Reflectance confocal microscopy, driverless cars, and Uber: The future of dermatopathology
By Warren R. Heymann, MDSept. 12, 2016
In a matter of days, you will be able to use Uber to hail a driverless car to your destination in Pittsburgh. During these trials, initially there will be a human monitor (1). You know where this is going — within a decade you will arrive in style without anyone behind the wheel! (As a matter of fact, the driverless cars being developed by Ford will not have any steering wheel at all!)
Reflectance confocal microscopy (RCM) has advanced over the past two decades to the point where it has its own CPT codes (96931 through 96936). The procedures are status indicator C — meaning that the codes are carrier-priced (individual carriers will determine reimbursement) (2).
Although I find RCM fascinating, I have not embraced it for practical reasons — I have not had adequate training, have trouble conceptualizing the images (especially in black, white, and gray), do not wish to fight for reimbursement, and honestly, do not have the time to use anything but the current gold standard (routine biopsies and histopathology).
After reading Mu et al on the use of digitally stained confocal mosaics (DCSMs) mimicking the colors of routine histologic specimens, the future of routine microscopy looks as bright as the horseless carriage. In their study of 64 Mohs cases generating 133 DCSMs, they found that the average respective sensitivities and specificities for detecting nonmelanoma skin cancer by 3 physicians were 90% and 79% prior to training and 99% and 93% after training. The training session took 5 minutes (3). After looking at the figure of a basal cell carcinoma comparing a DCSM to routine H&E, I’m surprised it took that long — it’s spectacular!
I just put in my order for the iPhone 7 plus. Allegedly, it comes with a fabulous camera. Within a few years, I suspect that an app for the iPhone 12 will allow the camera to perform DCSMs. That image will be interpreted by an Uber-like algorithm rendering a precise diagnosis. The iPhone 15 will convert the flashlight to a laser. There’ s the future — using the iPhone for diagnosis and treatment of skin cancer without a dermatologist. My partner used to say, don’t worry, we can always drive for Uber. Sorry Justin, you’ll need to find another backup career.
1. Kang C. No driver? Bring it on. How Pittsburgh became Uber’s testing ground. New York Times. September 10th, 2016
2. Derm Coding Consult 2015; 19(4): 1-2.
3. Mu EW, et al. Use of digitally stained multimodal confocal mosaic images to screen for nonmelanoma skin cancer. JAMA Dermatol 2016; September 7th [Epub ahead of print]
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