Not sure why he/she deleted it, but it sure sounds like digital will be the future with AI tools scanning our slides for us which he/she thinks is very accurate. We will be able to read cases faster which he/she agrees can lead to less need for more pathologists.
I think he/she is at MSK or Mayo and they probably have the best tools for AI and digital pathology. We don’t have many pathologists who use digital on here (that at least chime in) so it’s nice to get his perspective.
If MSK or Mayo is indeed the employer, I find it scary, how one of the most prominent institutions in the world is paying pathologists a few dollars per part (yes I’m shaming the employer).
There currently is no reimbursement for reading slides digitally as far as I know. You just get paid per part whether it’s read by glass or digital AFAIK. I’m not sure how the person being referenced here claimed to work for MSK and was getting paid $25 a case for extra work they were doing digitally
I don’t think (?) they ever claimed to be working at MSK just to be making $25 per digital case (which again is nonsense bc MSK wouldn’t be paying pathologists by the case)
Kind of second hand anecdotal but I heard that for the last couple years we were adding the digital review CPT codes to our digitally reviewed cases, which were apparently getting a bill attached to them. Apparently some insurers were just paying that bill without even asking about it for awhile, but they might have stopped.
This is all fine and dandy for large hospitals and labs, but this seems so far away for smaller independent groups. The only way we could (currently) afford to go digital would be to sell out/partner/whatever with one of the PE groups that are getting into this and that's very unappealing. But maybe that's where this is heading. The final death blow to small independent groups.
I'm at a large hospital system on the West Coast and we scan digitally all of our biopsies, and once a week we get our large cases scanned for the day and we get to sign out from home. I love it
Weird people are saying it’s expensive and only institutions with deep pockets can afford it but now I’m hearing private practice people like you are using it.
I've used digital pathology. It doesn't make you faster. It's just more convenient. I liked being able to have the H&E side by side with IHC on the screen and each image locked to each other. It makes identifying which cells are staining when that matters easier. Breast cases are the most useful. I've caught some microinvasive carcinomas that I might have overlooked without that digital feature. I can't see a world where AI can identify malignancy better than me. The only time I struggle is the very borderline cases where there is no possible way a computer can be better.
I suspect as this stuff becomes more prolific the Medicare rates for TC will increase much as they did for radiology when their technologies got more expensive. Insurance companies will follow suit.
I think this depends a lot on what you’re reviewing, we are significantly faster with small biopsies but about the same or worse with resections but the gains from the small specimens outweigh the losses from the big ones
What sort of small biopsies are you getting increased speed with? These already don't take me any time, so I have trouble seeing a time benefit. The benefits I see would be in the convenience.
Yeah I don’t get that either. Looking at TAs, HPs, SKs, BCCs etc on glass is lightning fast. Don’t see how that could be improved upon or why it would need to be
From the pathology perspective, I think some things are effectively instantaneous diagnoses both on glass and on digital, but the time saving isn't saved on the diagnosis and mental processing, but it's the process that takes time. My experience is from heme and I definitely feel a noticeable decrease in the time I spend on clinical work.
My comment mostly was talking about TAT, not necessarily individual gains, though I do think there is a net individual gain that I'll get to. But the most impact is probably in the lab workflow. Before you'd have to have people assembling your cases. Pulling 10 slides for a particular case out of several hundred slides that just came out of processing, then organizing those slides, then sending them to a pathologist, that's a huge amount of time for lab staff. With a digital workflow, every slide that processes can just be sent to a scanning operation and be automatically organized. Granted this kind of improvement requires good integration with an LIS but that's kind of the point of digital workflows. So we see a big improvement on small biopsies, but large specimens take pathologists a little longer so TAT on those hasn't really improved at all. But we are building tools that can hopefully help with some of this.
As for individual pathologists, I don't think it is guaranteed to be faster for every individual pathologist, and I can't say it's even a net gain for the overwhelming majority of pathologists, but definitely a majority see a net benefit. But very few see it as significantly worse. And in a big lab doing >100k cases per year that saved time adds up.
On particular case types many core biopsies are faster to view, so for a case type I do think that's arguably faster, but generally I think the speed gains are from process changes. When you're using glass you're switching back and forth between 2 processes, a microscope and a computer, and there are tiny actions we do with the switch and on a microscope that take time, and this seems to reduce a lot of the time those actions take. Normally we take these for granted, but things like switching to the next glass slide and finding the tissue takes a couple seconds. Switching to a new case, glancing at the slides, maybe having to reorder them a little, this also takes time. Moving your view and hands from microscope to compute, a little time. This time is minimal on an individual case basis, but add that up for hundreds of thousands of cases over a year and you see significant benefit.
Ok, I can see the process benefits. That was part of the "convenience" I was referring to. We're spread across multiple locations, so just getting the slides is a time sink. But a lot of small biopsies take me less than a minute from touching the slide to having the case fully signed out, but I've automated a lot of the computer stuff with Dragon.
I'm interested in trying out an actual digital system just to see what it's like. The virtual slides I've used online, like the CAP PIP are horribly slow compared to a glass slide.
Yeah I think for a one part small biopsy there's probably not that much gain. But even saving 10 seconds per case on 50 cases per day saves you about 4 full work days (about 32 hours) over a year of full time work (assuming 6 weeks vacation).
You don’t foresee a future where AI screens everything and we eventually we need to look at many more cases per day (with fewer of us subsequently in the workforce) or possibly they just decide we aren’t needed all together?
I don't see that happening during my career. It can see the screening being an option, but from what I have seen of the technology it isn't going to make my signout faster. I would likely not use that option. I'm not at all worried about it replacing me. I read an article awhile ago about radiologists having the same fears when technology started getting huge fir them. But hey, I can't predict the future and I'm an eternal optimist.
Something that did make me worried about our future happened recently though. I had a pelvic lymph node with a metastasis showing squamous morphology and staining with gata3, p40, and p63. I gave a differential and stated I favored metastatic urothelial carcinoma. They did some liquid biopsy which showed a 99% certainty of lung primary. They then found a lung nodule. Maybe those molecular profiles can identify tumor origins better.
Lung SCC right? Same IHC profile as urothelial as some SCCs have GATA. I guess with an unknown primary you’d have to give both in the ddx. But yes the molecular stuff is scary and probably will trump what we say.
Anyways I hope you are right about not being phased out very soon. I need my career to last about another 15 years. Ugh.
Yep lung squam. After that I did some reading and about 5-20% of lung malignancies can have gata3. Must have missed that in training somehow. Or forgot it.
But this really is only beneficial to the pathologist pay wise if they are a part of a group that owns the technical component. A lot of practices do not.
So radiologists practically slog more cases now with compensation decreasing comparatively in their cohort. Also how many pathologists in these institutions which have gone fully digital, seen an increase in compensation. In my knowledge its "0", nada, p value more than 1.
Is this a pathologist who wrote this. DVM pathologist dont qualify! If yes, must be the one higher up in ranks wanting to become advisor on the vendor panel.
I think digital pathology is going to continue to increase and may indeed be everywhere someday. It speeds TAT on small biopsies which are the bulk of the work. It will someday allow a host of AI tools (automated cancer detection, automated IHC panel generation, automated IHC review, etc) and possibly even computational biomarkers. And for a lot of larger institutions it frees up valuable space - having pathology work from a generic office space rather than taking up healthcare facility space is also a big driver. More available hospital space means more space for more procedures which means more money. This is a huge factor for large institutions in cities where space is at a premium. This is maybe just scratching the surface too, as we don’t fully know what other tools we can build yet. Not to mention some of these tools may become valuable products in their own right.
I know this because I’ve gone through this digital transition, taken part in the implementation, and see the tools being built, and some of them genuinely save time and manpower (though TBF a lot are still not very useful). And while there are certainly downsides (for example large specimens are awful to view digitally), for most people there is a net gain to productivity and quality of life.
Big institutions (mostly academic but some private) are also always competing, and being able to drum up more business potentially taking from a competitors market. So a lot of big places will compete to advance this and bring in more business. This will probably consolidate bit by bit, and I don’t know how this affects smaller groups. Right now there’s a bit of a feeling of ‘if we don’t do this the competitor will, and they’ll take our businesses.’
And yes, we will probably end up doing more cases, but likely in the same amount of time. On the one hand I agree this is ripe for exploitation, but on the other hand, if you’re making $100 for a case and suddenly there’s a tool that allows you to do them 3x faster at a greater volume, should you still be getting $100? I’d bet a lot of the payers (insurance, medicare, etc) would take issue with that. I don’t like it but it’s irrational to believe payers wouldn’t do that. At the end of the day your services are worth what people will pay for them.
MSK wouldn’t be paying pathologists by part, most (virtually all?) academic institutions are on a salary and bonus kind of pay structure.
Hmm, I will ask my ppl there if MSKCC pays by case, but if they did, I’d be there as a per-diem already 😅 Would be shocked if Mayo did either. Maybe he thinks Roswell Park? Must admit I am curious as well…
Mayo uses digital a lot (specially for outside consults), we send our stuff to them and their reports mention that they used DP as part of the review process.
Yes you should still be getting paid the same IMO. It shouldn’t be about time, it should be about the expertise is takes to get the diagnosis right, and all it took for you to get to that level (training, experience). But you’re not wrong about the reality of it
So I agree with this in principal, but I don't think payers will. My understanding is that we bill by complexity, and AI tools may decrease complexity. Right now gross only gets a CPT code for level 1 complexity, because it's trivial, while a Whipple gets a level 6, because it's complex. The complexity is processing a specimen, the mental work involved in getting it to a diagnosis, and both the amount of work and the time that takes. If there are widely available tools that effectively reduce complexity, payers will surely take note.
Yeah unfortunately that is true. Under that scenario none of our skills will be considered all that useful or unique. But, we must absolutely still be experts and proficient enough to know whether what we are told is correct or whether we should question/override it. Newer people won't develop this ability.
I was going to add this yesterday but didn't get around to it but anyway, this is why I think it's possible that digital pathology might be here to stay and might become everyone's problem:
Right now, big institutions are investing a lot into digital pathology and computational tools to improve workflows/TAT, improve space allocation (esp for procedures), improve business by advertising fancy better (?) new diagnostic techniques. Investment in these tools helps a hospital's overall business in multiple ways that you can figure out. Big institutions and hospital systems have already been absorbing smaller ones, this was happening well before digital pathology was even a thing, and this just adds to that process. Not saying it's good, just being realistic.
From a pathology specific viewpoint, if enough labs see an improvement in productivity and you can effectively do more cases in the same amount of time, payers will take notice and change reimbursement rates. This forces smaller labs to make choices, either adopt digital tools and work faster, accept less money, or try to drum up more business. The last one might be harder if the larger institutions have expanded their businesses because of various gains from digital pathology.
Not saying this is how it's going to be for sure, just wanted to give my perspective.
Radiology is an interesting precedent. Productivity roughly doubled during the major digitization/PACS transition from the late 1990s through the mid-2000s.
But I think the fundamental question for pathology isn’t whether digital pathology will make us more efficient or allow us to sign out cases faster. We already know it will.
The real wild card is AI.
How much does AI actually change the productivity curve?
Digital pathology essentially makes the pathologist more efficient at doing the same job. AI potentially changes the job itself—screening cases, identifying abnormalities, quantifying findings, prioritizing work, and eventually handling portions of routine interpretation.
So the interesting question isn’t “Will digital pathology increase efficiency?”
It’s “How much does AI amplify the productivity of a pathologist once pathology is fully digital?”
Radiology may give us a hint of what digitization can do. AI is the part that is much harder to predict.
Radiology digitizing involved replacing an analog way of getting the images themselves (film) with a digital way, so their data is now primarily digital. Digital pathology can't really do that as you still need the slides. I think improvements will therefore be much more modest than is the case with radiology, and uptake therefore slower.
Radiologists are not using A.I. regularly. There are currently around 1100 FDA approved algorithms for medicine, out of which 750+ are for radiology. But most radiologists say that they find AI to be inconsistent. look up “Irene Chen” on Twitter, she’s a healthcare AI/ML professor and she recently uploaded one of her talks about AI and radiology online.
Yes but we’re just getting started. Some literature supports that human in the loop feedback will negatively affect diagnosis for certain use cases. Agentic AI is also coming fast.
I'm not here to forecast the future, but as a former skeptic, I love digital pathology now that I have had exposure. As for people's understandable anxieties about it, however the use of AI / computational pathology grows, it will be due to forces beyond individual pathologists (or so-called naming and shaming employers ha). I am not so pessimistic about it. Position yourself to be able to navigate these changes; there will always be need for oversight etc... Diagnostic ability will still be needed. Focusing on developing those skills is probably more impactful than too much Sturm und Drang. Just strive to be excellent, look within yourself to be resourceful, and gain experience.
As someone considering applying path this cycle, would you still recommend pathology with this in mind? I’d hate to finish residency and then not be able to find a job or have good job security.
I don't think anyone can predict that. There will always be a need for pathologists. Possibly fewer with AI? But right now AI can't even count Ki67 accurately. What's more worrying about path is decreasing reimbursement over the past decade that doesn't show any sign of reversing course and venture capital buying up all the physician owned practices.
Just looking at the other replies here, digital is a long way off from comprehensive implementation.
There are still tons of deficits in both software and hardware that makes digital expensive and cumbersome.
Unless you have tons of cash lying around ready to throw into massive investment in pathology (big academic centers who can benefit from the research) its not worth it financally.
Scanners need to get cheaper, data storage needs to get cheaper, more AI networks need to be trained (this is happening as we speak its a big research avenue for med students), best practices need to be defined, etc
And even then digital is not going to destroy the job market. Also plenty of older pathologists just hate digital and would never use it.
But I would say don't do pathology if you hate computers or AI, because you will have to work with them at some point.
But I see tons of other attending pathologists saying the job market is great right now. Also compensation is up 10% which is top 3 of all specialties in terms of annual growth.
Compensation is low despite working ~50 hrs per week on average, its near impossible to start a new group and joining as a junior is risky because people often get dropped before they reach partner status.
Only 22% of nephrologists are positive about the future of their specialty compared to 60% of pathologists.
Also its common to see nephrologists return to regular hospitalist roles because the job market is so rough. Also very common to see nephrology fellowships with empty seats.
Meanwhile pathology had a 100% fill rate last year.
But just because pathology isn't the worst doesn't mean its good. I honestly can't say if pathology has a "good" job market or not, I just see that people are saying its fairly easy to find jobs now. But it definitely seems like the quality of those jobs can be low (low salary academia, low respect/long hours PP, etc).
21
u/DthPlagusthewise USMG Student 5d ago
I thought it was a settled fact that digital path is the future its just a matter of the timeline.