Usefulness of WhatsApp for Discussing Difficult Cases in Pathology Practice: A Moroccan Experience
Amal BENNANI1, Mohammed SEKAL2
1Department of Pathology, Mohamed I University, OUJDA, MOROCCO
2Mohamed Benabdellah University, FES, MOROCCO
Keywords: Pathology, Smartphone, Second opinion, WhatsApp, Social media
The primary aim of the study was to evaluate whether the WhatsApp application can be used for obtaining a quick second opinion on
histopathological and cytological diagnosis and also for discussing difficult cases in pathology practice.
Material and Method: A WhatsApp group named “FESPATH” was created with total of 17 pathologists (the authors of this manuscript as group
administrators and 15 general pathologists from 7 different cities in Morocco, working in 12 different institutions as members). The group was
used to discuss difficult routine sign out cases, to obtain a second opinion. Pathology-related academic files, books and links were also shared.
At the end of 20 months, members were asked to complete a feedback questionnaire.
Results: Over a 20-month period, 86 cases were discussed with 515 posted pictures. 78 cases were related to histopathology, and 8 cases to
cytopathology. Twenty-one links regarding educational materials and books were also shared. A total of 14 participants out of 17 were active
participants, and the majority of them found the discussions very useful for overcoming challenging cases.
Conclusion: Sharing microphotographs of histopathological or cytological cases via WhatsApp is a very easy and fast method to obtain a second
opinion in pathology practice and also to discuss difficult cases.
Technological improvements in the smartphone industry
and social networking have changed our life. Social media
has become a part of daily life for most people and is
indispensable for communication between peers across the
. It has also increasingly shaped our professional
life, as in pathology.
Pathology is a medical specialty, that involves the diagnosis
of disease through microscopic examination of surgically
removed organs, or biopsies. Pathologists need to have
valuable knowledge and skills to reach a correct diagnosis.
When diagnostic challenges persist, they have to consult
other colleagues for a second opinion. The slides or blocks
are usually sent to another pathology center for the second
opinion. However, this practice usually leads to diagnostic
delay, which can be critical for malignant tumors 2.
WhatsApp (WhatsApp, Inc., Mountain View, California,
USA) is one of the most popular freeware instant messaging
applications on smartphones. This application allows
sending text messages, documents, images, user location,
audio and video calls using an internet connection.
In addition, configuration of the smartphone camera
with high resolution and zoom has made it possible
for pathologists to take good quality images from any
microscope showing the morphological details of the
case with high accuracy. As most smartphones provide
high-speed 4G or 5G internet access, images can be sent
immediately via WhatsApp. As a result, the pathologist can
obtain a second opinion and discuss difficult cases quickly
The aim of the current study was to determine the
effectiveness of the WhatsApp application in the field of
pathology for obtaining a second opinion and discussing
A WhatsApp group named “FESPATH” was created with a
total of 17 pathologists (the authors of this study as group
administrators and 15 general pathologists from 7 different
Moroccan cities, working in 12 different institutions as
members). All these pathologists had graduated from the
Mohamed Benabdellah University in FES, a city in northern
inland Morocco . The group was used to discuss difficult
cases from sign out routine, and to obtain a second opinion.
It was also used to share helpful links, charts, algorithms,
figures from articles and updated classifications or books.
After a period of 20 months (from July 2016 to February
2018), members of the group were asked to complete a
feedback questionnaire. The discussion time was calculated
from the time of sending the photos and the time of the
first response. The average response time and the average
shared microphotograph was calculated using Excel.
Other statistics such as number of cases discussed, total
number of posts, the number of cases by pathology, and
total number of active participants were also calculated. An
active participant was defined as a member who had more
than two posts during this period. The group continues to
discuss cases and share files to this day.
All cases were related to histopathology or cytopathology,
and most of them were routine sign out cases. A brief
clinical summary, radiological and macroscopic pictures
accompanied by representative microscopic images were
shared. In most cases, the microphotographs were taken
directly from the microscope with a smartphone. Only one
pathologist used a commercially produced adapter (Figure
1). At least one scanner view (x50), and 1 low power (x100)
and 2 or more high power magnification (x400) images
were shared (Figure 2A-D)
Click Here to Zoom
|Figure 1: An example of a microscope adapter for smartphone
used in our study.
Click Here to Zoom
|Figure 2: A case of atypical fibroxanthoma shared in the group Fespath. A) With a scanner view (H&E; x50). B) Low power magnification
(H&E; x100). C-D) High power magnifications (H&E; x400).
The main thrust of the group was on sharing images
of difficult cases to create discussion on the differential
diagnosis and diagnostic pitfalls.
Over a 20-month period, 86 cases were discussed with
515 microscopic images shared. 78 cases were related to
histopathology, and 8 cases to cytopathology (Table I
20 links regarding online lectures and educational materials
were also shared. A total of 14 participants out of the 17 were
active participants. The average time required for the first
discussion was 169.4 min ±78 min. The average number of
shared microphotographs was 4 ± 2 microphotographs.
Click Here to Zoom
|Table II: Data of the use of WhatsApp by the group FESPATH
over the study period of 20 months
In 71% of the cases (61 cases) the final diagnosis was
resolved after discussion of the members of our group,
while in 29% (25 cases) the final diagnosis depended on
ancillary techniques (immunohistochemistry, special stain)
or an expert opinion.
The members of this group (excluding the authors of this
paper) responded to the questionnaire (Table III). Most
members liked this experience and found the discussions
very useful for overcoming challenging cases. Regarding
other social media applications, 50% would like to use
them for discussing cases and 30% were not sure about it.
Social media has definitely transformed our personal
life. It has made communication easier, faster and more
efficient than ever. With billions of users, Facebook,
Twitter, WhatsApp and many others are wide-ranging and
powerful social media platforms 1
Recently, many papers have been published about the
usefulness of the WhatsApp platform in medical practice
3-6. Most of them are about medical education,
communication with patients, or discussion of the patients
between doctors of many clinical branches 3. However,
there are only a few studies about pathology and WhatsApp
in the literature.
Petruzzi and De Benedittis concluded in their study that
WhatsApp can be used as a telemedicine program for
improving medical consultation and clinical examination
in oral pathology 6. Zotti et al. reported that WhatsApp
is an effective tool for improving oral health status during
orthodontic multibracket treatment of adolescent patients
Furthermore, Khanna et al. showed that WhatsApp is very
useful for communication and improvement of patientrelated
awareness, and also for orthopedic residents 4.
In pathology, Sarode et al. reported their experience
with WhatsApp in obtaining a second opinion on the
histopathological diagnosis in oral pathology practice 2.
They studied 247 cases of 34 different oral pathologies that
were photomicrographed using a smartphone through
microscopes and then sent for a second opinion to 20
different oral pathologists by WhatsApp. They proved the
effectiveness of the WhatsApp application in obtaining a
fast second opinion for histopathological diagnosis
Moreover, a second experience in pathology was reported
by Goyal et al. 7. A WhatsApp group was created to
discuss interesting cases, and pathology-related academic
issues. 16 cases were shared with 647 posts, in a period of
4 weeks. This group has increased interest in the specialty,
particularly among the 1st year postgraduates, and will
improve the academic performance of students if it is used
for a long period.
In the current study, the main aim was to evaluate a new
tool to discuss difficult routine sign out cases and to obtain
a second opinion which is rapid and in real time. In 71%
(61) of the cases, the final diagnosis has been resolved after
discussion of the members of our group, while in 29%
the slides or microphotographs of the cases were sent for
expert opinion in Morocco or abroad. The time required for a second opinion ranged from 4 to 480 minutes, which
is by far faster than a traditional request for second opinion.
The responses to the questionnaire were very encouraging.
The majority of the participants of our WhatsApp group
found the discussions very useful, but it can sometimes
disturb the daily routine. This can be managed if we choose
the right time for sharing cases like in the early morning
when most of the pathologists are on their way to work, or
around lunchtime and the evenings.
It is admitted that the resolution of images is decreased
by the WhatsApp application. In the present study, most
pathologists did not find any difficulty in the interpretation
of the photomicrographs but in some cases asked to have
more microphotographs with better quality in some areas
of the slide.
Regarding other social media platforms, 50% would like
to use them for discussing interesting or challenging cases
and 30% were not sure about it.
Twitter (Twitter, Inc., San Francisco, California, USA)
and Facebook (Facebook, Inc., Menlo Park, California,
USA) are other social media tools commonly used in
medical practice 8-10. Facebook has made significant
contribution in the field of pathology. Both trainees and
pathologists in regular practice can use public professional
Facebook pages, or pathology-related groups to improve
their knowledge and to discuss difficult cases. Numerous
pathology-related Facebook groups have been created
such as Dermatopathology (http://bit.ly/1L7n5Yg), Bone
and Soft Tissue Pathology (http://bit.ly/1EHYJQG),
McKee Derm (http://bit.ly/2kfkKXT), Surgical (Anatomic)
Pathologists (http://bit.ly/2xajmqC), and many others 11,12
Furthermore, Twitter can be used by pathologists to 1:
• Share images of challenging pathology cases.
• Share algorithms and links to scientific papers.
• Announce pathology courses or meetings.
• “Live-tweet” from conferences or meeting.
• Create short surveys using the native Twitter survey
WhatsApp is a good tool for discussing cases in
histopathology and cytology as it allows quick answers
and instantaneous discussion compared to other social
media tools. It also provides more protection for patient
information or data since WhatsApp groups are restricted
to a number of pathologists and can be protected with a password. Consequently, there is no ethical violation. As
well as using text messages to provide answers for shared
cases, pathologists can also use voice messages to give their
opinion. On the other hand, WhatsApp does not allow
creating surveys or provide statistics of shared cases or
other items like Twitter.
Sharing images on social media has been a cause of worry
for doctors as it raises some possible ethical issues about
patient privacy. However, most pathology images do
not reveal patient identity. There are few basic rules that
pathologists need to follow:
• It is judicious not to give the exact age of the patient and
if possible to round it off to the nearest multiple of 5.
• Do not mention the geographic subdivision of the
• Do not mention laterality wherever possible.
• Do not post full facial images. If they are necessary, you
have to provide consent from the patient.
But in all cases, sharing pathology images for discussing or
educational purposes on social media is legal and ethically
acceptable even without patient consent 13
Even though all social media applications are used to get a
second opinion in pathology, it is important to emphasize
that the ultimate responsibility belongs to the pathologist
who signed out the pathology report.
In conclusion, the present study showed that WhatsApp
is a good tool for discussing or obtaining a quick and
instantaneous second opinion in challenging cases. Its daily
and consistent use will tremendously enrich and grow our
careers as pathologists;
We would like to thank all pathologists of FESPATH group
whatsup for allowing us to publish this study. We also
thank Khanoussi Wafa and Marwa Atmane for the English
editing of this paper.
CONFLICT of INTEREST
The authors declare no conflict of interest.
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