cutaneous cancers. Over 1 million new patients are referred to dermatology each year and a large proportion require a diagnostic or therapeutic biopsy. Dermatologists often rely on histopathology to confirm or diagnose cancers, determine margins and perform specialist testing. The increasing rates of cancers are adding significantly to the histopathology workload. According to the Royal College of Pathologists (RCPath), only 3% of departments report having adequate staff to meet clinical demand. There are a significant number of unfilled training posts and a concurrent retirement crisis, with 25% of all pathologists over 55 years old. It can take up to 15 years to train consultants, with the more experienced able to handle greater workloads. The lack of pathologists, with widespread vacancies, has a significant impact. The resulting costs to the health service of employing locums and outsourcing work have been estimated to be £27 million annually. For patients, the costs of these shortages mean delays in diagnosis and treatment. A RCPath key performance indicator advises that 80% of cases should be reported within 7–10 calendar days. Across dermatology departments, there is wide reported variation in reporting times from 1 to 28 weeks. In 2019, the longest wait, on average, was 5.8 weeks. We surveyed 60 histopathology consultants across different National Health Service trusts in England to determine the reasons behind these delays. The survey response rate was 45%. The results showed that 78% of departments have unfilled posts, 83% have employed locum staff or outsourced reporting of skin biopsies in the last 5 years and only 20% are able to meet the RCPath guidance. Additionally, almost one-quarter reported that they have had complaints or serious incidences related to delayed dermatopathology reporting. Survey comments revealed many other areas of potential diagnostic delay from sample labelling and prioritizing to prolonged laboratory processing times, unclear pathways to expedite samples and the lack of histopathology secretaries. This survey highlights the increasing workforce demands and emphasizes the need for innovative changes to avoid delays in patient care. Possible solutions to address increased workload in an understaffed environment include adequate secretarial support, increasing pathology pathway navigators who prioritize urgent cases, improving information technology services, digital slide reporting and developing artificial intelligence to screen samples. Increasing dermatopathology training and exposure to histopathology at a junior level is mandatory. Raising these issues and making them a key investment priority for the government is imperative.

DP02 (P30) Declining staff numbers and increasing workload: is there a solution?

Abstract Within the UK, there is a rapidly rising incidence of malignancies, including cutaneous cancers. Over 1 million new patients are referred to dermatology each year, and a large proportion requires a diagnostic or therapeutic biopsy. Dermatologists often rely on histopathology to confirm or diagnose cancers, determine margins and perform specialist testing. The increasing rates of cancers are adding significantly to the histopathology workload. According to the Royal College of Pathologists (RCPath), only 3% of departments report having adequate staff to meet clinical demand. There are a significant number of unfilled training posts and a concurrent retirement crisis, with 25% of all pathologists over 55 years old. It can take up to 15 years to train consultants, with the more experienced able to handle greater workloads. The lack of pathologists, with widespread vacancies, has a significant impact. The resulting costs to the health service of employing locums and outsourcing work has been estimated to be £27 million annually. For patients, the costs of these shortages mean delays in diagnosis and treatment. A RCPath key performance indicator advises that 80% of cases should be reported within 7–10 calendar days. Across dermatology departments, there is a wide reported variation in reporting times from 1 to 28 weeks. In 2019, the longest wait, on average, was 5.8 weeks. We surveyed 60 histopathology consultants across different National Health Service trusts in England to determine the reasons behind these delays. The survey response rate was 45%. The results showed that 78% of departments have unfilled posts, 83% have employed locum staff or outsourced reporting of skin biopsies in the last 5 years and only 20% are able to meet the RCPath guidance. Additionally, almost one-quarter reported that they have had complaints or serious incidences related to delayed dermatopathology reporting. Survey comments revealed many other areas of potential diagnostic delay from sample labelling and prioritizing to prolonged laboratory processing times, unclear pathways to expedite samples and lack of histopathology secretaries. This survey highlights the increasing workforce demands and emphasizes the need for innovative changes to avoid delays in patient care. Possible solutions to address increased workload in an understaffed environment include adequate secretarial support, increasing pathology pathway navigators who prioritize urgent cases, improving information technology services, digital slide reporting and developing artificial intelligence to screen samples. Increasing dermatopathology training and exposure to histopathology at a junior level is mandatory. Raising these issues and making them a key investment priority for the government is imperative.

An analysis of pathologists’ viewing processes as they diagnose whole slide digital images

Although pathologists have their own viewing habits while diagnosing, viewing behaviors leading to the most accurate diagnoses are under-investigated. Digital whole slide imaging has enabled investigators to analyze pathologists’ visual interpretation of histopathological features using mouse and viewport tracking techniques. In this study, we provide definitions for basic viewing behavior variables and investigate the association of pathologists' characteristics and viewing behaviors, and how they relate to diagnostic accuracy when interpreting whole slide images. We use recordings of 32 pathologists’ actions while interpreting a set of 36 digital whole slide skin biopsy images (5 sets of 36 cases; 180 cases total). These viewport tracking data include the coordinates of a viewport scene on pathologists’ screens, the magnification level at which that viewport was viewed, as well as a timestamp. We define a set of variables to quantify pathologists' viewing behaviors such as zooming, panning, and interacting with a consensus reference panel’s selected region of interest (ROI). We examine the association of these viewing behaviors with pathologists’ demographics, clinical characteristics, and diagnostic accuracy using cross-classified multilevel models. Viewing behaviors differ based on clinical experience of the pathologists. Pathologists with a higher caseload of melanocytic skin biopsy cases and pathologists with board certification and/or fellowship training in dermatopathology have lower average zoom and lower variance of zoom levels. Viewing behaviors associated with higher diagnostic accuracy include higher average and variance of zoom levels, a lower magnification percentage (a measure of consecutive zooming behavior), higher total interpretation time, and higher amount of time spent viewing ROIs. Scanning behavior, which refers to panning with a fixed zoom level, has marginally significant positive association with accuracy. Pathologists’ training, clinical experience, and their exposure to a range of cases are associated with their viewing behaviors, which may contribute to their diagnostic accuracy. Research in computational pathology integrating digital imaging and clinical informatics opens up new avenues for leveraging viewing behaviors in medical education and training, potentially improving patient care and the effectiveness of clinical workflow.

The utility of digital pathology in improving the diagnostic skills of pathology trainees in commonly encountered pigmented cutaneous lesions during the COVID-19 pandemic: A single academic institution experience

Digital pathology has become an integral part of pathology education in recent years, particularly during the COVID-19 pandemic, for its potential utility as a teaching tool that augments the traditional 1-to-1 sign-out experience. Herein, we evaluate the utility of whole slide imaging (WSI) in reducing diagnostic errors in pigmented cutaneous lesions by pathology fellows without subspecialty training in dermatopathology. Ten cases of 4 pigmented cutaneous lesions commonly encountered by general pathologists were selected. Corresponding whole slide images were distributed to our fellows, along with two sets of online surveys, each composed of 10 multiple-choice questions with 4 answers. Identical cases were used for both surveys to minimize variability in trainees' scores depending on the perceived level of difficulty, with the second set being distributed after random shuffling. Brief image-based teaching slides as self-assessment tool were provided to trainees between each survey. Pre- and post-self-assessment scores were analyzed. 61% (17/28) and 39% (11/28) of fellows completed the first and second surveys, respectively. The mean score in the first survey was 5.2/10. The mean score in the second survey following self-assessment increased to 7.2/10. 64% (7/11) of trainees showed an improvement in their scores, with 1 trainee improving his/her score by 8 points. No fellow scored less post-self-assessment than on the initial assessment. The difference in individual scores between two surveys was statistically significant (p = 0.003). Our study demonstrates the utility of WSI-based self-assessment learning as a source of improving diagnostic skills of pathology trainees in a short period of time.

Reevaluation of the US Pathologist Workforce Size

There is currently no national organization that publishes its data that serves as the authoritative source of the pathologist workforce in the US. Accurate physician numbers are needed to plan for future health care service requirements. To assess the accuracy of current pathologist workforce estimates in the US by examining why divergency appears in different published resources. This study examined the American Board of Pathology classification for pathologist primary specialty and subspecialties and analyzed previously published reports from the following data sources: the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), a 2013 College of American Pathologists (CAP) report, a commercially available version of the American Medical Assoication (AMA) Physician Masterfile, and an unpublished data summary from June 10, 2019. Number of physicians classified as pathologists. The most recent AAMC data from 2017 (published in 2018) reported 12 839 physicians practicing "anatomic/clinical pathology," which is a subset of the whole. In comparison, the current AMA Physician Masterfile, which is not available publicly, listed 21 292 active pathologists in June 2019. The AMA Physician Masterfile includes all pathologists in 15 subspecialized training areas as identified by the ACGME. By contrast, AAMC's data, which derive from the AMA Physician Masterfile data, only count physicians primarily associated with 3 general categories of pathologists and 1 subspecialty category (ie, chemical pathology). Thus, the AAMC pathology workforce estimate does not include those whose principal work is in 11 subspecialty areas, such as blood banking or transfusion medicine, cytopathology, hematopathology, or microbiology. An additional discrepancy relates to the ACGME residency (specialties) and fellowship (subspecialties) training programs in which pathologists with training in dermatopathology appear as dermatologists and pathologists with training in molecular genetic pathology appear as medical geneticists. This analysis found that most sources reported only select categories of the pathologist workforce rather than the complete workforce. The discordant nature of reporting may pertain to other medical specialties that have undergone increased subspecialization during the past 2 decades (eg, surgery and medicine). Reconsideration of the methods for determining the pathologist workforce and for all workforces in medicine appears to be needed.

Factors associated with false-negative pathologic diagnosis of calciphylaxis.

Calciphylaxis is a rare, painful, and debilitating disorder of vascular calcification and skin necrosis that typically affects patients with advanced kidney disease. During our routine pathology practice, we noted several missed diagnoses on calciphylaxis consultation cases originating from outside institutions and sought to explore factors associated with false-negative pathologic diagnosis of calciphylaxis. The pathology database of a large tertiary academic medical center was retrospectively searched for "calciphylaxis" in inside reports on outside surgical consultation cases between 2007 and 2017. Inside and outside pathology reports were compared and medical records were searched for calciphylaxis clinical diagnosis and risk factors. Twenty-four calciphylaxis patients were identified, with median age of 63.5 years. Seven of 24 (29%) of specimens were inadequate (e.g., lack of subcutaneous adipose tissue for evaluation). Eight of 17 (47%) of adequate specimens had a first false-negative pathologic diagnosis of calciphylaxis. Histochemical staining for calcium significantly correlated with true-positive diagnosis (93% vs 55%, P = 0.004). Dermatopathology fellowship training significantly correlated with true-positive diagnosis (82% vs 38%, P = 0.047). Adequate sampling, dermatopathology training, and use of histochemical stains to identify calcium associate with decreased false-negative rate for calciphylaxis diagnosis. These findings need further evaluation in larger prospective studies.

Pathologist characteristics associated with accuracy and reproducibility of melanocytic skin lesion interpretation.

Diagnostic interpretations of melanocytic skin lesions vary widely among pathologists, yet the underlying reasons remain unclear. Identify pathologist characteristics associated with rates of accuracy and reproducibility. Pathologists independently interpreted the same set of biopsy specimens from melanocytic lesions on 2 occasions. Diagnoses were categorized into 1 of 5 classes according to the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis system. Reproducibility was determined by pathologists' concordance of diagnoses across 2 occasions. Accuracy was defined by concordance with a consensus reference standard. Associations of pathologist characteristics with reproducibility and accuracy were assessed individually and in multivariable logistic regression models. Rates of diagnostic reproducibility and accuracy were highest among pathologists with board certification and/or fellowship training in dermatopathology and in those with 5 or more years of experience. In addition, accuracy was high among pathologists with a higher proportion of melanocytic lesions in their caseload composition and higher volume of melanocytic lesions. Data gathered in a test set situation by using a classification tool not currently in clinical use. Diagnoses are more accurate among pathologists with specialty training and those with more experience interpreting melanocytic lesions. These findings support the practice of referring difficult cases to more experienced pathologists to improve diagnostic accuracy, although the impact of these referrals on patient outcomes requires additional research.

Educational Gaps in Molecular Diagnostics, Genomics, and Personalized Medicine in Dermatopathology Training: A Survey of U.S. Dermatopathology Fellowship Program Directors.

Molecular technologies offer clinicians the tools to provide high-quality, cost-effective patient care. We evaluated education focused on molecular diagnostics, genomics, and personalized medicine in dermatopathology fellowship training. A 20-question online survey was emailed to all (n = 53) Accreditation Council for Graduate Medical Education (ACGME)-accredited dermatopathology training programs in the United States. Thirty-one of 53 program directors responded (response rate = 58%). Molecular training is undertaken in 74% of responding dermatopathology fellowships, with levels of instruction varying among dermatology-based and pathology-based programs. Education differed for dermatology- and pathology-trained fellows in approximately one-fifth (19%) of programs. Almost half (48%) of responding program directors believe that fellows are not currently receiving adequate molecular education, although the majority (97%) expect to incorporate additional instruction in the next 2-5 years. Factors influencing the incorporation of relevant education include perceived clinical utility and Accreditation Council for Graduate Medical Education/residency review committee (RRC) requirements. Potential benefits of molecular education include increased medical knowledge, improved patient care, and promotion of effective communication with other healthcare professionals. More than two-thirds (68%) of responding program directors believe that instruction in molecular technologies should be required in dermatopathology fellowship training. Although all responding dermatopathology fellowship program directors agreed that molecular education is important, only a little over half of survey participants believe that their fellows receive adequate instruction. This represents an important educational gap. Discussion among those who oversee fellow education is necessary to best integrate and evaluate teaching of molecular dermatopathology.

The influence of tumor regression, solar elastosis, and patient age on pathologists' interpretation of melanocytic skin lesions

It is not known whether patient age or tumor characteristics such as tumor regression or solar elastosis influence pathologists' interpretation of melanocytic skin lesions (MSLs). We undertook a study to determine the influence of these factors, and to explore pathologist's characteristics associated with the direction of diagnosis. To meet our objective, we designed a cross-sectional survey study of pathologists' clinical practices and perceptions. Pathologists were recruited from diverse practices in 10 states in the United States. We enrolled 207 pathologist participants whose practice included the interpretation of MSLs. Our findings indicated that the majority of pathologists (54.6%) were influenced toward a less severe diagnosis when patients were <30 years of age. Most pathologists were influenced toward a more severe diagnosis when patients were >70 years of age, or by the presence of tumor regression or solar elastosis (58.5%, 71.0%, and 57.0%, respectively). Generally, pathologists with dermatopathology board certification and/or a high caseload of MSLs were more likely to be influenced, whereas those with more years' experience interpreting MSL were less likely to be influenced. Our findings indicate that the interpretation of MSLs is influenced by patient age, tumor regression, and solar elastosis; such influence is associated with dermatopathology training and higher caseload, consistent with expertise and an appreciation of lesion complexity.

How concerns and experiences with medical malpractice affect dermatopathologists' perceptions of their diagnostic practices when interpreting cutaneous melanocytic lesions

We sought to identify characteristics associated with past malpractice lawsuits and how malpractice concerns may affect interpretive practices. We surveyed 207 of 301 (68.8%) eligible dermatopathologists who interpret melanocytic skin lesions in 10 states. The survey assessed dermatopathologists' demographic and clinical practice characteristics, perceptions of how medical malpractice concerns could influence their interpretive practices, and past malpractice lawsuits. Of dermatopathologists, 33% reported past malpractice experiences. Factors associated with being sued included older age (57 vs 48 years, P < .001), lack of board certification or fellowship training in dermatopathology (76.5% vs 53.2%, P = .001), and greater number of years interpreting melanocytic lesions (>20 years: 52.9% vs 20.1%, P < .001). Of participants, 64% reported being moderately or extremely confident in their melanocytic interpretations. Although most dermatopathologists believed that malpractice concerns increased their likelihood of ordering specialized pathology tests, obtaining recuts, and seeking a second opinion, none of these practices were associated with past malpractice. Most dermatopathologists reported concerns about potential harms to patients that may result from their assessments of melanocytic lesions. Limitations of this study include lack of validation of and details about the malpractice suits experienced by participating dermatopathologists. In addition, the study assessed perceptions of practice rather than actual practices that might be associated with malpractice incidents. Most dermatopathologists reported apprehension about how malpractice affects their clinical practice and are concerned about patient safety irrespective of whether they had actually experienced a medical malpractice suit.

ISlide: a 'big picture' interactive teledermatopathology e-learning system.

Dermatopathology training is often limited by facilities and a dearth of specialists. Advancements in information and communication technologies have made possible the adoption of innovative learning techniques, especially in places where specialists are lacking. To implement and evaluate the performance of the iSlide system, which is an interactive dermatopathology training platform (http://scope.tmu.edu.tw/islide2/). Fifty-two cases representing a variety of dermatopathology conditions and complications were used to set up the iSlide system, and virtual slides of these cases were produced. Medical students from the Dermatology Department of Taipei Medical University were taught to use the system. Performance of the system was evaluated and validated using questionnaires, the first comprising 20 questions and the second a shorter, six-question telephone-based survey on 15 of the 96 interns. Twenty cases prepared by the iSlide system were also presented at an international dermatopathology conference and evaluated by conference participants. Ninety-six students and 72 experts participated in the study. Ninety-two per cent of the students and 98% of the experts found the iSlide system to be a useful tool for learning dermatopathology. Of these, 82% of the students and 63% of the experts felt that iSlide was easy to use. iSlide is useful for dermatopathology. As only 82% of the student evaluators and 63% of the expert evaluators found the system easy to use, further work has to be done to improve the iSlide interface to make the system more user friendly.

Dermatopathology in sub-Saharan Africa: a systematic 5-year analysis of all histopathological diagnoses from the Regional Dermatology Training Centre (RDTC) in Moshi, Tanzania.

Proper diagnosis of skin diseases relies on dermatopathology, the most important diagnostic technique in dermatology. Unfortunately, there are few dermatopathology institutions in sub-Saharan Africa, where little is known about the spectrum of histopathological features observed. To investigate the spectrum of dermatopathological diagnoses made in a sub-Saharan African reference centre of a large, mainly rural area. To retrospectively evaluate all dermatopathological diagnoses made over a period of 5 years at the Regional Dermatology Training Centre (RDTC) in Moshi, Tanzania. There were a total of 1554 skin biopsy specimens. In 45% of cases, there were inflammatory diseases, most frequently lichenoid conditions. Cutaneous neoplasms represented 30.4% of all diagnoses, with Kaposi's sarcoma (KS) and, less frequently, squamous cell carcinoma (SCC) being the two most common neoplastic conditions. The latter also reflected the intensive management of persons with albinism in the RDTC. The distribution of histological diagnoses seemed to correlate with the overall clinical spectrum of cutaneous diseases managed in the RDTC. In this African study inflammatory conditions are the main burden of skin diseases leading to a diagnostic biopsy. Our findings provide further evidence that KS, primarily related to the high prevalence of HIV infection is an epidemiological problem. Both SCC and basal cell carcinoma represent another relatively common malignant cutaneous neoplasms, reflecting the presence of specific populations at risk. The challenging spectrum of histological diagnoses observed in this specific African setting with basic working conditions shows that development of laboratory services of good standards and specific training in dermatopathology are urgently needed.

Discrepancies in dermatopathology diagnoses: The role of second review policies and dermatopathology fellowship training

Expert consultation and institutional policies mandating second review of pathologic diagnoses in the course of referral have been advocated to optimize patient care. We sought to investigate the rate of diagnostic discrepancies between pathologists with and without dermatopathology fellowship training. All available outside pathology reports were reviewed for material sent to the University of Pittsburgh Medical Center Dermatopathology Unit during 1 year. The outside diagnosis was compared with the diagnosis rendered by the referral dermatopathology service. Cases were assigned into 1 of 4 categories: melanocytic neoplasm, nonmelanocytic neoplasm, inflammatory, and other. For each case, the outside pathologist's level of dermatopathology training was noted. Any change in diagnosis resulting in significant alteration in therapy or prognosis, as dictated by the accepted standard of care, was considered a major discrepancy. A total of 405 cases were reviewed. In 51 cases (13%), no preliminary diagnosis was rendered at the outside facility. The referral diagnosis differed from the outside diagnosis in 226 cases (56%), and major discrepancies were identified in 91 cases (22%). Of these 91 cases, 84 were received from outside pathologists who were not dermatopathology trained and 7 were received from pathologists with dermatopathology training. The 91 cases with major discrepancies were categorized as: 36 nonmelanocytic neoplasms (40%), 30 inflammatory (33%), 23 melanocytic neoplasms (25%), and 2 other (2%). This was a retrospective study limited to 2 consultant dermatopathologists at an academic referral center, which typically receives and reviews select cases. Dermatopathology fellowship training is associated with a substantial decrease in major diagnostic discrepancies. Pathologists without dermatopathology fellowship training tend to successfully identify those cases for which expert consultation is most useful.

Perceptual Analysis of the Reading of Dermatopathology Virtual Slides by Pathology Residents

The process by which pathologists arrive at a given diagnosis-a combination of their slide exploration strategy, perceptual information gathering, and cognitive decision making-has not been thoroughly explored, and many questions remain unanswered. To determine how pathology residents learn to diagnose inflammatory skin dermatoses, we contrasted the slide exploration strategy, perceptual capture of relevant histopathologic findings, and cognitive integration of identified features between 2 groups of residents, those who had and those who had not undergone their dermatopathology rotation. Residents read a case set of 20 virtual slides (10 depicting nodular and diffuse dermatitis and 10 depicting subepidermal vesicular dermatitis), using an in-house-developed interface. We recorded residents' reports of diagnostic findings, conjectured diagnostic hypotheses, and final (or differential) diagnosis for each case, and time stamped each interaction with the interface. We created search maps of residents' slide exploration strategy. No statistically significant differences were observed between the resident groups in the number of correctly or incorrectly reported diagnostic findings, but residents with dermatopathology training generated significantly more correct hypotheses (mean improvement of 88.5%) and correct diagnoses (70% of all correct diagnoses). Two types of slide exploration strategy were identified for both groups: (1) a focused and efficient search, observed when the final diagnosis was correct; and (2) a more dispersed, time-consuming strategy, observed when the final diagnosis was incorrect. This difference was statistically significant, and it suggests that initial interpretation of a slide may bias further slide exploration.

Virtual dermatohistopathology at http://www.pathowiki.org

PATHOWIKI (http://www.pathowiki.org) is a new specialized information system in the form of a web-based wiki with content from all sub-disciplines of human pathology. Essential components are articles and specimens which are located thematically in dermatopathology. The project is presented on the basis of impressive examples and possibilities. The ability to link all kinds of content and integrate pattern analysis theories creates an effective tool for teaching and training in dermatopathology. Collaborative work ensures the effective usage of available resources and a continually growing amount of content, the quality of which depends on the number of users and should be as high as possible. Therefore, all interested colleagues are invited to support the project.

A static-image telepathology system for dermatopathology consultation in East Africa: The Massachusetts General Hospital Experience

The histologic diagnosis of skin lesions in the developing world is complicated by the shortage of pathologists with subspecialty training in dermatopathology, limited access to ancillary diagnostic testing, and costly referrals for expert glass slide consultation in challenging cases. In this study we evaluate the feasibility of a static-image telepathology platform in Africa for performing accurate dermatopathology consultations. A static-image telepathology platform using the iPath server was utilized by referring pathologists in 4 African hospitals. Diagnostic interpretations were provided by Massachusetts General Hospital dermatopathologists at no cost. The diagnostic accuracy and interobserver correlation was evaluated. The static histopathologic images were diagnostic in 22 of 29 (76%) cases. Diagnostic accuracy between static image and glass slide diagnosis in 22 cases was 91%, ranging from 86% to 95% according to years of dermatopathology subspecialty expertise. Comparison with the glass slides showed that the telepathology diagnosis was limited by inappropriate field selection in only one case. Interobserver concordance between two pathologists was high (K = 0.86) suggesting that this platform is easy to use with minimal training of both referring and consulting pathologists. Concordance between conventional microscopy and static image telepathology was performed in 22 of 29 cases for which glass slides were received. Interobserver concordance was performed for two pathologists. Static-image telepathology is a feasible means of rendering diagnoses on dermatopathology cases and is a cost-effective technology for obtaining much-needed second opinions in resource-poor settings.

Establishing telepathology in Africa: Lessons from Botswana

To the Editor: Few reports of telepathology in Africa exist in the medical literature. With the strong need for improvement in health care infrastructure and personnel training in many African nations, telepathology provides a rapid and versatile tool to improve clinical care and foster educational and research opportunities. We describe the challenges faced in establishing robotic telepathology (RT) services at a government referral center in Botswana and reflect on conditions under which such initiatives may be most likely to succeed in sub-Saharan Africa and other parts of the developing world. The Africa Teledermatology Project (http://africa.telederm.org) has been providing dermatology support to local providers throughout Africa using store-and-forward teledermatology/teledermatopathology since 2007. While the outcomes have been very positive, and similar telemedicine platforms are well accepted,1Brauchli K. Oberli H. Hurwitz N. Kunze K.D. Haroske G. Jundt G. et al.Diagnostic telepathology: Long-term experience of a single institution.Virchows Arch. 2004; 444: 403-409Crossref PubMed Scopus (38) Google Scholar, 2Geissbuhler A. Bagayoko C.O. Ly O. The RAFT network: 5 years of distance continuing medical education and tele-consultations over the Internet in French-speaking Africa.Int J Med Info. 2007; 76: 351-353Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar this method is limited by the number and quality of images available to the consultant (Fig 1) and by reliance on the referring provider, who may lack dermatopathology training,3Weinstein R.S. Static image telepathology in perspective.Hum Pathol. 1996; 27: 99-101Abstract Full Text PDF PubMed Scopus (51) Google Scholar to produce representative photomicrographs. In response to these problems, we installed a Zeiss Mirax Live RT system (Carl Zeiss MicroImaging GmbH, Jena, Germany) at the National Health Laboratory in Gaborone, Botswana in 2009. With up to 4 slides placed on the motorized microscope, the consultant controls stage position, focus, and magnification remotely (Fig 2). Certain factors facilitate the achievement of a functioning telepathology service:1.Availability of reliable histologic processing sets a ready stage for implementing telepathology. Telepathology systems must also be robust enough to handle significant heterogeneity in slide quality, focal planes, and specimen types/sizes.2.Adequate Internet connectivity and a stable power source are crucial. We installed a dedicated wireless broadband connection. An uninterrupted power supply (UPS) device was necessary to protect the equipment, which was configured to operate at local voltage.3.Demand for specialized pathology services is driven by concomitant availability of specialized clinical services (eg, dermatopathology in areas with practicing dermatologists). Given the professional isolation in this region, telepathology can enable solo pathologists to meet such demands, as well as to participate in continuing education and collaborative research.4.Governmental support is critical in logistical matters such as waiving of customs fees. Applying for a rebate certificate with the assistance of local partnerships circumvented this.5.Personnel with sufficient technical expertise to install and maintain the equipment are necessary when there are no in-country vendor representatives. For RT, identify individuals familiar with computer hardware, software, and light microscopy. Remote technical support is possible via screen-sharing, Internet telephony, and e-mail. Overstock wearable components such as microscope bulbs, which may need frequent replacement. In conclusion, telepathology is feasible in resource-limited settings, and its routine use can improve clinical care and education. The generalizability of our experience is limited by differing socioeconomic and health conditions in Botswana compared with other African nations; thus similar initiatives must be adapted to local settings. On-site technical prerequisites include tissue processing capacity, high-speed Internet, power stability, and personnel to install and maintain the equipment. Select a system that accommodates the types and sizes of specimens requiring consultation, differences in slide quality, and international bandwidth limitations. Local health professionals and government must support the initiative to fuel demand for such services and ensure ongoing utilization. Further research will need to evaluate changes in service utilization over time, effects on development of local expertise, and cost-to-benefit analysis of telepathology in these settings.

Global access to dermatopathology services: Physician survey of availability and needs in sub-Saharan Africa

To the Editor: The availability of dermatopathology services varies across the world. Developing countries have limited to no access to dermatologists, pathologists, or histology and laboratory services. To address healthcare needs in underserved areas, medical specialists are increasingly providing patient care in remote areas, either through establishing local clinics or through telemedicine.1Rao B. Lombardi 2nd, A. Telemedicine: current status in developed and developing countries.J Drugs Dermatol. 2009; 8: 371-375PubMed Google Scholar, 2Schmid-Grendelmeier P. Masenga E.J. Haeffner A. Burg G. Teledermatology as a new tool in sub-Saharan Africa: an experience from Tanzania.J Am Acad Dermatol. 2000; 42: 833-835Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar Expanding clinical services creates a need for histologic assessment of diseases requiring clinicopathologic correlations for diagnosis. Proposed strategies include shipment of wet tissue for processing, or “virtual dermatopathology” through the electronic transfer of photomicrographs, scanned slides, or live interactive telepathology.3Kayser K. Kayser G. Radziszowski D. Oehmann A. New developments in digital pathology: from telepathology to virtual pathology laboratory.Stud Health Technol Inform. 2004; 105: 61-69PubMed Google Scholar, 4Leong A.S. Leong F.J. Strategies for laboratory cost containment and for pathologist shortage: centralised pathology laboratories with microwave-stimulated histoprocessing and telepathology.Pathology. 2005; 37: 5-9Crossref PubMed Scopus (28) Google Scholar, 5Piccolo D. Soyer H.P. Burgdorf W. Talamini R. Peris K. Bugatti L. et al.Concordance between telepathologic diagnosis and conventional histopathologic diagnosis: a multiobserver store-and-forward study on 20 skin specimens.Arch Dermatol. 2002; 138: 53-58Crossref PubMed Google Scholar We seek to characterize the presence of histology and dermatopathology services in sub-Saharan Africa, where many patients are evaluated clinically but laboratory services are scarce. Forty-one countries south of the Sahara desert were included. We searched international professional databases, queried local physicians and the Ministries of Health to identify individuals and organizations with insight into the availability of dermatology and pathology services. Internet and PubMed searches performed between June 15 and August 14, 2008 used the following key words: dermatology, pathology, dermatopathology, hospital, university, Ministry of Health, department, medicine, and each country name. Each individual received an e-mail in English explaining the study aims and questions to answer voluntarily (Fig 1). Residents of French-speaking countries received an additional e-mail in French. One of the authors (M.W.T.) collected all responses by country. For discordant aggregate responses, the majority response of those surveyed represented the country's response. For cases with no clear majority, the longest time interval represented a country's response time. For dichotomous values, any “yes” response represented a final “yes” for that country. The survey had a 51% response rate. Because the search parameters failed to identify individuals in 34% of countries, surrogates in other parts of Africa, Europe, and the United States were solicited in these cases. Contacts in seven countries had undeliverable e-mail addresses. Countries in which data could not be collected remain white in Fig 2. Histology processing services and a pathologist are available in 86% of countries (Fig 2, A). In almost one-third of countries, it takes longer than 1 month for both sample processing and a pathologist's read. A trained dermatopathologist or specialized trained dermatologist is available in only 14% of countries (Fig 2, B). Interest in consult services was nearly unanimous (95%). The single “no” response arguably codes “yes” because his interest was contingent upon dermatopathology training for physicians in his nation (Senegal). All responding nations expressed interest in telemedicine as an adjunct to current clinical practice (Table I).Table IAggregate responses to availability of a dermatopathologist, histology services, and interest in teledermatopathology consultation servicesAggregate country informationNo.%No. of countries surveyed41—No. of countries responding21—Dermatopathologist available314%Histology service available1886% Same day211% <1 week317% <1 month844% >1 month528%Histology services unavailable314%Pathologist read available1886% Same day211% <1 week317% <1 month739% >1 month633%Pathologist read unavailable314%Countries sending specimens out524%Teledermatology would be useful2095%Interest in teledermatology21100% Open table in a new tab South Africa deserves special mention for the only respondents not interested in teledermatopathology. While these private practice physicians had processing and dematopathologist reports available within 24 hours, an understaffed general hospital reported waiting times similar to the remainder of sub-Saharan Africa. The availability of dermatopathology services in sub-Saharan Africa is limited. While physicians have access to histology in the majority of countries surveyed, long wait times impede reliance on this diagnostic tool. Those surveyed showed overwhelming interest in teledermatology and teledermatopathology services, but recognized fundamental challenges—lack of infrastructure, political bureaucracy, and cost—that must be addressed before expanding access to dermatology and dermatopathology through telemedicine. Digital imaging and mobile telecommunications offer one possible immediate and cost-effective method to shorten times to diagnosis. Specifically, digitalized images of processed slides may be electronically sent to dermatopathologists anywhere in the world for interpretation, and results could be retuned via telephone or e-mail. This system would use existing histology services, bypass delays caused by lack of ground transportation and local infrastructure, and bring remote expertise to underserved regions of Africa.

Interpretation of Dermatopathology Specimens Is within the Standard of Care of Dermatology Practice

Laws have been passed in New York, California, New Jersey, Nevada, Louisiana, and Rhode Island and were recently tabled in South Carolina to prohibit providers from billing for pathology services provided by other physicians. The Ohio proposal included language stating that only board-certified pathologists be able to directly bill for anatomic pathology services. Dermatologists, however, have extensive training in dermatopathology and frequently bill anatomic pathology codes. To determine if interpretation of cutaneous pathology falls within the standard of care of dermatology practice. We used Medicare part A and B claims data from the Medicare Current Beneficiary Survey, 1992 to 2000. We identified surgical pathology claims by Current Procedural Terminology (CPT) code 88305 and those related to skin disease by the associated International Classification of Disease, 9th Revision (ICD-9), code. Weights were applied to obtain nationally representative estimates. The number of physicians in each specialty was obtained from American Medical Association estimates. Pathologists, independent laboratories and group practices, and dermatologists submitted 59%, 26%, and 13% of total claims, respectively. For skin-related diagnoses, pathologists, dermatologists, and independent laboratories and group practices performed 34.5%, 31.2%, and 32.8% of cases, respectively. Assuming that independent laboratory and group practice claims were performed entirely by pathologists, dermatologists and pathologists submitted 1,047 and 1,154 cases/physician, respectively. Dermatologists have extensive training in dermatopathology and interpret a large proportion of cutaneous specimens. Interpretation of anatomic pathology, in particular, skin and subcutaneous pathology specimens, falls within the scope of dermatology practice.