According to a review by Niazi et al in 2019, “[d]igital pathology plays a critical role in modern clinical practice and is increasingly a technology requirement within the laboratory environment.”1 This includes the development of whole slide imaging (WSI), or complete digitalization of entire glass slides into computer images that can be stored and shared as high-resolution files.1 Clinically, WSI has helped laboratories establish primary diagnoses more efficiently, perform virtual consultations more effectively, improved telepathology (so pathologists can “adequately perform their duties without physically existing in the same location they would have otherwise been required to be”), hold multidisciplinary diagnostic meetings (ie, “tumor boards”), and follow the College of American Pathologists published guidelines for diagnostic validation.2
“We are a digital community of doctors created to share our clinical experiences and collaborate with each other.”3 This phrase can be found on the “About” page of Knowledge In Knowledge Out (“KiKo”), a virtual “metaverse for medical professionals” founded in 2019 by Jonhan Ho, MD, dermatopathology division and fellowship director at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania.3 Through this online platform, KiKo users can comment on each other's published articles, “discuss interesting topics and cases,” expand their network of colleagues, and customize curriculum vitae (CV)–styled personal pages that “can be easily shared with [their] own QR code[s]”.3 Available as both a free website link and phone app, KiKo is “steer[ing] medicine in the right direction” by enabling pathologists (active and retired), trainees, and medical students from around the world to “connect and collaborate” in real time.3 Although KiKo is not the first social media platform used for connection, collaboration, and networking in pathology, its novelty as a generational medium lies in its ability for users to upload batches or libraries of high-quality, scanned digital slides for blog posts, discussions, and educational opportunities.3
Nonclinical advances in pathology because of WSI include, but are not limited to, education (including American Board of Pathology board examinations), quality assessment (ie, of reagent staining, slide preparations, and digital imaging), research (eg, improved objective measurements), image analysis (such as developing diagnostic algorithms based on cellular and stromal components), and overall machine learning.2 Clinically, a review on this topic by Hanna et al2 suggests that a key driving force for machine learning in slide digitalization is using “pixel data embedded within whole slide images [to] integrate with other clinico-pathologic or genomic data [and] potentially establish novel digital biomarkers for diagnosis or prognostication.”2 In other words, improvements in digital slide scanners and WSI production have led to an evolution of incorporating artificial intelligence in pathology, including scoring of breast tumor immunohistochemistry markers,4 Ki-67 assessment for neuroendocrine tumors,5 Gleason scoring of prostate sections on routine hematoxylin-eosin stains, mitotic figure counting and localizing, fibrosis quantification,6 and much more.7
But what about WSI and scanned digital slides in social media? Within the past decade, the application of social media within pathology has taken root; it has allowed for increased networking, collaborating, communication, and “evolution of ideas,” as highlighted by Isom et al.8 Furthermore, Folaranmi et al9 acknowledged that social media platforms such as Twitter (Twitter Inc), and Facebook and Instagram (Meta Platforms Inc) may serve as sources of free, high-quality medical education readily available anywhere in the world, including in low- and middle-income settings, such as Nigeria. The COVID-19 pandemic, which forced many into remote learning environments, may have been a necessary catalyst that validated a pedagogic need for virtual implementation of structured pathology curricula using social media (or “digital pathology”) and other remote learning/training resources.10,11
According to Kumar et al,12 glass slides may be a scarce resource sometimes depending on the laboratory teaching center, and thus WSI “provides an opportunity of standardization of pathology education…with the same slides being viewed simultaneously by all students.” WSI also allows for stain (eg, immunohistochemistry) and other microscopy (eg, electron) interpretation by trainees who are learning in “remote areas” who otherwise may have “limited or no exposure to these specialized fields.”12 Annotated images with relevant clinical context and other pertinent lab findings, as well as less need for multiheaded microscopes, are other benefits of WSI that Kumar et al12 mention, too. On top of this, a survey of pathology trainees at 9 US programs by Elmore et al13 found overall positive attitudes toward WSI diagnostic and training use.
In a later study by Evans et al,14 pathologists at University Health Network (in Toronto) during the COVID-19 pandemic provided distance education to 15 trainees at the University of the West Indies (in Jamaica) via interactive, case-based videoconferencing lectures while using WSI. This study, which demonstrated the successful implementation of remote virtual engagement with trainees via digital pathology, was remarkable in that “[t]here was uniform support from teachers who felt that teaching was not hampered by the ‘virtual' engagement” and that the educators “unanimous[ly] endorse[d] that use of WSI was the future, especially for distance teaching.”14 In this same year, a study by Cho et al15 observing 28 pathology fellows without subspecialty (dermatopathology) training found statistically significant reductions in diagnostic errors when diagnosing common cutaneous pigmented lesions and improvement in learning after reviewing WSI teaching slides. A year after these studies, Hassell et al16 found that “high-quality digital pathology tools and resources” have been made available within all the major facets of anatomic and clinical pathology, and that digital pathology is well adapted to current understandings of optimal learning and teaching strategies at all levels.
Along with publicly posting scanned images of high-quality slides, KiKo allows its users to post messages, initiate case discussions, lead online conferences or “festivals” of unknowns, and much more.1 Although many have ethical and/or legal concerns regarding sharing of pathology images over social media platforms like KiKo, Gardner and Allen17 confirmed that the Health Insurance Portability and Accountability Act of 1996 allows for “public sharing of deidentified pathology photographs without specific patient consent, even on social media.” Gardner and Allen17 go on to explain that the legal risk for pathologists toward causing patient harm through sharing of deidentified gross and slide images is very small, especially when compared to both the academic and clinical benefits of social media use in pathology, which are numerous and well documented.
KiKo combines the strengths of current, well-established platforms like Twitter, Instagram, Facebook, and YouTube (YouTube LLC), which are all frequently used in different ways by pathologists of all ages.18 Thus, users can create their own personal libraries of blog-style posts, batches of scanned digital slides obtained via WSI, and educational videos that they can expand, edit, and share as they please.1 Users can also synthesize videos (like on YouTube) and/or other content from their different social media platforms onto KiKo, and likewise distribute their KiKo posts onto other social media platforms as well.19 This is an especially advantageous aspect of KiKo because other social media platforms have slight limitations toward their use, such as the 280-character count limit per post on Twitter,20 500 “total action limit” per day on Instagram,21 and unwanted video advertisements on YouTube.22
Nevertheless, all social media platforms have their respective pros and cons, KiKo included. Facebook is (and has been) the biggest social media platform worldwide, with more than 2 billion users currently, and its reach allows users to create specific groups and pages for others to follow and interact with at ease.23 Although Facebook pages may require teams of editors, administrators, and/or moderators in place to frequently interact with others,23,24 the scope of reach alone is a major advantage Facebook has versus KiKo and other platforms. Even though Twitter, with more than 330 million monthly users, may leave many feeling restricted because of its per-post character limit, Twitter's user-friendly platform allows for “concise, informative and engaging” readily accessible tweets, especially on mobile devices, from which KiKo can learn as it improves its own interface, which is currently less intuitive.23
Like KiKo, Instagram excels in allowing users to upload and share high-quality photos and short videos, and although KiKo may surpass Instagram in that users can write longer captions and attach multiple references with each post, Instagram still has more than 1 billion monthly users and does not have a limit on how much material can be uploaded.23 In other words, after 5 GB of digital slides, images, videos, etc, are stored on a user's account at any time, KiKo asks its users to upgrade their storage space for US $10 per 100 GB per month; this is a potential drawback, especially for pathologists, trainees, students, and other physicians who have a great deal of material they would like to share.1
KiKo is not the only social media platform to allow for CV-style personal pages and to allow for easy access to users' publications, too. Doximity (Doximity Inc) is currently “the largest community of healthcare professionals in the country,” with more than 1.8 million medical professionals (>80% doctors) as of March 2021.25,26 This platform verifies users are practicing physicians or other health providers before allowing them to become a user, allows for convenient electronic faxing, and even allows users to call patients and other providers from a protected dialer, none of which KiKo does.8,25 LinkedIn (LinkedIn Corporation), with currently more than 850 million company-reported members in more than 200 countries and territories worldwide, allows users to share professional accomplishments chronologically,8,27 similarly to both KiKo's and Doximity's CV capabilities. Furthermore, ResearchGate (ResearchGate GmbH), a Europe-based publication-sharing website of more than 20 million company-reported users in more than 190 countries, allows for easy publication uploading and sharing, including both PubMed-indexed and non–PubMed-indexed articles,28 whereas KiKo is limited only to PubMed-indexed articles.
Although KiKo is a relatively new platform with overall less experience, resources, and following than these and other social media “giants,” KiKo's ability to integrate WSI nevertheless sets it apart, especially during a time when the “transition from glass slides to digital workflow in clinical diagnostics is already underway,” according to Graff and Holland.29 As KiKo continues to grow, it will likely be prone to such risks as account hacking, which many social media users believe is a major security issue with Facebook.30 In an April 2021 online NordVPN survey study of 1022 US adults nationwide, 70% of respondents expressed concerns over their social media accounts being hacked, which has increased from recent years.31 Facebook had the greatest percentage of respondents' concerns (32%), followed by TikTok (26%), Instagram (20%), Twitter (19%), and YouTube (18%).31 Of the 37% of respondents who reported having their social media accounts hacked, the most frequent platform reported being hacked—by far—was Facebook (77%), followed by Instagram (35%), Twitter (24%), YouTube (24%), and TikTok (23%).31 For users to remain safe and protected from hacking on KiKo, precautionary measures, such as strong passwords, 2-factor authentication, new device login alerts, and account privacy checklist development, should be strongly considered.31
Other limitations of KiKo will also become apparent as time goes on, especially pertaining to improving platform visibility and user interaction/growth. With approximately 14 000 active users worldwide by August 2022,3 its innovative ability to intersect social media with digital pathology makes KiKo a favorable platform for pathologists, trainees, and students of any field to explore for years to come. Jerad M. Gardner, MD, dermatopathologist and bone/soft tissue pathologist at Geisinger Medical Center in Danville, Pennsylvania, has already exemplified KiKo's potential by making a free, organized “MEGA Index” library of both his dermatopathology32 and bone/soft tissue pathology33 files (with digital slides, recorded videos, and blog posts).
For those unsure of where to begin regarding digital slide and pathology image sharing on KiKo and other social media platforms, a recent blog post by Ho encourages new users to know their missions, know their audiences, tell stories, be consistent, be engaging, and to let their personalities shine.34 Will this unique feature of WSI, alone, attract physicians in other specialties to join KiKo? It is difficult to say; however, other medical fields, such as family medicine, find social media valuable for education, collaboration, and advocacy, which KiKo promotes and allows.35 The additive value of WSI may attract surgeons and other subspecialty physicians especially to this platform, too. According to Oh et al,36 digital pathology provides better accuracy when recording tumor margins in patients undergoing Mohs surgery, for example, which not only reduces the amount of time patients spend in surgery but allows patients to see images of the recorded slides and receive explanations of them even after the surgery. Given this utility of WSI, KiKo may allow for pathologists, surgeons, and other physicians/trainees to create virtual multidisciplinary, tumor board–private groups to discuss cancer diagnostics for education and training purposes, because digital tumor boards have been shown to reduce discussion time, reduce postponement of cases, and provide better therapeutic patient decision-making in real time.37–39
Even though it is difficult to ascertain how many other general and subspeciality physicians currently use KiKo to provide their opinions, ideas, and expertise for medical education, KiKo is not restricted to pathology only, and the reasons explained above support its use within all medical fields. In conclusion, KiKo is an exciting new platform that represents the next generation of digital pathology and social media and should continue to be used by not only by pathologists but also by physicians, trainees, and students across all medical specialties.
Schukow is an ambassador for Knowledge In Knowledge Out but does not receive financial compensation for this position. McKee has no relevant financial interest in the products or companies described in this article.