The main focus of education in most pathology residency and subspecialty pathology fellowships is the light microscopic examination of pathology specimens. Classes with multiheaded scopes are the most popular among pathology trainees. Until recently, it was difficult to imagine that this educational approach could change. In the beginning of March 2020, our country faced a serious challenge, which all of us now know as the coronavirus disease 2019 (COVID-19) pandemic. The rules of social distancing and work from home were applied. These types of restrictions were implemented in almost all parts of our life, including work and pathology education.
To share our experience in the Department of Hematopathology at the University of Texas MD Anderson Cancer Center during the COVID-19 pandemic. We describe our experience in modifying our approaches to education. We show how we overcame many obstacles to learning by building one of the largest virtual hematopathology educational platforms via Cisco WebEx and using social media, in particular Twitter. These tools facilitated the learning of hematopathology by medical students, pathology trainees, and practicing pathologists from all over the world.
During the first 3 months of the pandemic (April, May, and June, 2020), we evaluated the visitor attendance to the MD Anderson Cancer Center Hematopathology Virtual Educational Platform using data collected by the Cisco WebEx Web site. To determine the impact that the platform had on medical education for the hematopathology community on Twitter, the analytic metrics obtained from Symplur LLC (www.symplur.com, April 27, 2020) were used via its Symplur Signals program.
Our experience using the MD Anderson Hematopathology Virtual Platform showed that there is substantial global interest and desire for virtual hematopathology education, especially during the COVID-19 pandemic.
The recent coronavirus disease 2019 (COVID-19) pandemic challenged every part of our lives. Social distancing practices to prevent the spread of viral infection made traditional pathology sign-out and education using multiheaded microscopes and in-person conferences impossible.
The hematopathology fellowship program at MD Anderson Cancer Center, Houston, Texas, before the COVID-19 pandemic was heavily focused on sign-out of cases at multiheaded microscopes and daily group meetings including weekly didactic lectures by faculty, twice-weekly didactic lectures by fellows, twice-weekly “unknown” conferences on bone marrow or lymph node pathology, and subspecialty lectures on flow cytometry immunophenotyping, molecular diagnostics, and cytogenetics.
During the COVID-19 pandemic, MD Anderson Cancer Center instituted strict rules for the institution that almost fully prevented the usual educational routines of the Department of Hematopathology. The rules permitted a maximum of 6 people per auditorium and attendees were required to wear masks and maintain a distance of 6 feet (1.8 m) apart or use a mask with a plastic face shield, effectively preventing the use of double-headed or multiheaded microscopes. Our daily conferences and lectures, usually attended by 20 to 30 people, lost their main educational purpose when only 5 people per room could be accommodated in compliance with COVID-19 distancing policies. The question of using virtual education methods was raised, and our department fully committed to this approach.
The decision to move our teaching into a virtual environment was made. Although personal interactions were missed, technically all conferences were done by using Cisco WebEx (Cisco Systems, Inc, San Jose, California), a Web-based application for conducting online videoconferences.1 For the additional benefit of our trainees, we scanned the glass slide cases for unknown conferences and uploaded the images into the Pathpresenter Web site (https://pathpresenter.net/; accessed April 23, 2020).2 After scanning, the online links made for convenient access to slide images before the Cisco WebEx conferences. We knew that whole slide scanning had previously been used in pathology education, so we decided to use the same approach.3
During the first week of virtual education, we invited only MD Anderson hematopathology fellows and faculty. The experience with a new teaching tactic was so well received that former MD Anderson trainees and faculty started sending us requests to join our virtual conferences. Soon enough, the news about our educational platform, which was active despite the COVID-19 pandemic, spread quickly and the group of attendees reached 200 to 300 people per session. Persons who never had access to a high-quality hematopathology education started sharing the information via social media: Facebook (Facebook, Inc, Menlo Park, California) and Twitter (Twitter, Inc, San Francisco, California). Soon after, we started placing all our announcements on Twitter for notification purposes. Consequently, Twitter was used to place not only announcements of our future conferences but the links for Cisco WebEx meetings, scanned slides, and the correct answers of unknown conferences. Due to high interest in our educational platform, we decided to help our Twitter followers and other interested people to find the information about our sessions easier by creating the specific hashtags #VirtualHemepathMDA and #LJMFridayUnknowns. We divided our Cisco WebEx meetings/conferences into 3 subgroups: (1) lectures, (2) bone marrow unknown conferences, and (3) lymphoma unknown conferences. Medical students, pathology residents, fellows, practicing general pathologists, and especially hematopathologists from all over the world began regularly joining our classes.
Here we would like to share the MD Anderson Cancer Center Department of Hematopathology experience in transferring our education from in-person to virtual under the pandemic influence.
METHODS
During the first 3 months of the pandemic (April, May, and June, 2020), we evaluated visitor attendance using data collected by the Cisco WebEx Web site.
To get a clear understanding on attendance of our educational platform, we used data from Cisco WebEx usage reports. Additionally, our visitors were asked to write their names and locations in the chat box. The information from the chat box was collected and consequently analyzed. Also, we analyzed the number of entries, the number of domestic and international attendees, and their dynamics with time.
Some Cisco WebEx clinical conferences were not broadcast (were not made available for public access) in order to protect patients' private information, but still required attendance and participation of MD Anderson hematopathology trainees: lymphoma, leukemia, and myeloma tumor boards and in-person sign-outs.
The Aperio AT2 (Leica Biosystems, Wetzlar, Germany) slide scanner from Leica was used to scan all glass slides before bone marrow and lymphoma unknown conferences. The Aperio AT2 runs on the Microsoft Windows 10 operating system. For security precautions, the MD Anderson Cancer Center information technology team built in-house software called Striplable, which is used to remove any patient identification from the scanned slides and prevent any Health Insurance Portability and Accountability Act violations. After slides were scanned and de-identified, the images were uploaded to the Pathpresenter Web site.2 Pathpresenter has an option to create online links for easy access to the images.
We examined the impact the platform had on medical education for the hematopathology community on Twitter using analytic metrics obtained from Symplur LLC (www.symplur.com; April 27, 2020) via its Symplur Signals program using previously described methodologies.4 The analysis was made possible using Symplur's Healthcare Hashtag and Symplur Signals projects, which assist in organization of data sets available on Twitter.5
There were no specific software purchases for the MD Anderson Cancer Center Hematopathology Virtual Educational Platform. Most of the equipment and software was provided by MD Anderson Cancer Center (Cisco WebEx, scanning and de-identification software) or was available for free via the Internet (Twitter and Pathpresenter).
RESULTS
The experience of the hematopathology fellows at MD Anderson Cancer Center after switching the education format from in-person to virtual was extremely successful. It was measured not only by increased attendance of our own faculty and trainees, but by increased interest from others in the United States and the world pathology and hematopathology community in our online education.
We were able to keep all our educational lectures/conferences running using Cisco WebEx software without the need to physically come to the conference room. We allowed our trainees and outside visitors to preview the slides for unknown conferences by scanning them and uploading the images into the Pathpresenter Web site instead of leaving the glass slides in the fellows' room.
During the period of evaluation (April 1–June 30, 2020) we had 57 broadcast lectures: 9 lymphoma unknowns, 9 bone marrow unknowns, and 39 lectures. At the same time, we had 39 clinical conferences, which were not broadcast: lymphoma planning clinic, leukemia planning clinic, and myeloma tumor board. In addition, all our fellows had multiple one-on-one sign-outs with different hematopathology attendings. All lectures were given on diverse neoplastic and/or benign hematology topics by MD Anderson Cancer Center faculty and the outside institution faculty (every Monday, Tuesday, and Thursday, 9:00 am; duration, 1 hour), bone marrow unknowns (every Wednesday, 9:15 am CST; duration, 1 hour), and lymphoma unknowns (every Friday, 4:00 pm CST; duration, 1–2.5 hours). Lymphoma planning clinic, leukemia planning clinic, myeloma tumor board, and in-person sign-outs were not available for the general public because of possible Health Insurance Portability and Accountability Act violations.
We analyzed all tweets using the hashtags #VirtualHemepathMDA and #LJMFridayUnknowns during 3 months of the COVID-19 pandemic (April 1–June 30, 2020). The study analysis period was divided into 3 distinct periods to allow for comparison over time: April 2020 (172 tweets), May 2020 (85 tweets), and June 2020 (12 tweets) for #LJMFridayUnknowns, and April 2020 (734 tweets), May 2020 (546 tweets), and June 2020 (678 tweets) for #VirtualHemepathMDA. During the time our VirtualHemepathMDA platform was active, the total number of visits was 12 597 and the total number of individual emails was 9492; 4218 emails were from the United States, 3725 from outside the United States, and 1549 from unknown locations (Table 1). The median number of visitors per week was 871.5 (range, 648–1291) (Figure 1). The educational platform was very popular worldwide and was visited by people from 53 countries (Table 1). The highest number of international visitors were from India. The most distant place from which persons accessed our conferences was Mauritius. The median number of visitors per session from the United States was 38 (range, 8–203) and from outside of the United States was 56 (range, 0–157). It is interesting that the number of visitors from outside of the United States grew significantly with time and, by the end of the analyzed period, was larger than the number of visitors from the United States (Figure 2). The median number of countries per conference was 15 (range, 1–37), the median number of US institutions was 14 (range, 1–79), and the median number of states was 8 (range, 1–32).
Geographic Distribution of the University of Texas MD Anderson Cancer Center Hematopathology Virtual Educational Platform Visitors Between April 1 and June 30, 2020a
Number of MD Anderson Hematopathology Virtual Educational Platform visitors per full week during the coronavirus disease 2019 (COVID-19) pandemic (from March 30 to June 26, 2020).
Number of MD Anderson Hematopathology Virtual Educational Platform visitors per full week during the coronavirus disease 2019 (COVID-19) pandemic (from March 30 to June 26, 2020).
Compare the numbers of MD Anderson Hematopathology Virtual Educational Platform visitors from the United States (blue line) and from the rest of the world (orange line) from March 23 to June 30, 2020. The x-axis represents the number of virtual lectures.
Compare the numbers of MD Anderson Hematopathology Virtual Educational Platform visitors from the United States (blue line) and from the rest of the world (orange line) from March 23 to June 30, 2020. The x-axis represents the number of virtual lectures.
Furthermore, using Symplur statistics services, we were able to analyze our Twitter experience activity from March 1 until July 26, 2020. Our results showed that during this time interval, 465 users made 2265 tweets and 1860 retweets, with the generation of 3 329 807 impressions (times people saw these tweets/retweets), in addition to 1586 and 2624 shared articles and visual media, respectively (Table 2). A peak in engagement was noted on April 5, 2020, with the establishment of widespread national social distancing rules, followed by a period of engagement stabilization until June 21, 2020, where another peak in engagement was identified (Supplemental Figure 1; see supplemental digital content at https://meridian.allenpress.com/aplm in the November 2021 table of contents).
The switching of our educational approach from mainly in person to a virtual mode allowed our MD Anderson hematopathology fellows to continue their training without significant interruptions, and also allowed our fellows to fulfill the American Board of Pathology criteria for hematopathology subspecialty boards.
DISCUSSION
During the time of the COVID-19 pandemic, many academic institutions and societies realized the need for different ways to teach and share the experience in general pathology education. At the beginning of the pandemic, there were few educational platforms for people who wanted to study hematopathology. Later, the Society of Hematopathology released some prerecorded lectures, and several hematopathology lectures were broadcast and recorded by the College of American Pathologists (Virtual Lecture Series for Pathology Residents) on its Web site and Virtual Pathology Grand Rounds on YouTube.6,7 The need for high-quality hematopathology education worldwide in a pandemic was high, explaining such a large number (almost 10 000) of our lecture/conference attendees.
One of the main differences between multiple prerecorded hematopathology educational sources and the MD Anderson Hematopathology Virtual Educational Platform was in allowing attendees to ask difficult questions to speakers or teachers in real time. This ability brought our education to a different level. Interestingly, even after the lecture or conference was over, discussions and teaching often continued via social media, particularly Twitter, where participants were sharing their experience by posting images and topic-related papers.8,9 There have been several recent studies10–14 dealing with similar experiences in cytopathology and dermatopathology. To our knowledge, our manuscript is the first one to concentrate only on hematopathology education.
The number of attendees differed between didactic lectures, lymphoma unknown conferences, and bone marrow unknown conferences, probably related to differences in pathology practice in different countries. In most countries, lymph node neoplasms are signed out by general pathologists and bone marrow disorders are addressed by clinicians or subspecialized clinical pathologists.
Solid support for the relatively easy transformation of our educational program into virtual mode was provided by our institution, which provides a slide scanning facility. We were scanning slides for all of our unknown cases and providing the Pathpresenter links for preview. Additionally, there was no need for direct, hands-on interaction between slides and trainees. This approach significantly decreased potential exposure to COVID-19 and simultaneously allowed people from all over the world to preview interesting cases for MD Anderson unknown conferences.
Remarkably, most of our MD Anderson hematopathology faculty also liked the new virtual platform, and they joined these sessions from their offices without the need to come to the conference room during busy clinical services. Using the virtual platform, just by clicking a couple of keys on the keyboard faculty members could follow the conferences or lectures. If faculty were sick or happened to be on vacation, they could still attend all lectures and conferences from home or any place on our planet with Internet access. Additionally, it became easier to invite renowned speakers from clinical departments at MD Anderson Cancer Center and pathologists from other well recognized universities/medical centers, which we have done successfully. During the time that the MD Anderson Hematopathology Virtual Educational Platform was in place, multiple speakers from different institutions, including the University of Arkansas (Fayetteville), University of Kansas Medical Center (Kansas City), Memorial Sloan Kettering Cancer Center (New York, New York), Emory University (Atlanta, Georgia), and the University of Iowa (Iowa City), were given an opportunity to speak.
Based on regular positive feedback and comments on Twitter, we realized that our lectures and educational conferences are very helpful for medical students, scientists, pathology residents, hematopathology fellows, general pathologists, hematopathologists, and even clinicians from all over the world, especially from places with limited resources.
Our experience using the MD Anderson hematopathology virtual platform showed that there is substantial interest in virtual hematopathology education, not only during the COVID-19 pandemic, but even after the pandemic resolves. After reviewing the data received by Cisco WebEx and Twitter, the Department of Hematopathology at MD Anderson Cancer Center will continue to offer online education, not only for our own fellows, but for interested trainees from all over the world. Our goal, certainly shared by many others, is to solidify the hematopathology community around a single idea—to be able to learn hematopathology no matter what.