One Dermatopathologist's Case for Going Digital

What does it look like to be one of digital pathology's biggest advocates without actually being digital yet? In this episode of PathPulse, host Bianca Collings sits down with Dr. David Terrano, a dermatopathologist and Medical Director at Bethesda DermPath, for a candid conversation about the gap between believing in digital pathology and actually making the leap. 

From his training at Columbia, Memorial Sloan Kettering, and Mount Sinai, to running high-volume private practice labs in Arizona and the DC area, David brings a uniquely operational lens to the question of adoption. 

He talks about what an ideal digital workflow would actually look like, why ROI and IT friction keep getting in the way, and why sometimes the best thing you can do is just get the box in the lab and start. If you've ever wondered what's really holding experienced pathologists back, or what it would take to finally push them over the edge, this is the episode for you. Listen now!

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Sponsored by the Digital Diagnostic Summit and Lumea.

Submit questions for our future recordings here: https://lumeadigital.com/ask-a-pathologist-podcast/

Sponsored by the Digital Diagnostic Summit and Lumea.

Transcript

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Bianca Collings: Welcome to PathPulse. This is the digital diagnostic podcast. It's the podcast that showcases pioneers, innovators, and forward-thinking individuals within the digital pathology arena who are making a difference in day-to-day care. I am Bianca Collings, and today we are joined by Dr. David Terrano, a specialist in advanced dermatopathology.

He's someone who represents a very fascinating perspective in digital pathology. As one who has not fully adopted, but is one of its most enthusiastic advocates. David, would you mind introducing yourself to our listeners and walking us through the path and where you are today?

David Terrano: Sure, thanks. Thanks for having me on. I appreciate it. I am a pathology trained dermatopathologist. Just to go back briefly, did MD and PhD training in Little Rock, Arkansas. Went on to do path residency at Columbia and a couple fellowships in pathology. One in general oncologic pathology at Memorial, Sloan Kettering, and then dermatopathology at Mount Sinai.

So from there, I got my first job. And that was a fun story because my wife, who's also a dermatopathologist, finished her fellowship a year ahead of me. Because she was smart, she only did one fellowship. I did two. And so she was out in Scottsdale.

I ended up, during a visit, sort of serendipitously met Dr. Rich Berner, who had owned and started and sold an amazing lab called Arizona Dermatopathology at that time and just kind of hit it off. And, as every fellowship person does, eventually they start asking people for jobs. So I emailed him after a meeting and said, "Hey, I'm sure he saw, I think he's a very forward thinker so he kind of saw the same connection like, because he's trying to phase out in his career at that time and do something different and he's gone and done amazing things.

So, you know, reached out to him and eventually, through a couple meetings and interviews, landed a job out there, with the plans to be Medical Director, maybe after a year, he was ready to scale back and he kind of said after six or nine months, he's like, "I think you're ready. I'm gonna scale back, you're gonna be director now."

And that was a little abrupt, but he had such a good system in place. You weren't really doing much, but you wanted to be involved and learn it. And we were the largest market share lab in that county, Maricopa, at that time. I'm sure they still are, but he taught me a ton about how to run a lab, how you set it up.

And as we get into more discussions about DermPath, we could talk about the role your first real-world mentor plays in becoming what you really become more than your other training. That's all good for knowledge and it's necessary, but that's the person who shows you how it's done and gives you the confidence.

Bianca Collings: So, very operational. It sounds like he came in and showed you, "Okay, now you've had your medical training. I am going to mentor you into how we have operationalized this."

David Terrano: Yes. And he mentored me in how to be a diagnostician, too. You got all this knowledge. Here's the reality in real life. Here's how we do it. Here's how to have confidence in being a diagnostician.

Bianca Collings: So the practical side of it.

David Terrano: Yes. For example, if you know what it is, just say it. Limit the words. Just put that diagnosis down and go on.

And then, during that time, we wanted to move back out east, my family and I. The job at Bethesda DermPath opened up, interviewed, and during Covid, I think I interviewed in January, right before, you know, everyone was outside in January, it's actually warm here, and then Covid hit, still had the job in place, and came out here and just got going, and that was obviously a weird time for everybody, and segues into digital pathology, how that was really the catalyst that, you know, made Memorial Sloan Kettering really validate their digital pathology and everyone else just say, yep, it was the trigger and you never know.

And we can get into my dermpath or digital journey at some point, which, but yeah, that's how I landed here. Became the Medical Director here within probably about six months, you know, kind of the same situation. A lot of these folks will start a lab and then they kind of want to sunset out or do less and then they find someone newer and fresher.

And it was good to come into here and bring that operational knowledge, but also knowing you can't just come in and completely change the way they do things. Something he taught me also, Dr. Berner, was at the beginning, you want to be really conscious of what you're doing, keep a notebook or something, because at the beginning, you're fresh, you see things you want to change.

And so you're kind of a note taker for a month, not a sledgehammer right away. You don't want to bulldoze the way they were doing things. And then, after that, you get so busy, you probably never think about what to change again. So try to keep some of that in mind.

Bianca Collings: I love that. We talk about that, just in general, in business, when you are in a new venture or a new position, we have this tendency to take all of the knowledge and jump in and want to start knocking down walls before understanding, maybe there's pipes. Ooh, maybe that's a load bearing wall. So, you know, I like that: a month of note taking.

I do often tell new hires to take six months, breathe, learn, and ask questions. There usually is a reason why. So that, yeah, that's fascinating. So you took that same philosophy into your new role. I love, though, that both times you went from almost zero to the top in 60 seconds, no, in six months. You're incredible to be able to do that and want to manage it and be hungry.

David Terrano: Yeah, I think it's that. I even told the RPP, I was like, "Okay, I'm ready to go. I even used that word: I'm hungry. So while I still have the energy…" I only had one kid at the time. "You better ask me now or else I'm gonna…"

Bianca Collings: Okay, tell me now before I'm sleep deprived.

David Terrano: Exactly. So yeah, and I learned a lot coming into a new place. What I tend to do is micromanage a little bit too much at first, and then you start getting the signal that you're doing that, and then you realize: the people are there. You can trust each other.

And when you first come in, they either really love you, because you're new, or they're really skeptical, and then it fluctuates back the other way. And eventually, through time, you just sink in, have a good relationship. You kind of see some of the people who just don't need to be there anymore, and eventually they kind of sunset out.

The Art of the Diagnosis: Confidence, Humility, and the Gray Zones

Bianca Collings: They will weave themselves out. Yeah. Well, what you said was interesting, though, micromanage, I think is just, it's another, like, trust is the antidote for micromanagement, and you did say that. And I know from just the work we've done with derm paths that even the most experienced pathologists can be humbled and humility is a huge factor here.

Just curious to, I mean, talk to me about that aspect of the diagnosis and humility and getting it right in the specialty, and what's at stake, and why humility is so important.

David Terrano: Yeah, that's a great question. I mean, the majority of derm paths, assuming you get the right specimen and you could see everything you need is very diagnostic. A lot of it's pretty straightforward. There are details that matter, even within an obvious diagnosis, like a basal cell carcinoma.

But, another mentor I had said "Even a seborrheic keratosis, which everybody knows is benign, nothing happens, even that can," he would say, "bring you to your knees."

You know, and I remember my first case I signed out was an easy, benign case. And the director there, he took a picture of me hitting "sign," you know, because it's, until you cross that threshold and your name's on it, you have a lot of knowledge and you are, you're kind of shaken a little bit when you're signing that first one. So you have to continually build systems and pattern recognition to make sure you're diagnostic.

You want to be very confident, you know? But the humility part is any case, any day, any type of specimen can just, it could surprise you. And in derm path, one reason I like it is the very high throughput. It's efficient. It keeps you interested. And you don't have to take a lot of it home. You kind of make your decisions and think about them the next day if you have to.

But with that said, you could easily go too fast, and a lot of the mistakes are, from all of us, I'm not saying anyone in particular, are when you make things too complicated, you overlook something. There's just a wide variety of diagnoses. Everybody knows the basics, but it's just like everything in life, it's the gray zones. Those are the hard ones that you have to be really conscious of.

For me, personally, rare diseases are always attractive. That's what draws you to certain specialties. But I learned, in my job in Arizona, to get good at the bread and butter, that's a unique skill. You get really good at those and be diagnostic and definitive and confident, because then you have to spend time on the hard ones. And that's sort of the philosophy he taught me there. And fellowship, you're just trying to drink from the fire hose and you're just trying to learn.

Entering the Digital World: AI, Efficiency, and the Frictionless Workflow

Bianca Collings: So I want to talk about this, the very high throughput and your operational background. I love that you are continually mentioning these mentors. So with all of this knowledge, you had this desire to use tech in your workflow, in your practice. Tell me about how that came about and what made you want to investigate adopting tech.

David Terrano: Sure. Well, I think in terms of tech, you know, pathology right now is obviously digital, right? I wasn't much of a, I guess you'd have to call it a non-believer. Because glass, you just get comfortable with it. It's kinetic and you think it's faster.

Fast forward to seeing a lot of folks using it now. One person who I send consults to a lot, he's got decades of experience. And he says, "It's even better now, it's faster." And a lot of the non-believers who are very experienced, probably because there's less slide fiddling, paper fiddling, tray handling, they sit, just use their expertise, their eyes and their brains, and just look at cases and move forward and are just very focused on the work.

There's a lot of things we do with papers and trays and clicking and all these things, before you even write a diagnosis. So even now, with not being digital, I use generative AI like everyone else does; to check grammar. If that was more integrated into my software, it'd be way better.

If I have a really tough case, I use OpenEvidence. Only doctors can use it because you have to have an MPI number, but you can kind of tell it what you're seeing and it can give you differential ideas. "My colleague said this and I think it's wrong," you know, it'll help you reason it out. It's gotten better at reasoning. We've all gone through Gemini or ChatGPT, and you start going down a rabbit hole of discussions and you're, like, having a conversation.

Bianca Collings: It's true. And the flavor of the day, right? And Claude is our new flavor, you know, it changes, it is, it's getting better. And you said "the non-believers," and I've heard from the mouth of many derm paths that say, "Don't tell me this is going to make me faster."

And you know what? I've watched, and that isn't always the promise of digital pathology—that we're going to make you faster. We may make you more efficient. We may make your lifestyle a little bit better. We're going to make consults easier. We may make billing issues easier. I mean, just, all of that that's available and at our fingertips, trying to bring it to just amplify your work.

But I did learn very quickly, do not tell a pathologist you are going to make them faster. But it's true. I mean, you've got the patterns of everything. Like you said, it's all patterns, and you have a way. And the software is catching up with your, when I say your workflow, you talk about all the clicks. They don't want, you don't want multiple clicks.

David Terrano: You don't want clicks at all.

Bianca Collings: You want to see all your slides arranged in a certain way. You don't want to be on multiple screens when you're dealing with one. And so, it's catching up to, I would say, your wildest dreams. I'm hoping.

David Terrano: I believe it. And I think, well, like you said, it's about efficiency. So less moving this way and that way and looking at different things and writing down a code.

Bianca Collings: Right, even a head turn. Like they don't, you don't want it.

David Terrano: Yeah, exactly. After a hundred cases, that kind of adds up. And I think the big thing it might be is you're reducing the friction and all the brain drain of doing all these little tasks. That's an added value as well.

But I think the other value to add, and I would love to visit a lab who's maybe doing all these things, is voice commanding of every step you do, scanning in cases or bottles and requisitions, very, like, hands-free operations, like extracting insurance information from a requisition.

To me, that's where digital anything will add the most value in terms of efficiency, reducing the number of people you need to go grab cases and pull material and send to someone else. So it might not be a huge ROI, but there will be an ROI there.

The Dream Workflow: From Bottle to Cockpit

Bianca Collings: Well, absolutely. So tell me, so you just described different pieces of your workflow. Tell me, if you would, what that ideal workflow looks like. An ideal digital perfect workflow. I wonder if it exists.

David Terrano: Yeah. In the lab itself, like in something Lumea does with their, sort of their RFA sensors and bottles, that's ideal—where once the specimen hits a bottle and it's barcoded in the clinic, you, in the lab, can already detect it. You see it in your system.

You know, barring that being perfect, you know, once the specimen's received, it's under camera, there's obviously a person inspecting it and taking out the requisition in the bottle and making sure everything matches and putting it where it needs to be.

But that should trigger, either through a video capture or a quick accession into your system. And then you could just move it to the grossing bench where they, mostly hands-free from any paper, just handling the bottle and the specimen, dictate accurately, you know, even Siri on my phone still doesn't understand a lot of things I say. But, you know, dictate accurately what the specimen is, the measurements, and then off it goes, scanned in.

And then when I come in, you know, I'm just at a desk and looking at a couple screens and going through my cases. I'd prefer, if it was up to me, and I'd have to see how it goes, but I would have a large iPad. I like to, you know, pinch in and zoom around. I think that would be better for me, but who knows? I'd probably do either.

Bianca Collings: Yeah, iPads are interesting because we, I mean, we do have that option. We work with one derm group, and they are so sticky. In fact, I think they would go out kicking and screaming if we took away their iPads. I will say the Microsoft Surface Pro 2, if you wanted a bigger screen, having the ability to manipulate with your hands, where it's familiar, to the standard of tech, just continuing to be able to manipulate that with your hands. Very tactile, like here I am moving my hands. If you're listening this way, yeah, it is very tactile and you wanna keep what's familiar, familiar. So yeah, that is ideal.

David Terrano: And I think a lot of the workforce, for the technical part, we have trouble finding people. It's very hard now.

Bianca Collings: Okay, the recruiting aspect.

David Terrano: Yeah, and I think you probably get a lot of new grads who are probably more digital savvy than most of us who've been, because they've only ever lived in that world, they probably easily, instead of being people who arrange slides and papers, they can just drop a digital slide into someone's folder, and I'm sure that would be very easy for them to run those interfaces and, you know, they can start doing more high-level things and advancing their careers, and it's the technical things that drive any science, medicine, or workforce. It's the things you don't see.

Bianca Collings: Do you think they'll demand that?

David Terrano: I don't know.

Bianca Collings: I haven't seen it be a make or break situation yet, but I wonder in the coming years, and especially as our academic centers are using digital, more than just a digital microscope, because there's a huge difference in a digital workflow and then digital pathology as just your viewer that's literally a digital microscope. And I don't know that I have seen a full digital workflow being taught, but it's there.

And your dream, it is a reality, right? RFID tracking, and it's capturing, you know, the grossing station and the visualization, but even the tech, when you have that digital hub, there is tech, you've got, like your Voicebrook or your Alaya that you just voice dictate and you've got your gross description.

And also, not to devalue the standardization where you're eliminating, I'm not going to say 100% of the human error, but when you're using a ruler to measure, or different modes of description, bringing in that tech standardizes everything. So then when the pathologist receives what you're viewing, there are multiple checkpoints to make sure, "Okay, this is really what has come over. There are that many samples."

So yeah, I think it's just interesting to me that this is so attractive to you and that you started out with that operational mentor, because everything you're talking about, it just screams efficiencies. You just want to be efficient. You want to give the very best care.

David Terrano: Yes, a lot of the times that you make mistakes or correct a report is because it's just some small technical thing. You didn't see all the tissue. You could dream of an algorithm that says you call it "cyst" and every time you get a cyst on the slide, because "cyst" is a common clinical description that often comes back as some really bad malignancy. Because clinically, they can't see anything, it looks like a cyst clinically, but then they shell it out, send it to you. And a lot of times, that could be a very bad malignancy that had some cystic change but wasn't a benign cyst.

So an algorithm that says, "Did you review the whole slide?" like a kind of checklist item, because if you see "cyst" on a requisition, you see so many per day that your mind will have an anchoring bias that it's probably a cyst. So that's what it is.

Bianca Collings: Yeah, confirmation bias. So it's probably a cyst.

David Terrano: Exactly. But if you can activate that every time you diagnose "cyst," and it just scans that slide and looks for it, I mean, that probably would take a lot of computing, but I'm sure there's ways to do that.

And that's how I view digital. Obviously, you're right. You get a scanner in, you just start viewing it, and just start doing it. And that's cool in itself, but that doesn't convince…

Bianca Collings: Yeah, like almost "Phase one, we're gonna digitize," but then you have this. So maybe it starts there, but then it expands both directions to the pre, almost pre-analytical to post and prognosis with add-ons in that hub. You've got your molecular, ancillary molecular test options.

You just mentioned AI, which is the first time we've really talked about AI in this world, which is very much a big part of digital pathology. However, I would say it seems to be the buzz, but adoption isn't where I think we anticipated it would be. I'm just curious, what is your opinion on that?

David Terrano: I think it's… Right now, the main use of AI is what everyone's probably using in their regular life. One of these generative AI apps that makes things better. Like I talked about OpenEvidence, just a little bit of an assistance. You know, like "I don't know the literature right now," or "Here's a tough gray zone case." You can, you know, have a back and forth conversation with it and get some references to help you make sure you're not crazy or which direction to go.

I do think some algorithms that help screen a slide and maybe just help you avoid missing things, check a margin for you, it doesn't have to be 100%.

Bianca Collings: A QC type like, hey, did you see this? Did you see that? Or triaging as they come in.

David Terrano: Or grammar checking within your LIS. Like, it doesn't have to be fancy at all. Extracting insurance information and demo from requisition. You know, we could… It would save us tons of time. And a lot of missed billing. A lot of missed billing issues arise from that. I think the possibilities are endless.

It's probably just technical, you know. And you just have to, there's a lot of smarter people out there than me who are very technical and those types of things who could probably develop just a small piece, and you just keep growing the technology over time.

But the big issue with a lot of the stakeholders is they don't want to invest because you don't see an immediate ROI. It's, what is it, $300-500,000 to get one or two scanners and set up the infrastructure. But for a lab like us, we're at a large scale. You have to think 5-10 years down the road so that you don't start seeing an exodus of pathologists go into labs that are digital, that you don't see a client saying, "Well, you guys don't share dynamic images with me that I could look at myself or show my patients. I'm going to use that lab."

So, you know, you don't want to oversell all these technical advances. But I think just the fact that you go digital, you integrate and start learning how to use the tech, because there's no doubt in 5-10 years, if we're not already there, you know, you're just going to be using it fully and you have to use it to really learn how it works. And we already know how to do things efficiently in a manual way. I mean, you just need to apply it to different tech.

What's Actually Holding Labs Back

Bianca Collings: Right. It's not "When will the train leave the station?"—it's left. It's a matter of "When are we going to jump on?" And your obstacle is not unique, but what is amazing, as we've seen digital pathology catch up to your workflow and the needs.

Scanners are doing the same thing financially. I've seen, know, in the beginning it was, you know, it's this one-time cost and you know, $250-400,000, but now they're getting very creative with financing and it's almost like a service, right? And they have pay-per-slide options.

There's so many different ways. I don't want to say "to skin the cat," but that's really what this is. There's many different ways to do this, but you're also learning to scale your most expensive, FTE. I should say that you are making yourself more efficient and doing more and making yourself more attractive as far as recruiting goes.

I've also seen it can't just be one, it has to be all. There are those that like half will go digital and half long, but now you're incurring the cost of storage on both ends. But there are so many advantages. Now you have the data play and all of that, which makes that data incredibly valuable.

All right, so you're a believer. What is the number one pain point or obstacle to adoption right now?

David Terrano: Yeah, I think especially, I guess if I rewind a little, if I was a starting out lab or very new, I bet they're the ones who are more rapidly adopting because they are so new. They've probably got some startup capital and they realized, "I just do it now, and then I have it in perpetuity."

Whereas the other labs like ours were more established, brick and mortar. It's the ROI. It's a mental change, right? It's a cost. There are reimbursement codes for viewing digital slides, and you know, we've shown that and told the people who make our decisions that, and they know it, but I don't think it's reimbursing at a super high rate, but yeah, the ROI is probably the biggest thing, right? Obviously, like, holding it back.

And there's also another piece of the puzzle, you know, you want to have good IT support. But I don't know how vital it is. I mean, certainly it's important. It's the most important thing because if you can't transmit your report, you can't transmit your product. So you're dead in the water there.

But I feel like when we tried to demo it here and bring it on board, maybe the better approach to get it on board would have been to just say, "Hey, let's get the box in here and just start viewing slides. And we don't have to integrate it with our systems. We don't have to worry about security right now. We'll worry about that as we go."

Because IT, especially at larger organizations like ours, they're always going to be worried about security, because there's always someone hacking them and wanting to, or trying to, and that shuts down everything. They're on the hook for the federal government. You lose data. Even if it was impossible to stop, it's still a risk. All that data can get lost. So those are risks and concerns they have, and they're valid.

But if you think of a long-term horizon, which is how you have to think, that's why, if I was a smaller lab, maybe 10,000 specimens or really tiny, I'd probably digitize from the get-go and just go from there.

Bianca Collings: Sure. Well, you brought up an interesting point. Both of your labs were pre-existing. You came in with a process that had been in place for… I don't know how many years versus. It goes back to the house, right? It's like getting into a house. It's a 50 year old house, and you're like, "I want to remodel this. I'm going to need a new HVAC, a new water softener. I'm going to need new plumbing." I mean, bringing this into the modern age is going to cost a lot of money versus, "I'm just going to build a house from scratch," and it is a different mindset.

David Terrano: But, at the end of the day, you're still doing…all the things I've learned there, and all the things I do here in terms of quality control, diagnostic excellence, those things don't change. Maybe you have binders for your manuals, but now it's all digital. It's all still there. So honestly, I feel like if you just get the box in the lab, all your lab managers and techs, they'll figure it out, and I'm sure these companies give a lot of support when you need it.

The little things will always get in the way. "Does my barcode, is it readable on the slide?" We have a lot of technical things that really scare our lab folks that they really don't want to face. They're valid.

Bianca Collings: Yes, it's change management too, though, right? This goes beyond cost, and that's what you're talking about: the trust. Trust security, trust that the process isn't going to fail. Also, just tech in and of itself. We've interviewed pathologists through different hospital systems. They are digital, but they're still using 90% glass because of the system. He said, "I don't want to watch it render when I know that I can continue." So you really do need that system that will match your speed and that the tech infrastructure is there as well to not slow anyone down.

David Terrano: True. The pathologists I work for, they're smart. They were even doing everything manually. They know how to say, "Okay, if I arrange my slides, I do it in this way and I use these codes, I'll be efficient." So you don't want to bring on something that gets in the way of that. You probably have to validate it, probably in parallel, and then get it going. So I agree.

I remember I learned about digital path in fellowship with Dr. Raj Singh at Mount Sinai. He founded PathPresenter, and he showed me his system, and he did a bunch of things. He's very entrepreneurial. I was like, Raj, you just do this. It looks really good. And it was still slow then. It was more educational then. It worked better for that because it was slow.

But I'm sure it's gotten better. I've done some advisory work with one derm path company, and their solution wasn't amazing, but it was fine. But it does a little annoying things, like it's always upside down when you open it. I always wondered why they couldn't do it right side up, but I feel like those things just take care of themselves.

Bianca Collings: Well, they do, but with a good partner, and meaning you being that partner. And there are companies, and I'm just, I mean, an advocate for Lumea, obviously, where it's more, it's the most interesting software client tech partnership. I didn't see that before in tech. I wasn't as close to our customers. But I see our technical team is very much invested in building for the customer.

So it is this, you know, if the screen is upside down or if, "Three less clicks will make us faster," like they really do listen, so that they're building for you and that, and it won't always be that way, but we're in this period. I mean, I think of it almost like electric cars. You know, the infrastructure wasn't there. The cost wasn't there back in the day when Tesla came out. Now, you know, we've got several different competitors on the market.

And, I mean, it was really hard in the beginning to drive an electric car without charging stations along the highway or, you know, all of that. But they're really building for the user and trying to make this the best experience possible, which is our goal.

So finding a really good tech partner, I think, will also help the trust issues, the change management issues. Like, we really do want to make this the very best experience. Not just for the pathologists, yes, you're very important, but for your lab and everyone involved in that workflow.

David Terrano: For sure, yeah. Yeah, and especially in DermPath, we're in private practice. We're very client friendly. We serve them really well. So we would wanna work with companies who do that for us as well. Because yes, it's a business and you have to survive, but it also just makes the relationship better when you, for DermPath specifically, they're sending us work voluntarily—they're not obligated to. So, you know, you build that trust through service.

Bianca Collings: I agree—it's mutual. And I agree that we're in this together. We're all building this together. And in the end, we really want what is best for that patient. And, you know, if we can get answers faster and be more confident in the diagnostics because of consults or whatever that may be, we are invested in this with the patients. So let's say you would, in the next six months, you figure this out and you're going to adopt some platform two years down the road. What does your practice look like?

The Road Ahead: Ready to Make the Leap

David Terrano: Yeah, I think when we talked about the dream world, you know, that's probably too fast for that—what I proposed. You know, that that would be the ideal, I think, starting from the specimen bottle, having some way of detecting that that specimen hit the bottle and can get it almost accessioned at that time, but truly setting up a very virtual, camera-driven type of workflow in the technical lab and just having images scanned and viewed.

In our type of setting, our LIS is pretty old. So integrating with that would be problematic or require adopting a new LIS. So that's probably what would happen. But I feel just being, to me, ideally, I'd be on an iPad or just at my desk in some cockpit and just looking at slides all day, starting to create little algorithms or workflows that help me quality control.

To me, it's just a "use it and you figure out how to do it" type of thing. And more of my time will be spent communicating with clinicians. I've already got three texts right now about a case. And I feel like, for example, one thing we do, if we have a melanoma, we report it to the clinician as a critical result. I would love it if I could put in a little bit of a script into my LIS. And once I make that diagnosis, I hit "sign," and I could even hit "send message" to alert them, certainly be encrypted or something, just something small so that I don't have to go to my phone and do it. I don't have to make a call. I don't have to hit teams to tell my assistants, "Can you call them, get them on the phone with me?" Just kind of streamline right from the cockpit of the screen.

But at the end of the day, now I'm much less worried about the efficiency part because what I've learned recently is you speed up by slowing down in a way. And I've learned enough after 9, almost 10 years of doing this, that that's the way you become efficient and accurate. You build a little system of how to look at the slide, how to approach the case. So I think all that stuff probably will never change.

So in those two years, I wouldn't see a problem with adopting it, and I do think a lot of my aspirations wouldn't come true in two years, but you could certainly see some of it starting. I mean, and if all of the improvements came in the black technical part of the lab itself only, I'd be happy if I just had a viewer and my old LIS I'd still be happy with that because whatever you get to help, that's the engine of the system, the lab over there. And whatever you could do to help them, it always pays dividends.

That's what I learned in Arizona. And then we get back to what he also taught me there is: the patient no matter what you do, if you're focused on them, for whatever your reasons for doing medicine, if it's very altruistic, which I know a lot of us, we go into medicine for that reason, but also, you take responsibility—we're professionals—you want to do a good job too. So the best way to do that is do what's best for that patient. That's more of a diagnostic discussion, if we want to get into that. I think all that stuff will take care of itself.

The Flexibility Factor: Life Beyond the Microscope

Bianca Collings: Yeah, absolutely. With the right goal in mind, always, I think your game plan, your roadmap, it's only going to get better for you, for the patient, for your lab. And I don't know if we'll have this opportunity, but I'd love to circle back with you in two years. And I'm sure you, I'm telling you, you're going to go digital. I know you will.

David Terrano: Yeah, we hope so. We only hope so. Yeah, even if we just got a scanner in my office, that'd be good too.

Bianca Collings: Yeah, hey, we'll see what we can do. I'm not a scanner company. No, but this has been really fascinating. And you've validated a lot of my theories on why a derm path would want to be digital. And it sounds like you've got an incredible background. I'm sure, I don't know, is it a remote work desire? That's one thing you didn't mention at all.

And I know for some, that is the driver. I know a lot of female derm paths that have young children. And that was the motivating factor and very…like from testimonials of, "You know what, it actually didn't make me a lot faster, but now I can be a mom when I need to be a mom and I can sign out cases at any time of day."

David Terrano: No, I think, you know, that's something the stakeholders, they kind of think like, "Well, is this the only reason you guys want to go digital?" And I'm like, "Look, who wouldn't want to be flexible? Of course. Yeah, I would love that aspect." And I agree. But as a director, you know, I'd have to be in here at least a few times a week, just making sure things are going well. 100% I want the flexibility. Who wouldn't?

And, you know, if it's 3:00, I have to go pick up my son. Traffic here, where I live, is not fun. And I still have work to do. And if I could space out my time instead of trying to rush it all into these short hours, maybe space it out on those harder days. Definitely. I would love to do that.

The vacation coverage, you know, we're a little short-staffed now. And if one of the high-volume people like me goes on a vacation, too much falls on one or two people. Maybe I can't do my regular volume, but I could help with a small set of cases.

Bianca Collings: But it's not going to stop, right? And then that was another scenario, was the woman telling us she wanted to spend the summer with her widow mother. And she couldn't figure out how that was going to happen. And then she remembered, and it actually accelerated them to the finish line. They'd already started adopting digital pathology.

David Terrano: Got it. Yeah. So you need an accelerant. For sure.

Bianca Collings: Yeah, use that accelerator. And I admit, she was one of the ones that had the biggest obstacles. But when she realized, "Oh, I can have this. Okay, let's get it done, at least to the point where I have the viewer."

David Terrano: Yeah, right, all those other things. My aspirations are, you know, I'm a little bit of a dreamer. My aspirations are high, but just get the viewer, get the scanner, you're doing good. So, yeah.

Bianca Collings: Right, right. Well, it's been lovely meeting with you today. Thank you for joining us on PathPulse. I'd love to invite you again to join us in the future. I want a retrospective, after you've adopted. I think it would be very fascinating to say, "Did the dream come true? Was the dream everything you thought it would be?" It won't be, right?

David Terrano: Yeah. And it definitely won't be. Nothing's ever perfect. Right.

Bianca Collings: But what if it's more?

David Terrano: But yeah, it could be more. Yeah, for sure. And I've only heard positive things from people and yeah, I appreciate you having me on. So yeah, it was fun.

Bianca Collings: Yeah, I know. Thank you. And enjoy. And thank you for joining us on PathPulse, and we will see you next time.