INTRODUCTION {#sec1-1}
============

Over the past few years, the evolution of information technology has vastly changed the practice of pathology. Novel techniques have been implemented, primarily in the form of digital images and telepathology (TP).\[[@ref1]\] Digital pathology can be defined as the electronic capture, management, analysis and distribution of gross or microscopic specimens. It encompasses the use of digital images as well as TP.

The spectrum of applications of digital pathology is wide and includes primary diagnosis, intraoperative diagnosis, consultation, quality assurance, archiving, education, conferences, and research.\[[@ref1][@ref2]\] Widespread adoption of digital pathology applications could expedite second opinion consultation;\[[@ref3]--[@ref5]\] digital consultation can be performed within hours versus days to weeks for cases sent through the mail.\[[@ref6]\] It can also help improve service quality to under-serviced areas,\[[@ref7]\] facilitate immediate conferencing about a specimen by individuals in different locations,\[[@ref8][@ref9]\] reduce costs of slide storage, limit slide loss,\[[@ref10]\] expedite slide retrieval and overcome the problem of slide fading.

There are, however, several challenges to the widespread implementation of digital pathology, including cost, and a lack of standardization. Added to this is the potential negative attitude of pathologists towards the change.

Canada is emerging as a hotbed of digital pathology for several reasons. The geographic distribution of the population necessitates the presence of dispersed pathology centers serving small populations with minimal resources available and a lack of subspecialty practice. Added to this is the difficulty and expense of travel for specialist pathologists to these centers, especially in the harsh Canadian winter. This makes Canada a unique target for the widespread implementation of digital pathology.

Since pathologists represent the immediate "customers" of the technology, it is of prime importance to fully understand the reaction of pathologists towards this emerging technology. The objective of this study was to analyze the attitudes of pathologists and pathology residents throughout Canada towards the spectrum of digital pathology applications. This will be an essential step towards better implementation of digital pathology in our practice through a thorough understanding of the needs, concerns, and expectations of digital pathology.

MATERIALS AND METHODS {#sec1-2}
=====================

The study was conducted through an online survey consisting of 24 questions of different formats. The requested answers were in the form of yes/no, multiple choice and free text questions. The questionnaire was created in English and in French and addressed to all Canadian provinces. An E-mail was sent out through the databases of the Canadian Association of Pathologists-Association canadienne des pathologistes (CAP-ACP), which includes all anatomical pathologists across the country (practicing and retired) in addition to residents, fellows and non-degree trainees. E-mails with a link to the questionnaire were also sent to all anatomical pathology residency directors across Canada. A reminder was sent half-way through the study. The study was approved by the Research Ethics Board of St. Michael\'s Hospital. A copy of the questionnaire is shown in [Supplementary Table 1](#T1){ref-type="table"}.

###### 

Survey

![](JPI-4-3-g001)

RESULTS {#sec1-3}
=======

A total of 157 individuals answered the survey. The overall response rate was 17% of all CAP-registered pathologists (27% of practicing pathologists and residents). The breakdown of respondents according to level of practice is shown in [Figure 1](#F1){ref-type="fig"}.

![A pie graph showing the distribution of the respondents according to their level of practice. Fifty five percent of our respondents had either less than 5 years or more than 20 years of experience. Total number of respondents = 157](JPI-4-3-g002){#F1}

Telepathology {#sec2-1}
-------------

Survey participants gave a range of definitions for Telepathology (TP) as shown in [Supplementary Table 2](#T2){ref-type="table"}. Forty-three percent of respondents state that TP is used in their institutions. As shown in [Table 1](#T3){ref-type="table"}, the main applications were for teaching purposes, followed by frozen section (intraoperative) consultation, and routine diagnostic consultation services (30%). TP is not widely used for routine diagnosis or quality assurance activities. Interestingly, 71% of respondents see a need for TP in their practices.

###### 

Responses to survey question 2

![](JPI-4-3-g003)

###### 

The applications of telepathology in Canadian institutions

![](JPI-4-3-g004)

Digital Images {#sec2-2}
--------------

The majority of the respondents are familiar with the term "virtual slide" (97%). Static or virtual digital images are routinely used by 85% of pathologists and residents as part of their practice or training and 90% of respondents feel there is a need for digital pathology in their institutions. Twenty eight percent of practicing pathologists have requested a second opinion/consult using a digital image. The suggested applications of digital pathology are depicted in [Figure 2](#F2){ref-type="fig"}. Of note is that only 35% indicated the potential use of digital images for routine diagnosis. Interestingly, 63% of our cohort felt that it would be an advantage to have "routine" digital images for gross pathology specimens. Only about one third of the participants (37.4%) had experience of image analysis programs. This was mainly used for research purposes (83%), estrogen and progesterone receptor quantification (22.6%) and ki-67 proliferation index calculation (30%). As shown in [Figure 3](#F3){ref-type="fig"}, digital pathology became a significant component of pathology education in Canada. 40-70% of participants indicated the use of digital pathology as a tool for learning and continuing medical education (CME). Moreover, the vast majority (98%) were in favor of an on-line digital image library (static or virtual) to review the features of challenging and rare cases.

![Suggested applications of digital pathology. The majority of Canadian pathologists and residents indicated a need for digital pathology for different purposes including consultation, intraoperative sections and teaching. Of note is that only 35% indicated the potential use of digital images for routine diagnosis](JPI-4-3-g005){#F2}

![The use of digital images as an educational tool among Canadian pathologists](JPI-4-3-g006){#F3}

The potential advantages of using digital images are depicted in [Figure 4](#F4){ref-type="fig"}. The 'other' category responses given for advantages of digital pathology included the ability to perform automated images analysis, that images could be projected at conferences versus sitting at crowded multi-headers and the fact that it enables remote pathology.

![Perceived advantages of using digital images among Canadian pathologists and trainees. Easier access and faster results are among the most desired advantages among pathologists](JPI-4-3-g007){#F4}

As shown in [Table 2](#T4){ref-type="table"}, there are a number of limitations that were raised for using digital imaging in practice. Within the "other" category for disadvantages of digital pathology, responses included the possibility of image manipulation, technologic limitations of institutions, poor inter-observer variability, time to scan/digitize slides and issues regarding billing/payment for consultation services. Interestingly, most pathologists did not recognize the difficulty of training as a major disadvantage.

###### 

Perceived disadvantages and limitations of using digital images

![](JPI-4-3-g008)

Digital Pathology Infrastructure and Training {#sec2-3}
---------------------------------------------

In terms of equipment, 51% of respondents state that their institutions have a virtual slide scanner and 45% of respondents have used a slide scanner before. The majority of respondents (64%) would prefer cases to be stored as both glass slides and digital images.

Eighty-four percent of respondents stated that they are interested in following the literature on digital pathology. A favorable response is observed towards pursuing digital pathology training; 57% of pathologists and 77% of residents stated that they would attend informatics workshops these if made available to them. In addition, over 90% of respondents feel that resident training programs across the country should include an informatics component that focuses on the creation of digital images and the uses of various imaging modalities. Only about a quarter of respondents, pathologists and residents alike, were in favor of digitizing the Royal College certification examination in pathology.

DISCUSSION {#sec1-4}
==========

The main limitation of this study was the low survey response rate. This most likely introduced automatic bias to the study and probably included respondents who were more familiar with and interested in the topic of digital pathology. Another limitation was the lack of a sharp demarcation between the definition of digital pathology and TP in the survey itself; this might have affected the responses of the study population. The phrasing of some of the questions was a little vague and broad, for example asking questions beginning with the wording "have you ever heard of ...." It should also be noted that our results might have been affected by the type of practice the individual respondents belonged to; e.g., academic versus community versus remote underserved areas.

There are many factors that make Canada ripe for early adoption of "digital pathology" including large geographic size with a relatively small population, extreme disparities in population density, and available technically advanced health-care with a shortage of anatomical pathologists. There are only 1195 practicing pathologists in Canada, of which approximately 615 are anatomical pathologists.\[[@ref11]\] Although, this survey involved only Canadian pathologists, we feel that the findings apply to the pathology community at large as several other countries share similar geographic and demographic characteristics.

Our results highlight three applications of digital pathology to be of practical interest to pathologists; namely frozen section diagnosis, consultation services, and teaching. Only a small proportion of pathologists support the use of digital pathology for routine diagnoses. Many of the Canadian concerns regarding digital pathology were similar to those previously listed in the literature, including cost and image quality. They also shared similar views of the benefits of digital pathology, including easier access to cases and faster turnaround time. Interestingly, the need for learning to use the technology was essentially a non-issue amongst respondents and very few were "not comfortable with the technology" \[[Table 2](#T4){ref-type="table"}\].

An important concern that was highlighted in our survey was the potential compromise of diagnostic accuracy due to lower image quality or under representation of the lesion in digitized images. More recently, accumulating literature has shown good to superior agreement between glass slides and digital slide diagnoses in a variety of specimen types.\[[@ref10][@ref12]--[@ref14]\] In a study by Evans, *et al*., the authors reported average accuracy rates of 98% for TP frozen section diagnoses with rapid turnaround times.\[[@ref15]\] Worries concerning image quality would be overcome with standardization procedures of the steps involved in the digital imaging process, which are yet to happen.\[[@ref2][@ref6][@ref16]\] An important issue in the process of creating a digital image, more specifically a virtual slide, is the consistent focus which can affect image quality.\[[@ref16]\] This is being addressed, and there are now commercially available scanners that have continuous focusing mechanisms, which prevent unfocused areas in whole slide imaging.\[[@ref6]\]

In terms of cost, setting up the infrastructure to support digital imaging and TP using whole slide scanners can be costly. It is likely that with time, the technology will become more affordable and greater numbers of institutions will be able to avail of its benefits; most especially remote institutions that are not affiliated with universities. Over time the technology will likely pay for itself by no longer having to employ full-time pathologists in remote locales and/or saving on pathologists' travel to these areas for part-time service. In addition, the cost of shipping consult slides across the country would be eliminated.

According to our results and previous reports, digital pathology is highly favored for educational purposes. Whole slides as well as static images have replaced the microscope in several university histology and pathology courses with good student satisfaction and performance on exams.\[[@ref17]--[@ref19]\] Up to 33% of US medical schools have integrated digital microscopy into their pathology courses.\[[@ref17]\] Many educational courses at national and international pathology meetings have adopted the digital pathology approach; this way the number of participants does not need to be capped due to insufficient room at a multi-header microscope or because of a limited number of glass slides that can be distributed to participants.

Overall, the attitudes toward digital pathology in Canada are positive. We have found strong support for obtaining more training in the field of digital pathology by residents and staff pathologists alike. Based on our findings, we recommend the integration of digital pathology into current resident training programs. Education in digital pathology from an undergraduate level through resident training will yield generations of pathologists who are more familiar with the technology\[[@ref6]\] and will be better equipped to use and apply it in daily practice.

Lastly, our survey shows that as the field evolves, pathologists are more welcoming for digital pathology to be gradually incorporated for specific applications that are integrated into our current practice rather than a sudden revolutionary change.

Available FREE in open access from: <http://www.jpathinformatics.org/text.asp?2013/4/1/3/108540>
