René Buesa shared his thoughts on changes in the field of histology he has observed over his lifetime. Below are some excerpts from our conversation. You can read the first part of our interview here: René J Buesa’s Path into Histology & Tips for Lab Managers
How has histology changed over the time you’ve been involved in the field?
You have to remember that I started in the field in 1952 and that there have been many changes since. I still remember the day we received a Histokinete tissue processor made in the UK and how it eased our manual processing and the quality improvement we achieved.
Also doing frozen sections back then was a process that involved fixing the tissue in boiling formalin and then freezing it with bursts of CO2. The tissue was then cut with a steel knife using a bench manual swinging microtome where obtaining a 10 µm section was very challenging. The invention of the cryostat has been a very important advancement for the quality of the diagnosis, especially when the data will tell the surgeon if more tissue needs to be removed. This is also the whole basis for the Mohs surgery, very popular amongst dermatologists nowadays.
I have witnessed the introduction of better tissue processors, disposable blades, many types of autostainers, microwave technology (as controversial it is), immunohistochemistry, fluorescence and immunofluorescence, in situ hybridization, DNA typing, and detection technologies, all with different impacts on histology work. I summarize these advances in my 2007 article titled: “Histology: a unique area of the medical laboratory”.
What change has been the most positive in your view, and what change are you most worried about?
Based only on their wider impact on quality and the workflow, all automated tasks (tissue processing, staining, and cover slipping) and disposable blades have had the biggest positive impact for me.
I am more worried about the special procedures becoming automated tasks because some managers consider that anybody, qualified or not, will be able to “feed a machine, and start it” which can lead to troubles they will not be able to solve. What we need are instruments that will assure quality with the required speed and allowing human intervention when a problem is arises.
How do you think histology will change in the next 5 years? 15 years?
This is something to define. Histology as such, as the art of preparing quality sections for diagnosis, has only changed in terms of improving workflow since the middle of XIX. The principles (dehydration → infiltration → sectioning → staining) have remained essentially unchanged, with only minor modifications in the steps regarding automation and speed. As such, histology will remain basically unchanged in the time period you ask about.
Now, diagnostic pathology is a completely different issue, or as they say “it is an animal of a different color”. The sky is the limit as to how the diagnosis is made and what methods are used, referring to molecular and DNA methods. None of these changes affect the need for good sections. Pathologists will keep making diagnoses using slides all around the world and in each country only the best hospitals in the most populous cities will be able to use the most sophisticated procedures. This also applies to hospitals in the US with fewer resources, although these labs always have the possibility of using the services of reference labs.
Also, tele-diagnosis, the use of digital imaging for consultations, and all the resources provided by the World Wide Web will be used in the future more and more.
Additionally, whether we like it or not, malpractice suits are the the “Damocles’ Sword” hanging over the pathologists. In many cases, the possibility of litigation is the driver for development and application of newer and more refined technologies to produce a more accurate diagnosis. Unfortunately (and cynically), I think that the motivation is monetary and not that of patient care. Lawyers specialized in medical malpractice become everyday more “knowledgeable” and may ask any pathologist “did you ask for test X, Y, or Z in this case?” or something similar. Until there is wide reaching tort law reform, pathologists will feel the need for more and more tests in the ever increasing defensive testing medical practice, even when a good section can show a pathognomonic microscopic image.
I may be wrong but this is how I see it, and at my age and being retired I can say (and write) what I really think without fearing any consequences or reprisals. When he became 80, the world famous Spanish histopathologist and Nobel laureate Santiago Ramón Cajal wrote a book titled: “The World seen at the 80. Impressions from an Arteriosclerotic.” Also at 80, I can write and say whatever I want regardless of the consequences, although in all reality I have done just that forever, which have gained me scores of friends and foes along the years.
How do you feel about the proposed changes to NAACLS’ Standards that primarily affect HT programs?
Histotechs can sometimes be “disrespected” or considered laboratory personnel of a “lower category” when we are not. This problem is easily solved if ALL members of the medical laboratory are educated enough, are knowledgeable enough, and trained in how to do ALL the tasks in the medical laboratory. This issue is solved in the UK and all members of the British Common Wealth of Nations where histology is just one of the specialties they study, in the same way that in our medical studies an MD has an idea about all the specialties and their importance, but is dedicated to just one. When the level of education is improved and working in the medical laboratory requires at least a Bachelor’s degree this is something easily solved.
Thank you so much for sharing your view of histology over many years, René! Stay tuned this Thursday for the next part of our interview. You can read our previous interview here:
René J Buesa’s Path into Histology & Tips for Lab Managers