Episode 81: Digital Cytology: It's Like Having a Pathologist on Your Team

This episode of The Vet Blast Podcast is sponsored by Zoetis. Subscribe to The Vet Blast Podcast on Apple Podcasts, Spotify, or wherever you get your podcasts.

Discussing the workflow and turnaround time for digital cytology, Sarah Barrett, DVM, PhD, DACVP, said, "...[The scan] comes to the cloud to the pathologists [and] we get a notification, and then we'll give you a report within 2 hours. The scanning typically takes between 5 and 15 minutes start to finish, because scanning occurs simultaneously with uploading."

Listen to the full podcast for more and read the full transcript below.

Adam Christman, DVM, MBA: Hello and welcome to The Vet Blast Podcast. I am your host, Dr Adam Christman, Chief Veterinary Officer here at Fetch dvm360®. So I always wanted to know more about digital cytology. And I hear it's like having a pathologist on your team. And we want to thank our friends from the letters for supporting this podcast and joining us today is Dr Sarah Barrett. Welcome, Sarah.

Sarah Barrett, DVM, PhD, DACVP: Thank you. Thanks for having me.

Adam Christman, DVM, MBA: Yeah. So to our listeners a little bit about our friend Sarah. She's a native of southwest Virginia and completed her BS in biology and DVM at Virginia, Maryland College of Veterinary Medicine, we always got to give a shout out to the vet school so that Virginia Tech, '99 And '05, respectively, and she practiced emergency medicine and critical care, followed by a small animal day practice in Houston, and Central Texas before returning back to Virginia Tech for a clinical pathology residency. She was board certified in 2014, and completed a PhD in autoimmune glomerular nephritis in 2015. She spent the next five years as a clinical assistant professor with a joint appointment at Virginia, Maryland College of Veterinary Medicine, and Virginia Tech Carlyon School of Medicine, think I said that right, before joining Zoetis in 2021, when not in the office, she spent time with her family wrangling many animals and working on her lavender farm. Wait, I got to ask you a little bit about the lavender farm. So what made you get into that? That's wonderful.

Sarah Barrett, DVM, PhD, DACVP: Oh, okay, so this might be a long story, we won't have time for this. So we went to...my family went to a wedding on the Olympic Peninsula. And there was this town there called Sequim, Washington. And it is...they completely turned around their socioeconomic status by starting lavender. And so I'm from rural Appalachia and seeing that I wondered if we could do the same thing where I live and really help the local economy. So that's like the long-term goal. Right now I just like have a field of purple, which is really cool.

Adam Christman, DVM, MBA: Oh, that's beautiful. What a great story to me. Well, that's a time for another podcast. Well, let's get into it. We really want to know, to our listeners about digital cytology. And I think the first question that we always try to ask ourselves in this profession is, is the why. So why digital cytology?

Sarah Barrett, DVM, PhD, DACVP: Yeah, and it's a great question, I have to admit, I was a glass snob for many, many years, and was slow to catch on to digital. And now I think it is, it's really exciting. So you know, the first thing is turnaround time. So, you know, as I just said, I'm from a rural place, I grew up on a farm, you know, not a lot of access to specialty hospitals or things like that. So what's really cool about digital, for me is that it's kind of an equalizer between rural, international hospitals and what people would have in a big city. So there's that. And we're talking like a two hour turnaround time, there's just it's kind of like having back in vet school, when you had a pathologist down the hall, you could watch the results and talk to that's really what we're trying to give is that same experience. And I think that it's really, honestly the future of the field. That's, that's where everybody's going. And we just, we're excited to kind of be on the cutting edge of that.

Adam Christman, DVM, MBA: It really is a cutting edge. I can't think of a better time honestly, when we're in this pandemic right now to with the technology, you know, the pet parents want answers really quick to make these decisions. So I can't think of a better way to have it. So I do know that there are like other companies out there that have the digital cytology. And we want to know to what makes a wellness, like a good solution for that.

Sarah Barrett, DVM, PhD, DACVP: Yeah, yeah. So and I'll just say right here at the outset that, that those other companies have outstanding world class pathologists, that's all around. But there are some things that makes us unique. I think the first is that our scanner is multi-platform. So it's not just digital cytology, but it's also the thing that came first was this AI fecal analyzer. And so it's really cool. It works really well. And you can, man when I was in practice, I would have loved something like this. Yeah, instead of having your technician have to look at the fecal side and ask you, you know what this egg is that will do it all via AI. So that same scanner that will do that fecal count, egg identification, will also you can do your cytology slides on it, and then it gets uploaded to a cloud of pathologists. So you have access to that. And not only that, but there are more things in the pipeline. So this is just the beginning. We're going a lot of cool places with this.

Adam Christman, DVM, MBA: Yeah. And you know, it's like that accessibility that you have the pathologists...client accessibility.

Sarah Barrett, DVM, PhD, DACVP: Yeah, yeah, actually, um, our pathologists, we love talking to clinicians, and we specifically look for pathologists to want to do that we select for that. Many of us practice before we went into residency, so we loved that part. And we were very involved with helping clinicians troubleshoot the issues and preparation problems, because those are the sorts of things that you end up having to get resubmits for. And it can be really frustrating as a clinician.

Adam Christman, DVM, MBA: If I had to resubmit a sample, like we asked for the sample, maybe I didn't get enough cells, or there was a concern that you as a pathologist would have, do you have to do charge my hospital like another charge for that, like, how does that work?

Sarah Barrett, DVM, PhD, DACVP: We don't actually and that is something that's different about Zoetis versus some of the other folks out there. We don't so if you have a problem, because again, this is it's so common, it's it happens all the time. And it's a barrier to using cytology. So we want to decrease that barrier, you know, help you troubleshoot it and get a better sample so that you actually get your money's worth. And for the patient, it's all about the patient.

Adam Christman, DVM, MBA: It is about the patient. But you know, it's also about to his space. Space is a commodity in vet med. And I'll tell you this, I know that this scanner size, what I do love about the scanner, it's small and mean to the listeners, I'm sure you can relate to that. Because like space is a commodity in vet med. So tell us the importance of having that size in a bet practice.

Sarah Barrett, DVM, PhD, DACVP: Yeah, 100%. So the scanner, it is revolutionary. I've never seen a scanner like this. It's eight inches by eight inches and eight pounds. So it'll fit in your hand. And it's it's just it's really slick. It looks like it's you know, space age tech is really cool. I keep saying it's cool, but it is. I work in clinics, those labs, the little mini labs, they're small, you need your counter space. And this does not take up a lot of it's very small footprint.

Adam Christman, DVM, MBA: Yeah. And they talk to me about the stains too, because I think this is a big question that we get a lot with when you talk about digital psychology. You know, what is it about the stains? Do clinical pathologists want unstained slides versus the same slide. Like how does that work?

Sarah Barrett, DVM, PhD, DACVP: Yeah, we get that question all the time, because there's confusion. So obviously, I am a prima donna about stains. Because I'm a clinical pathologist. I love my Wright-Giemsa. So it's you know, to be quite frank, that is really the best cytologic stain, but it is a pain in the neck to do, it takes significant time to prepare. And the truth is, these are quick aqueous room announcing stains like diff quick, dip stain, those are actually really decent stains. And so what folks already have in their practice is sufficient. So if you're sending out glass slides to a brick and mortar lab, like if you need to go do some kind of specialty tests, like if you're sending it in as glass, then unstained is best because they'll put it through the right game sustainers but if you're sending it to us virtual, you're sending us an image so you stain it right there in your practice with whatever stain you have on hand. And it does...it does a really good job diff quick, it's accessible. It's cheap, not just quick, all of those that type of thing. And it's quick for clinicians or for technicians to do and it's a decent cytologic stain. It gives us enough information to evaluate cell populations that we would evaluate with right chemo and I'll tell you a secret it's actually better than Wright-Giemsa at a couple things like canine distemper inclusions. So every now and then it's a little bit better.

Adam Christman, DVM, MBA: I got to ask you because you know we all have different types of tips. What kind of dipper Are you? Would you recommend? Like? Is it the 20 dips? Do you say the letter of the alphabet like what really matters to our listeners, like if you can give us a good hack?

Sarah Barrett, DVM, PhD, DACVP: That is hilarious. Okay, so the thing that matters the most and nobody likes hearing this is that you are using the protocol for the stain that you have. So nobody looks at what the protocol is and I never looked at that when I was about...I didn't pull out the diff quick and look at it but in general, okay, so a couple things. It's really important to dip. You know, there are people who will just stick it in, you can just dunk it in and leave it but sometimes there's a little bit of film from the previous stain and it won't get it won't hit it. Some people like to take a syringe or something and flood this slide and just let it sit. Don't do that because it does uneven staining. So the main things that matter the most that you put it in that fix it of that first solution. That's the most important step. So once you fix it, you can fix the other...you can...if you mess up the rest of the stain you can go back and redo it. But the fix it is the most important part so you want to stick it in there like at least, you know, you can leave that in there overnight but let's say a minute. And then for the second two so the easiest is that pink one. And then the purple one is that new methylene so what you want to do, or methylene blue, sorry. What the main thing is that those next two stains that you're putting them in for the same amount of time. So if you're putting it in for 15 seconds into the pink, you want to put it in for 15 seconds into the purple. So that's those are really the main keys and you can peek at it to see if it's too purple or if it's too pink, and you can go back and dip it right into the one that needs a little bit more of.

Adam Christman, DVM, MBA: That's good to know that you can actually re dip it back into those two stains, because, you know, sometimes we're all guilty of doing it, you're on a call or you're in another exam. You forget about it, like, oh, no, do I got to redo the whole thing? So that's helpful. So thank you for that. I guess I want to know more about like workflow too. So, you know, to the listeners, walk me through a little bit of how we get from the cells and a pet to digital diagnosis. Yeah, absolutely.

Sarah Barrett, DVM, PhD, DACVP: So here's the workflow, you would see you have a golden retriever, who comes in with a, an enlarged lymph...a Boxer with a skin mass. We all know what that is going to be for boxers.

Adam Christman, DVM, MBA: Wow.

Sarah Barrett, DVM, PhD, DACVP: I know, I know. So you would make your cytologic preparation. So that might be maybe maybe if it's a lymph node, you might do a woodpecker, nonaspirin techniques, so you don't rupture all the lymphocytes. Or if it's a skin mass, maybe you'll do an aspirin, you put it on your slide as normal, or you make a blood smear, and then you stain it with your stain. You let it dry, you place a couple drops of immersion oil on it, and then you put a coverslip on top. So from there, you just go ahead and scan it. We have an initial AI step that will scan and look for and it looks for our blob detector. So it's looking to see where it thinks you should scan on the slide, that's gonna save you some time. And I'll explain why just it takes longer to upload the, the larger the scan area is. So what you would then do, you can adjust that scanning area, if you want to kind of cut down on time, I don't recommend you do that. Because sometimes, so we'll see. So after that, you would go ahead and scan it, it comes to the cloud to the pathologists we get a notification, and then we'll give you a report within two hours. The scanning typically takes between five and 15 minutes start to finish, because scanning occurs simultaneously with uploading.

Adam Christman, DVM, MBA: So okay, so I guess you do need internet speed, too?

Sarah Barrett, DVM, PhD, DACVP: Yeah, good question. So we recommend a minimum of 10 megabits per second for internet speed requirements, which isn't too bad. But you know, we're still getting up to that point with some practices in our country.

Adam Christman, DVM, MBA: So let me understand this a little more. This is pretty impressive. So turn around is always two hours, 365 days a year, 24 hours a day. That's impressive.

Sarah Barrett, DVM, PhD, DACVP: Thank you. So every diagnostic lab will have a target turnaround time. And usually, we try to meet it at about 90% Depending on the lab that'll vary. And right now we're greater than 99% of our cases we're meeting or exceeding that. So yeah, and you know, we do that by scattering people around all over the place so that we have continuity. And so far, it's working pretty well.

Adam Christman, DVM, MBA: Well, you gotta tell me who are the superheroes? I mean, pathologists. Where are they located? Are there throughout the US?

Sarah Barrett, DVM, PhD, DACVP: Yeah. So yeah, we have a US-based team, that's, well, our whole team is growing constantly. Our US-based team is scattered around the country. So in all the time zones, except Hawaii, I'm trying to get them to move to Hawaii for me, so that I have that extra coverage. And then we do have a newly onboard fall and just Italy. So that's the early morning hours for me. So he starts about 2 am my time. And then we have a wide range of contract pathologists scattered about the globe. So our Australian team is fantastic. And then some in New Zealand as well. They're awesome and some contractors in the US too. So that allows us to provide that 24/7 coverage. while also learning our pathologists maintain a good work life balance on all of our cases are read by board-certified pathologists, and we also get back to our profession by offering residency externships for students, those trainees are also under the supervision of a board psychologist.

Adam Christman, DVM, MBA: Wow, that's teamwork. Right there and communication. That's fantastic. That really is. So well, I want to know I'm sure the listeners want to what so tell me like, What are some of the most common types of samples that you see that's going to be so cool, what are some of the things that you see?

Sarah Barrett, DVM, PhD, DACVP: That's impressive. That really is. So wait. So if I have a snake that has some sort of a mast-like slash abscess and potentially I want to send it out, do you have any exotic specialist there that could read that? Yeah, routine things that we get certainly blood smears and those should be done with every CBC? I know when I was a vet I didn't do that. But when I was practicing the other common things lymph node aspirants skin lumps, bumps, we've seen a lot of visceral organs, so liver, spleen, kidneys, bladder masses, repro tract things, any of the internal lymph nodes, lungs, muscular skeletal things, both masses, joint fluid. We're seeing a lot of breeding soundness exams right now for the equine world, effusions, retrobulbar masses. We had a meningioma pretty recently, so anything you can put on a slide can be submitted on our scanner. We get this question all the time. So it turns out that clinical pathologists have to be boarded on all the species. So not just the companion animals are, you know, farm animals. So we all have to be proficient with snakes, any avian reptiles, fish, pocket pets, all of those things together with normal things. Now, some of our Australian cases are pretty fun. So we're starting to learn about crocodiles and alacrity and automation.

Adam Christman, DVM, MBA: Impressive

Sarah Barrett, DVM, PhD, DACVP: Yeah, the main thing is, we have this...our team is really close. We love consulting with each other. So it turns out that if you know, what you know about a snake is going to depend a lot about who trained you and where you did your residency. But we have this robust network of pathologists who love to talk to each other, love to learn and love to learn from each other and teach each other, and we all we put in the extra work to get other opinions if we're not sure about interpretation. So this is occurring in real time. So while we're looking at the case, if we have a hard case, you may end up getting a consensus opinion from multiple pathologists with without ever even needing to request a second opinion.

Adam Christman, DVM, MBA: It's like a referral within a referral, you know. Really impressive. So it's so cool. So shout out to the biologists out there, because your team gets to see you all, you know, you see some different animals of all different species, different pathologies that's happening and disease process states. So I got to ask you, I'm sure you get asked this question all the time. But what's one of the most like interesting cases you've seen recently?

Sarah Barrett, DVM, PhD, DACVP: Oh, okay. So one of the most unusual cases, it was kind of new to most of us was an African lungfish. So these are these really cool animals who can be in water or on land, and it had a lesion on his chin. I didn't know that, like fish had chins, but that's what it had, a lesion on his chin. You know, so it turns out, it was fibrosis and inflammation. And, you know, we're all like, looking up all the papers on African lungfish, to see what this could possibly be in, there are not any papers on African lungfish. These are the kinds of cases that my group just like, loves, because we're all you know, digging and trying to find an answer and learning together. But you know, but one of the cool things about that is that these processes are so similar across species. So fibrosis looks like fibrosis, and inflammation looks like inflammation. Well, digging a little deeper with the clinician, it turns out that the owners had been touch-training it. So, you know, like you would do with like a seal. And so it was coming out of it's a little pond, and it was touching this target. And so we think that it was actually causing them. I don't think African lungfish, that their their tissues are really equipped to do that. So that was a really cool case.

Adam Christman, DVM, MBA: Oh, cool. Oh, my gosh, I had no idea. Wow. But you know what, this is what I love about this profession. So we just talked about, like, how collaboration you're working together, collaborating. And you know, just the one thing that I mean, there's so many things I love about veterinary medicine. But this is an exciting time right now for us to be a veterinarian, because the technology that we have, and the ability to lean on each other, and our colleagues really do make the difference. Don't you agree?

Sarah Barrett, DVM, PhD, DACVP: Oh, yeah. And that's, that's one of the core beliefs of Zoetis. As a matter of fact, it really makes a difference. But just in general, and you know, what that means is, when we help each other, we all succeed.

Adam Christman, DVM, MBA: Right? And at the end of the day, at the end of the day, whether it be the end of the microscope, or the other end of that leash is the animal, you know, and that's what we're all in this for. You know, I really want to thank you for all you and your colleagues for what you're doing to advance in the profession and looking at all the weird gross stuff that we're sending you.

Sarah Barrett, DVM, PhD, DACVP: No, thank you. We love doing it. I think we're all really glad to be able to have this little niche inside of it new medicine because we like Yeah, we love all the gross stuff. Send it to us.

Adam Christman, DVM, MBA: Love it, too. Well, thank you so much, Dr Sarah Barrett for being on with us. This has been so fun. Like, I've learned so much already.

Sarah Barrett, DVM, PhD, DACVP: Gosh, it's so much for having this was really fun.

Adam Christman, DVM, MBA: Oh, thank you and thank you to our friends at Zoetis. Thank you for all you do Zoetis, too, and for sponsoring this podcast. To learn more obviously head on over to Zoetis' website, too. And, you know, again, this is just so wonderful that we're learning all the newest, latest, and greatest in veterinary medicine. It's just as one great example of why it's just so pawesome to be a veterinarian. So thank you so much. Thank you to our listeners for tuning in. Please stay safe out there and we'll see you next week. Take care everybody. Bye everybody.