As pathology departments across the world continue to provide patient care during the coronavirus disease 2019 pandemic, academic institutions must find creative ways to facilitate education. Pathology has traditionally been a field driven by apprentice-like education of trainees at the microscope and on the bench. However, given current safety requirements in place to ensure a healthy working environment, work-arounds are being created to enable continued training and care.
Departments are rapidly adopting digital resources such as scanned slides and virtual sign-outs with live microscope images, but these tools are untested as a sole means of education. Microscope cameras have enabled residents and fellows to participate in sign-out; however, without one-on-one interaction, it is often unclear whether trainees are able to concentrate or comprehend all of the details of a high-level concept. Studies evaluating digital teaching are ongoing, but noninferiority, to the authors' knowledge, has not been established.
Digital sign-out is also challenging to the normal workflow in which the resident or fellow is able to prepare and go over cases in close proximity. Likewise, having both trainees and attending physicians at the scope can help catch small details regarding a case, such as information listed on the requisition, a missing slide, or a labeling issue, that might go unnoticed during a Zoom session (Zoom Video Communications, San Jose, California). It is the authors' collective opinion that one-on-one microscope teaching is a vital part of pathology education and patient care.
In an attempt to facilitate teaching and continue to provide care for patients, our department has designed and put in place acrylic shields at our multiheaded microscopes (Figure). The department has a mask-wearing and social distancing policy, but these devices may provide an additional measure of safety at multiheaded scopes. The shields are designed to be freestanding and are made of acrylic, supported by custom steel feet. The standard height is 76.2 cm (30 inches) with a thickness of 0.64 cm (0.25 inches) and a width designed to provide 15.2 cm (6 inches) of overhang on either side of the desk. As the microscope oculars are adjustable, the top of the shield ranges between 31.1 and 35.6 cm (12.25 and 14 inches) above a viewer's nostrils, accounting for a 30-cm air exchange radius.1 There are currently 13 shields installed, with more on order.
Shields are being used at sign-out, both with and without the use of video conferencing and microscope cameras. In general, the resident who has prepared the case will sit at the scope while other residents sit in the room watching on a screen or streaming from off site. This approach allows for social distancing for residents without direct ownership of the case.
It has not been established whether digital education is inferior to at-the-scope teaching, but it is the authors' collective opinion that there may be something lost with the exclusive use of digital sign-out. Although feedback can be provided across the room, there are numerous distractors available when trainees are away from the scope. With the number of Zoom meetings and streaming lectures increasing day by day, learners may become weary and inattentive. Conversely, some advantages cannot be overlooked with having the rest of the team at computers where clinical information can rapidly be obtained, facilitating the sign-out process. Moving forward, some combination of both may become more common.
To that end, acrylic shields represent only one part of reducing risk of droplet and particle exposure between attending physicians and trainees in addition to mask wearing. All parties continue to socially distance in other situations, and the number of persons allowed in a room at one time has been determined in all shared workspaces. Canadian recommendations suggest regular cleaning of partitions, and our department is having discussions regarding a cleaning policy at this time.1
Prolonged forceful exhalation leads to increased aerosol production, which could lead to spread over extended periods, as demonstrated in an outbreak associated with a church choir practice.2,3 It is unclear if this could occur because of teaching at a microscope, but transmission is certainly possible, as air is circulated throughout a space. To that end, the shield acts as only an additional precaution, as all employees in our hospital must complete daily screening surveys prior to coming to work. There is a strict health-system travel policy preventing trips to high-incidence areas. Extensive evaluation to qualify the efficacy of these devices has not been performed, and all parties must remain responsible with regard to limiting risk of exposure when off site.
Both the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration recommend barriers, specifically at pharmacy counters.4–6 These devices, in theory, help to reduce the amount of droplets and particles parties are exposed to on either side of the shield. Likewise, these shields are being put in place in numerous locations in everyday life, such as restaurants and stores.7 Unfortunately, at the time these shields were produced no guidelines had been provided for construction of acrylic partitions by the Centers for Disease Control and Prevention or the Occupational Safety and Health Administration. Retrospective evaluation demonstrates that our devices meet recommendations provided by Canadian guidelines when all parties are seated.1
In unmasked individuals, there is a 30-cm-radius air bubble in which individuals recirculate air. Shields create a physical barrier when aerosolized droplets and particles encounter the surface.1 We require all individuals at sign-out to wear masks, which likewise reduces range of aerosols.8 Unfortunately, at this time no extensive evaluation of partitions has been performed regarding their efficacy, and likewise we have not done testing to qualify their use.
To that end, use of barriers has been adapted from the Occupational Safety and Health Administration and Centers for Disease Control and Prevention recommendations designed for pharmacy counters. Any barrier set up is in an institution's best attempt to help prevent transmission of coronavirus disease 2019. As evidenced by the Centers for Disease Control and Prevention's recent acknowledgment of particle transmission of the virus, over 6 months into the pandemic, it is clear that our understanding of the virus is incomplete.9 If departments do not have means to install barriers at this time, other risk-mitigating strategies such as social distancing and digital sign-out should be implemented as a first step before investing in acrylic shields.
The authors acknowledge that prolonged sign-outs can and do still occur, and it is the responsibility of the attending physician to limit exposure for trainees. When possible, maximum distance is maintained at multiheaded scopes for sign-out. There may be concern that residents are forced into this situation, and there may be some fear that they are at the scope under duress. However, adoption of shields has been embraced by our department, where we have regular residency meetings both with and without faculty, and to date no complaints have arisen about intimidation over in-person sign-out with shields.
The number of persons per room was decided by an internal task force throughout the university and distributed among the school of medicine. These practices were determined by the number of persons who could safely distance (6 feet [1.8 m]) within a space based on square footage. There is still residual risk associated with close proximity, though this risk is theoretically reduced by acrylic shields. Masks reduce droplet sharing but do not eliminate it. Working in close proximity for prolonged periods is a high-risk activity, and teams must remain cognizant of this reality.
Fortunately, the number of cases per 100 000 individuals in our area is low, but devices such as these may help enable a more traditional workflow in areas with higher rates of disease.10 We suggest this may help reduce spread as a secondary measure along with responsible mask-wearing, social-distancing, and health-screening practices. Digital pathology techniques are being pushed to the forefront in this moment and will likely continue to advance even after the pandemic ceases. Conversely, it is our hope that acrylic shields at microscopes soon become an artifact of the pandemic, a curiosity more than anything else, but that for the time being the devices may help facilitate education and patient care.
The authors have no relevant financial interest in the products or companies described in this article.