Considerations for remote learning in pathology during COVID‐19 social distancing

Abstract

“They live completely apart and never see one another except under the most extraordinary circumstances.” Isaac Asimov, “The Naked Sun“1 In his 1956 novel The Naked Sun, biochemist and science fiction writer Isaac Asimov described Solaria, a planet whose inhabitants communicate almost entirely through holography.1 As communities throughout the world implement social distancing to reduce the spread of coronavirus disease 2019 (COVID-19), his descriptions of individuals working and socializing solely through remote video connections are unsettlingly familiar.2 Clinics have replaced in-person appointments with video visits, all but the most urgent surgeries have been postponed, and teaching hospitals have reduced resident and faculty time on site, in some cases eliminating it altogether. Across the country, academic pathology departments have rapidly pivoted toward remote learning through broadcast sign-outs, didactics, and digital teaching slides.3 Here, we take the opportunity to reflect on the subtle yet effective differences between in-person and remote experiences. According to recommendations by the Centers for Disease Control and Prevention, the accepted minimum physical distance between individuals is 6 feet. This distance precludes sign-out at most multiheaded microscopes, and, in fact, faculty and learners may be separated by even greater distances. Participation in teaching sessions may now occur from a separate room, separate hospital, or even home. Thus, many institutions have turned to broadcasting the microscope view to internet-enabled endpoints, including computers, smartphones, and tablets. The amount and quality of remote learning will vary greatly, depending on the experience of the teacher, the experience and engagement of the learners, and the equipment and software used. These variables give numerous permutations, and, in most instances, institutions will begin with what is rapidly available and fill needs as they are identified. The most common setup consists of a camera attached to a microscope, with the camera software broadcasting the microscope view in real time to participants through videoconferencing software. Although most trainees are able to stream video broadcasts at home without significant additional resources, program directors should be sensitive to potential increased financial costs. If trainees are required to learn from home, consideration should be given to providing adequate computer equipment and software. Faculty who are expected to teach remotely should also have access to adequate computers, cameras, software, and internet connections. Even with appropriate distancing, some learners and faculty may feel uncomfortable being in the same room as others, or even in the hospital environment itself. Because many learners and teachers are able to choose their own environments, remote learning potentially also can promote safety, comfort, and a feeling of control, with attendant benefits in concentration and retention of material (Table 1).4-7 However, learners may continue to have concerns about individual well-being, the safety of friends and family, childcare, rescheduled board examinations, and uncertainty in the financial and job markets, all of which are stressors that can hamper concentration. Both faculty and trainees should be committed to decreasing background distractions during remote learning sessions. Sequestration at home or in a private office can be viewed as an opportunity to create a distraction-free environment that eliminates some of the interruptions of in-person learning, such as people entering or leaving a room. However, faculty should be sensitive that trainees may not have a dedicated study space and, in fact, may be more distracted than usual. The software used for broadcasting can undermine the immediacy and centrality of the microscope. For example, videoconferencing software increases the cognitive load of a teaching session by adding a point of failure as well as a layer of management functions. Multiple participants can join a session. Options can be set to control microphones, video, screen-sharing, chat, and recording. Various security management options usually are available and should be used to meet institutional guidelines. Managing all these aspects of a session can quickly overwhelm a teacher's ability to deliver educational content (Table 2). One solution is to designate a moderator for some or all sessions. This role is crucial to the success of virtual education initiatives, as the moderator(s) can provide live support to session participants, thereby alleviating many basic issues and frustrations. Before a session begins, the moderator can help the teacher set up the correct participant management settings and ensure video, screen-sharing, and audio input/output functionality. Moderators can also troubleshoot minor technical issues, prompt the teacher if the audio/video stream falters, facilitate feedback between trainees and faculty members, and onboard faculty new to the remote teaching process. Scheduling is an important component of a remote learning curriculum. Given that remote learning does not necessarily restrict the number of learners connected to a session, programs may be tempted to make every session available to all residents. However, this may create a burden for residents on service, especially because such sessions cannot all take place during protected didactics time. It is important to remember that, although case volumes have decreased, it is likely that the number of faculty and residents on service has decreased as well, resulting in similar or even higher daily workloads. The development of an easily accessible schedule to coordinate various remote teaching sessions is required to prevent scheduling conflicts and to keep trainees aware of available learning opportunities. Thus, programs may find they need to devote more resources to schedule coordination. Moderators may be senior or chief residents in a program, but it is important that they are provided with the appropriate technology support, administrative assistance, and resources (Table 3). “You're viewing me right now… I'm two hundred miles away from you at least. So how can it be the same thing?” Baley grew interested. “But I see you with my eyes.” “No, you don't see me. You see my image. You're viewing me.” “And that makes a difference?” “All the difference there is.” Isaac Asimov, “The Naked Sun”1 The capture and transmission of live microscopy results in poorer image quality compared with the optical transmission of a multiheaded scope, but it is typically sufficient for the visualization of most important morphologic features. For participants, the overall experience may require an adjustment period during which even good-quality image broadcasts may seem suboptimal. Minor issues with microscope calibration or imaging software configuration may become magnified with remote broadcasts. Although better quality equipment may increase image broadcast quality, even the best equipment can be inadequate if misconfigured. Fields viewed through the microscope may not be completely represented by the video broadcast, and faculty should frequently monitor the broadcasted image to ensure that areas of interest are both in the broadcasted field as well as in focus. Alternating between the microscope and the video broadcast requires additional time and patience on the part of the participants and the faculty (Fig. 1). Faculty must also be aware of the latency between image-capture and broadcast. Movement of the slide is difficult to visualize compared with optical transmission, and ghosting of the field will occur with even the slightest movement. When areas of interest are encountered, faculty should pause and ensure that the area of interest is in focus on the video broadcast before teaching. Frequent movement between fields and magnifications without adequate pauses will almost certainly render a video broadcast useless. The remote broadcast of cytopathology microscopy is further complicated by at least 4 issues: 1) the 3-dimensionality of the specimens (z-axis), 2) the high magnifications used for many diagnoses, 3) the often focal nature of diagnostic cells, and 4) learner discomfort with cytopathology specimens. For the first 3 issues, faculty need to be additionally sensitive to ensuring that cells of interest are focused on the video broadcast and that time is allowed for each plane of focus to be broadcast while focusing within the z-axis of a specimen. Learners sometimes require additional time to adjust their eyes to cytologic specimens, especially at the start of rotations. This adjustment period may take longer while viewing slides remotely. A possible solution is for trainees to view cytopathology teaching sessions on a regular basis, even when not on a cytopathology rotation. Faculty can use either the microscope arrow or the mouse cursor to highlight areas of interest in a field. One benefit of a video broadcast is that all participants see the field and microscope arrow in the same orientation. Although variation exists among types of camera software, most will allow faculty to capture and annotate images. Digital zoom can allow for areas to be enlarged (particularly useful in cytopathology) and for extremely small features to be better demonstrated compared with optical transmission. Images can be captured relatively quickly during sign-out and shared in a saved folder for future review by residents, quality assurance (QA) conferences, sharing on social media, or documenting in a case report. Trainees also benefit from witnessing how to best identify and capture a field of interest. “Ideally you're supposed to be proper, but no one ever is. Not when viewing. There's no personal presence involved so why take any pains?” Isaac Asimov, “The Naked Sun“1 Perhaps the most challenging difference between remote and in-person learning is the interaction between the learner and the teacher. Remote learning, even if participants share video streams, cannot capture the nonverbal cues that teachers and learners may rely on when physically adjacent; some of these cues may be subtle and only subconsciously identified. The level of learner engagement may also be difficult to assess. It is possible that some learners who are otherwise hesitant to speak at sign-out may feel more comfortable speaking during a remote session or by using the software's chat function. Conversely, some learners may speak less because of audio connection problems, the lack of a computer microphone, overuse of the mute function, unfamiliarity with the technology, and/or uncertainty with the overall experience. Likewise, teachers may have similar issues. A multipronged approach can solve these problems. Both teachers and learners should become familiar with the software, which may require training. The use of a single videoconferencing platform within the institution decreases the need to learn multiple methods. Teachers should encourage learners to speak through a specified method (eg, by voice or chat) and provide additional opportunities for communication by asking questions and fostering conversation among participants. If available, the chat box should not be ignored; the moderator or another participant can be assigned to check the chat regularly. Faculty should be cautious to avoid language that may be misinterpreted, especially in an environment with fewer nonverbal cues. It may be difficult—perhaps impossible—to judge a learner's response to an off-hand remark. If a sign-out session is now open to viewing by additional participants, a trainee may become more readily embarrassed by a misdiagnosis or an improperly answered question. It may be appropriate for the faculty member to mutually agree with the trainee as to whether a sign-out session should be open for viewing. Alternatively, screensharing may be configured to allow the faculty to see a trainee's diagnosis without sharing to the broader audience, and any necessary critiques can be shared afterward. Remote learning allows for an expanded audience, as learners are no longer limited by the number of heads on a multiheaded scope, or physical room location. Faculty should be aware that a larger attendance may reduce participation, as no single participant feels on the spot to answer questions or interact. Learner 1: “I always learn better when I make mistakes.” Learner 2: “If I have not previewed the slides, I have not found the remote sign-out as helpful… it is exacerbated in cytopathology because I am less comfortable with the material.” Although some institutions may choose to have trainees work strictly from home, unless clinical slides can be rapidly scanned, cases must be previewed at the hospital. Reviewing cases with an attending physician is the traditional method for pathologists in training to learn pathology. It is an intimate learning experience in which the trainee is not only verbally taught by the attending but also learns different approaches to reviewing a slide (physically and theoretically)—connecting findings to clinicoradiologic impression, wording a diagnosis, constructing a note, and communicating with the clinical team. A benefit of remote sign-out is the ability of trainees to join sign-outs for services outside of their currently assigned rotation. Many trainees may wish to spend more time reviewing cytopathology cases to prepare for the board examination as well as before starting their first jobs. In addition to accommodating additional trainees, remote sign-out has the potential to include cytotechnologists, expert pathologists from other services for on-demand consultation, and members of a patient's clinical team. Additional trainees joining a sign-out session likely have not previewed cases and lack a sense of ownership, leading to reduced interest. The traditional sign-out process itself is not high-yield, and time is spent reviewing areas that may not be diagnostic or important; many cases do not provide new learning opportunities. However, new opportunities may arise unexpectedly and may be missed by remote learners who are not fully engaged in sign-out. Remote sign-outs typically take longer because of broadcast latency and the need to switch between video broadcast and patient records, which may exacerbate impatience among trainees who are viewing cases they have not previewed. Among residents who were asked, remote sign-out was uniformly ranked as the lowest yield activity because of the lack of previewing. For trainees who had previewed slides, remote sign-out was a critically important experience, similar to in-person sign-out. In the absence of social distancing, all trainees on service can be physically present in the hospital and thus multiple trainees can preview the same case to increase engagement. In the setting of social distancing, the number of trainees at the hospital are limited, and fewer trainees have the opportunity to preview each case. The separation between the trainee and attending responsible for a given case may alter preexisting workflows that have developed to prevent slide misidentification. For instance, a workflow in which both the trainee and the attending verify the slide label together would no longer be possible if they are 6 feet apart or are signing out in separate rooms. A sign-out workflow should be developed that maintains a slide verification process. Because protected health information (PHI) is often presented when verifying a slide's accession number and/or patient name, as well as during discussion of a patient's history, such sessions should not be recorded for later review. Participants who the session should be in a of and the broadcast connection needs to be of a should not be or broadcast. Learner “The attending all the or educational cases during sign-out and in a In the at a set time every the attending through the cases in to One for better trainees who not preview cases for regular sign-out is to a sign-out in which cases are This may with a daily or may be as a separate session. As to conferences, sign-out sessions focus on teaching at a trainee level and provide time for trainees to questions about The is the additional of slides and areas during regular as well as scheduling and an additional sign-out session. Trainees who for a session may out on learning opportunities that occur during regular as described Many pathology a daily in which cases a are can be broadcast to facilitate remote learning, but should be to avoid sharing which is not during Although these may trainee engagement because they are for and they are often at a that may not allow for all the teaching of a case to be presented or for trainees to questions about a case. Remote broadcasts of using software as from a given to a audience, but the use of software to broadcast a layer of technology between the and which can management issues. can be and the use of a chat box to questions eliminates the need for the to a in the of a Because is not can be recorded and for later review. The number of is and the of the does not other Learner 2: the teaching set on to when you are is Learner there had been of cytopathology teaching available before my first cytopathology that would have been the first I used to In with trainees, teaching didactics were uniformly as the best remote learning opportunity compared with broadcasted sign-outs and using preexisting teaching or slides, the faculty broadcasts live microscopy with This method is similar to the video microscopy sessions that are at many pathology and has the benefit of providing information on a focused Because the teaching is more than in a and does not faculty may be more to allow sessions to be recorded and for later review and for learners who cannot the live session. A of on the part of the can the educational of a session, by slides that best teaching and by slides or focused with the slides and allows the faculty to quickly identify important areas during the session, thus time for slides can also be for broadcast, and digital can be areas of interest to be found rapidly during a session. Digital slides can be shared on a or service, providing trainees with an opportunity to preview slides before the session, which can increase engagement. sessions that slides with live microscopy require additional but can provide a learning experience for participants. microscopy the sign-out experience and the approach to a slides can that morphologic features and include that can be later by The slides can be saved in a that, if provided in can be used for by participants. and other and many academic pathologists have spent the of their effective Learners should not or material without For in which a faculty member that a can be for access the pathology should provide a software allows for more less through However, faculty should be aware that any remotely viewed broadcast can be recorded and without their or Faculty should be to with the that the of teaching material is a Learner 2: teachers are uncomfortable with remote and would need to adjust their teaching and slide new method with Even at institutions with well digital it is likely that some teaching faculty will have no experience with remote teaching. Although can provide feedback about audio and quality, teachers should feedback on a to the quality of their remote teaching. A of teaching that may have in the for a given teacher may no longer be appropriate for a remote learning session. This may to in teaching and content or the of technical issues that can be in sessions. Faculty should review their recorded material for the of and institutions and/or academic departments should teaching in this area for faculty that include basic teaching as small with microscope become magnified with a video broadcast and remote learning, teaching and/or a toward teaching can also become remote learning, it is even more important for teachers to be and “The not to his has to the development of even more viewing and as the viewing equipment grew better there was less and less need to ever see It was a Isaac Asimov, “The Naked Sun“1 distancing because of will not need may in the or it may Although in-person learning should be when available, we should be to to remote learning when This requires that departments the equipment and software and that trainees and faculty training on remote for both in-person and remote learning should be and of recorded didactics should be in an accessible and Even in the absence of social distancing, of remote learning should be to help an remote learning technical and faculty the of trainee broadcasting and didactics and and other likely will continue at remote sign-out sessions would have limited because of engagement by who have not previewed is no for Isaac Asimov, “The Naked Sun“1 In to we are likely to continue for in-person The of nature do not allow for remote to need for or of Although remote learning cannot be a for in-person learning, it has the potential of an component of training. is on the of while cytopathology is more challenging because of the presence of a it will we whether we can teach pathology best as and should also how we will for learning, and sharing pathology during an in which we may not be able to together at the in the same is a at the of with in and pathology. is currently a in at will be a in at and has additional in education and is an at the of as the and the

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