Professional Practice, Training and Competency

Pathologists undertake a variety of professional development activities, including training, participation in Internal Quality Assurance (IQA) and External Quality Assurance (EQA), and Continuing Professional Development (CPD).

There should be a double-up of conventional and digital processes initially to ensure each pathologist acquires competency in digital microscopy. Many aspects of professional practice, training and competency in digital microscopy relate to existing policies and guidelines in anatomical pathology practice. This demonstrates the importance of double-up between techniques and importance of gradual integration.

When implementing a digital microscopy system for diagnostic use consider professional practice issues such as:

• Human resourcing, which includes:
  • resource requirements during the transition period,
  • workload and the hours of work,
  • level of remote supervision of cases (such as cut-up, slide preparation, slide scanner magnification settings),
  • professional isolation,
  • the RCPA Reporting of Histopathology and Non-Gynaecological Cytopathology Specimens outside the Laboratory and the organisation’s policies on reporting outside the laboratory.
• Handling of peer reviews or second opinions for cases. It is recommended to have a policy for the use of digital microscopy for professional second opinions, that considers situations such as cases from:
  • same organisation but different locations / time zones / disciplines,
  • different organisations,
  • cross border (NOTE: there should be a separate policy for cross-border pathology).
  • the sending/receiving organisations should comply with this guideline with respect to all elements of digital microscopy.

Also refer to Royal College of Pathologists of Australasia Position Statement Telepathology May 2016

Before using digital microscopy for diagnostic purposes each pathologist must:

1. Undertake appropriate training from the vendor;

2. Be proficient in using WSI and be able to:

   1. assess the quality of WSI;

   2. understand the system limitations, including situations where turnaround times are longer or accuracy is lower using the digital system;

   3. understand the system features such as how to navigate WSI, add annotations, etc.

   4. understand patient confidentiality pertaining to digital pathology;

   5. remove metadata from WSI file to copy for teaching sets and educational purposes.

3. Credentialing of pathologists and certification of technicians is recommended.

The pathologist should decide the best method for diagnosing each case, i.e. digital or conventional microscopy or a combination of both according to their clinical judgement.
Pathologists should incorporate digital microscopy to their continuing professional development (CPD). This development could include training from the RCPA, industry or in-house training, especially in informatics or bioinformatics. RCPA IQA activities can also be incorporated. Section 1 activities, or Diagnostic Measures (the analytic phase) relates to peer review activities, participation in 10 hours per annum is required. This can involve internal random case review of digital microscopy cases or internal targeted case reviews of digital microscopy cases. Documentation of case/patient number and any type of discordance you may have reviewed.

Reference: RCPA. IQA Framework in Morphological & Interpretative Disciplines 2015 – Anatomical Pathology

Templates for IQA Case Reviews can be found on the RCPA Website.

The new digital microscopy system should create no additional medico-legal liability issues for the reporting pathologist. Pathologists must adhere to all existing supervision and accreditation requirements when using digital microscopy for diagnostic purposes and be cognisant of any additional obligations incurred by electronic transmission and storage of patient information (see Modules 4 and Module 5).
It is the College’s position that satisfactory supervision of a laboratory occurs when medical and scientific supervisors ensure that all elements of the following three areas have been executed:

1. Pre-analytic, analytic and post-analytic aspects of laboratory testing.

2. Clinical Governance and Laboratory Management

3. Operational Requirements

All areas of testing in a laboratory must be able to be mapped to a medical or scientific supervisor with relevant qualifications and competency. Nominated supervisors must demonstrate that they have provided sufficient time to execute their duties including review of methods and assay performance. Supervisors must demonstrate that they have implemented systems to monitor quality measures including review of QC and QA. Relevance to anatomical pathology and digital microscopy the table below has been developed from the RCPA Policy: Supervision of Diagnostic Laboratories in Australia.

Reference: RCPA Policy: Supervision of Diagnostic Laboratories in Australia. August 2015

A tendency has been observed that in general the digital system is more favourable for low magnification tasks rather than for high magnification work. Experienced pathologists would have an easier transition to digital work since they are generally able to diagnose cases at a lower magnification level.

20. Thorstenson S et al. Implementation of large-scale routine diagnostics using whole slide imaging in Sweden: Digital pathology experiences 2006-2013. J Pathol Inform. 2014. 5: 15

Situations have been identified that have raised concern regarding digital microscopy and intraobserver discordance rates and these include:

1. difficulties in identifying mitotic figures in WSI and under-grading in primary diagnosis of surgical neuropathology cases
   

   45. Pekmezci M et al. Pitfalls in the use of whole slide imaging for the diagnosis of central nervous system tumours: A pilot study in surgical neuropathology. J Pathol Inform. 2016. 7: 25.

2. loss of nuclear details and distortion of the chromatin pattern with erroneous impression of dysplasia in Barrett oesophagus and cervical squamous dysplasia
   

   45. Pekmezci M et al. Pitfalls in the use of whole slide imaging for the diagnosis of central nervous system tumours: A pilot study in surgical neuropathology. J Pathol Inform. 2016. 7: 25.

   46. Snead et al. Validation of digital pathology imaging for primary histopathological diagnosis. Histopathology. 2016. 68: 1063-1072.

3. helicobacter-positive gastritis was missed because the organisms were only visible when scanned at x60 magnification or require z-plane focusing
   

   45. Pekmezci M et al. Pitfalls in the use of whole slide imaging for the diagnosis of central nervous system tumours: A pilot study in surgical neuropathology. J Pathol Inform. 2016. 7: 25.

   48. Kalinski T et al. Virtua; 3D microscopy using multipane whole slide images in diagnostic pathology. Am J Clin Pathol. 2008. 130: 259-264

4. intensity of red colour not as strong in periodic acid Schiff-diastase stain for fungi, and Ziehl-Neelsen stain in mycobacteria
   

   46. Snead et al. Validation of digital pathology imaging for primary histopathological diagnosis. Histopathology. 2016. 68: 1063-1072.

5. identifying bacteria, small cell carcinoma and granulocytic inflammatory cells best performed by scanning slides at x60 magnification
   

   46. Snead et al. Validation of digital pathology imaging for primary histopathological diagnosis. Histopathology. 2016. 68: 1063-1072.

   41. Bauer TW et al. Validation of whole slide imaging for primary diagnosis in surgical pathology. Arch Pathol Lab Med. 2013. 137: 518-524

6. examination of ulcer bed
   

   49. Ito T. Lecture: Validation of whole slide imaging. Digital Pathology Congress: Asia. Global Engage. Kuala Lumpur Malaysia. 2016: 22-23 August

7. it is not possible to examine digital slides with polarized filters unless the scanner has a polarising lens attached and the glass slide is scanned with a polarised lens

8. renal biopsies even when scanned at x60 can be difficult to interpret subtle features of membranous change
   

   46. Snead et al. Validation of digital pathology imaging for primary histopathological diagnosis. Histopathology. 2016. 68: 1063-1072.

9. such specific situations from the literature, relating to digital diagnostic error need to be tabulated and addressed.
   

   46. Snead et al. Validation of digital pathology imaging for primary histopathological diagnosis. Histopathology. 2016. 68: 1063-1072.

1. Objective

   To understand the principles for professional practice, training and competency to consider when implementing digital microscopy in the workplace for diagnostic use in histopathology and cytology.

2. Knowledge

   Section 1: Professional Development Activities

   Outcomes: Understand the principles and importance of professional development activities to consider when implementing digital microscopy for diagnostic use, such as:

   1. Pathologist participation in Internal Quality Assurance (IQA) and External Quality Assurance (EQA), and Continuing Professional Development (CPD);

   2. The initial double-up of conventional and digital processes.

   Section 2: Professional Practice

   Outcomes: Understand the principles of professional practice to consider when implementing digital microscopy for diagnostic use, such as:

   1. Human resourcing;

   2. Handling of peer reviews or second opinions.

   Section 3: Training and Competency

   Outcomes: Understand the principles and importance of training and competency to consider when implementing digital microscopy for diagnostic use, including:

   1. Appropriate training from vendor;

   2. Proficiency in using digital slides;

   3. Credentialing of pathologists;

   4. Certifications of scientists and technicians;

   5. CPDP and IQA activities;

   6. Adherence to supervision and accreditation requirements.

3. Behaviours

   Practices the fundamental principles of digital microscopy.