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The Association of Clinical Pathologists

Autumn 2012

ACP news

Engaging with politicians From the sublime to the amphibious ACP National Scientific Meeting An apple a day...


Association of Clinical Pathologists Officers

Calendar of Forthcoming Meetings DIARY DATES FOR 2012/13

President Dr M J Galloway President-elect Professor T Reynolds Vice-Presidents Dr S Smellie Dr E Benbow Chairman of Council Dr W J Fuggle Secretary Dr M Wood Treasurer Dr A Oriolowo ACP news Editor Dr Julian Burton Assistant Editors Dr E Carling Dr S Enn Low Dr A Pugh Dr A Freeman Postgraduate Education Secretary Dr M K Heatley

Date 2012 & Organisation

Title

Venue

Contact Details

Wednesday 5 to Friday 7 September

26th ACP Management Course

Hardwick Hall Hotel, Sedgefield

01273 775700 admin@pathologists.org.uk www.pathologists.org.uk

Thursday 14 February 2013

Hot Topics/Current Issues Management Day

Institute of Physics 01273 775700 76 Portland Place info@pathologists.org.uk London www.pathologists.org.uk

Thursday 6th & Friday 7th June 2013

ACP Annual Scientific Meeting

RIBA 66 Portland Place London

01273 775700 info@pathologists.org.uk www.pathologists.org.uk

The ACP accepts no liability for errors or omissions in this calendar of meetings. Readers are reminded that advertised meetings may be cancelled. Those intending to attend are obliged to check the details on booking with the organiser in every instance. There will be a £25 administration fee per issue for entries in this table.

Management Course Organisers Dr G Spickett Dr H Bourne Secretariat The Association of Clinical Pathologists 189 Dyke Road Hove, East Sussex, BN3 1TL Tel: 01273 775700 Fax: 01273 773303 email: info@pathologists.org.uk http://www.pathologists.org.uk Administrator Mrs R Eustace

Dr Ed Carling is Assistant Editor of ACP news and Consultant Histopathologist at James Cook University Hospital

Dr Su Enn Low is Assistant Editor of ACP news and Consultant Histopathologist at Pennine Acute Trust

(Correspondence should be addressed to: The Editor, Association of Clinical Pathologists, 189 Dyke Road, Hove, East Sussex, BN3 1TL Email: JulianBurton@doctors.org.uk ) © acpnews 2012 all rights reserved. No part of this publication may be reproduced in any way whatsoever without the permission of the Association of Clinical Pathologists. Charity registration number: 209455

Dr Abigail Pugh is Trainees Editor of ACP news and ST4 in Histopathology at Birmingham Children’s Hospital


ACP news Autumn 2012 Contents P4 P5

Invitation to contributors Editorial

LEAD ARTICLES P7 Coroners’ post mortems and the National Hospital Service – Dr Sidney C Dyke P10 Political engagement: how far can we go? – Dr Eric Watts ARTICLES P15 A Zambian interlude: leadership, management and kalamari – Dr Simon Knowles P20 The edible fauna of Cambodia, and other things: from the sublime to the amphibious – Dr Ian Chandler P24 A history of leprosy – Mr Michael Phipps BURSARY AND AWARD REPORTS P28 ACP Career Development Award: Rhode Island Hospital, USA – Dr Anna Piskorski P30 ACP Incentive Prize for Junior Doctors 2012: Are we learning enough pathology in medical school to prepare us for our postgraduate training and membership exams? – Dr Emma Marsdin P32 ACP Incentive Prize for Junior Doctors 2012: Bowel Cancer Screening Programme: an audit of histology reporting at University Hospital of North Staffordshire – Dr Alyn German MEETINGS REPORTS P34 Hot topics/current issues management day: the Liaison and Branch Officers’ meeting, February 2010 (a trainee’s perspective) – Dr Zena Slim P37 The ACP National Scientific Meeting, The Royal Institute of British Architects, London 28-29 June 2012 – Drs Abbie Pugh, Eamonn Trainor, Bill Simpson and Eric Watts P42 31st Annual meeting of the British Association of Ophthalmic Pathologists – Dr Caroline Graham P45 Trainee fringe session at the 58th Scientific and Standardisation Committee (SSC) meeting of the International Society on Thrombosis and Haemostasis (ISTH) Liverpool, 26 June 2012 – Dr Gill Lowe P47 Problems in tumour pathology – Dr Su Enn Low

p10 Taking a stand

p21 One of these is about to meet its maker

TRAINEES’ ZONE P48 Leisure time in Oxford with the BDIAP – Dr Monika Beauchamp P50 Meet the Trainee Members Group BOOK REVIEW P51 Another book review by and for readers THE COLUMNISTS P52 An apple a day… – Professor Kevin Kerr P53 Food of our time – Dr Mike Harris

p39 Phossy Jaw

CURETTINGS P55 More of the weird and wonderful spotted by readers

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Cover Story In flagrante delicto. This image of a Reed-Sternberg cell progressing through a rather convoluted mitosis comes to us from Dr Paul Bishop.

Invitation to Contributors In addition to the constant flow of material from ACP Council, ACP committees and ACP branches, ACP news needs new material from you, the members of the ACP. Pathology news items (1200-1500 words): Any items related to the ACP or the College, pathologists in general, or medical and management matters that may have an impact on pathologists. Articles (1500-2000 words): These can be papers, reviews, essays, commentaries, critiques or polemics. Submitted articles are always very welcome, as well as suggestions for articles and/or details of people whom the editor may approach.

Trainees: Trainees are especially encouraged to submit material in any and all of the above categories. These will normally be placed in the trainees’ section. Appointments committees in particular value publications in ACP news. Editorial Policy: The editor would particularly encourage overseas contributors, material from trainees, material from non-histopathologists, commentary on current affairs in pathology, occasional columnists, innovations in pathology, humorous writing on pathology-related topics, and anything downright cantankerous.

Columns (600 words): Regular and irregular columnists exercise their thoughts. Please feel free to rant.

Format: The ACP news style guide is now available on line via the ACP website in PDF format at: http://www. pathologists.org.uk/allpagestuff/publications_frameset2.htm. The publication is a magazine, not an academic journal, and long lists of references are generally considered unnecessary. Where given, references should be in the Vancouver style and should be kept to a maximum of around six per article, unless absolutely necessary. Alternatively, authors may prefer to give a recommended reading list, or a list of relevant internet links. The editor prefers these as they take up less space.

Pathological creative writing: All literary forms, including short stories, serials, surrealism and even poetry.

All suggestions are welcome; however, the editor’s decision is final.

Appreciations (1000-1500 words): We prefer appreciations on retirement, rather than obituaries. Please discuss these with the editor before submission.

ACP news is published quarterly. Regular publication dates are:

Reports (1000 words): These may be personal views and reports on interesting meetings, travel or anything else of interest to the readership. Travel reports are specifically for holders of ACP travel fellowships; however, other reports from abroad are welcomed.

Photo-journalism: Favoured subjects include pathologists doing something interesting, or College and ACP officers doing anything at all. Interesting or artistic photographs are welcomed. Cartoons: Suggestions are welcomed. Curettings: Jokes and humorous titbits are always needed. Debate: Letters to the editor are welcomed, but may be shortened for publication, or even converted into articles. Please try to refrain from writing unless you are prepared to be published. All criticisms of organisations or named individuals will entitle the parties to a right of reply. Please bear in mind the UK libel laws!

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Issue SPRING SUMMER AUTUMN WINTER

Publication month February May August November

Copy date 5 December 5 March 5 June 5 September

Copy is best submitted by email, or on disc if the file size is large, in any version of Microsoft Word, although it should be possible to accommodate other formats. Submissions on paper by snail mail will also be accepted. Illustrations should be sent as JPEG digital images or hard copy prints. Please do not embed images in your text. Send them as separate files. Please send email submissions direct to the editor at julianburton@doctors.org.uk

ACP news - Autumn 2012


Editorial Dateline: July 31st 2012. The Olympics have started, and my, wasn’t the opening ceremony good?! I was impressed, even though I have no interest at all in sport or in watching any of the rest of it. The games have been blessed with a few days of glorious weather, though our climate seems to have decided that summer is now well and truly over and it has started to rain again. Hmmm. Looking back over my last few editorials I see that I have that typical British obsession with the weather. I must stop that! ACP members have clearly been busy over the summer, evidenced by the plethora of copy that flooded into my inbox over the past couple of months. Hopefully now there will be time for us all to relax, enjoy the Olympics (if you are so inclined) or take a nice holiday. With luck I will be in the Algarve when you receive this issue, enjoying some wonderful seafood and the occasional glass of port. National Pathology Year continues and accounts of your experiences are of course welcome. I have begun preparations for my own event, an evening lecture titled “Dicing with death: 5500 years of human dissection and the autopsy”. I’m cheating a little as I have already given this lecture to the Royal Society of Medicine but they seemed to like it, so if it is good enough for them it should satisfy medical students in Sheffield. A new member of the editorial team I am very pleased to report that the editorial team of the ACP news has now reached its full complement. Dr Alex Freeman, a Consultant Histopathologist at the University College London Hospital joins the team as the Book Reviews editor. I hope that you will help him to continue the success of the Book Reviews section. Good news for trainees Without doubt, trainees are the future of our profession. As we slowly slide towards our dotage there needs to be young blood coming along behind us. Trainees are also the lifeblood of our Association, and will guarantee its future. The ACP has a lot to offer trainees beyond being part of a vibrant organisation. As well as this wonderful publication, membership includes the Journal of Clinical Pathology, along with access to a host of educational events and the annual National Scientific Meeting, bursaries to support education, training and research, and prizes for Journalism in Pathology. Come January 2013 all of this is set to be even better, as the membership fee for trainees will fall from £54 to just £25. I hope that you will spread the word and encourage your trainees to join us. (They’ll also have a

Dr Julian Burton is Senior Teaching Fellow at the University of Sheffield and a Coronial Pathologist at the Medico-Legal Centre Email: julianburton@doctors.org.uk

reduced membership fee for that all-important first year as a consultant.) In this issue As ever, the ACP news is packed to the drawstrings with interesting articles. We begin this issue with another leader article by our founder, Dr Sydney Dyke, on Coroners’ post mortem examinations. Although he was writing about coronial autopsies in the 1930s and 1940s it is remarkable how little has changed, and his thoughts then remain of interest and relevance today. Our other leader article comes from Dr Eric Watts. In the light of recent events surrounding the Health and Social Care Act, and perhaps also in light of current events around the NHS Pension Scheme, Dr Watts considers the important but thorny issue of engaging with politicians. How can we do it, and how can it be done successfully? In describing his own experiences, Dr Watts’ article makes essential reading. The wonderful British climate tends to make our thoughts turn to sunnier climes over the Summer, and in part this is reflected by two of the articles in this issue. Dr Simon Knowles reports on his experiences of teaching management and leadership skills to pathology trainees in Zambia as part of a Masters of Medicine degree that will allow them to work as independent heads of service. Medical practice is rather different in Zambia compared to the UK, but if you’re considering a busman’s holiday, this is the article for you! Dr Ian Chandler, the ACP’s

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Editorial answer to Bill Bryson, has been off on his adventures again and recounts his travels and culinary experiences in Cambodia. (All of which makes my trip to the Algarve seem rather lame.) For those of you with an interest in medical history, Mr Michael Phipps considers the history of leprosy. Thoughts on the nature of this disease have evolved over time and Mr Phipps takes us on a fascinating journey. Elsewhere in this issue Is that all we have to offer you this time? Of course not. Dr Zena Slim reports on the Liaison and Branch Officers’ meeting and Drs Abigail Pugh, Eamonn Trainor, Bill Simpson and Eric Watts report back on this year’s National Scientific Meeting, which was held at the Royal Institute of British Architects. (I went for the Forensic Pathology session and it was superb. If you missed it you missed out.) We also have reports on the 31st Annual Meeting of the British Association of Ophthalmic Pathologists, the Trainee fringe session at the 58th Scientific and Standardisation Committee meeting of the International

Society on Thrombosis and Haemostasis, and a meeting at the Christie Hospital in Manchester. As I said, people have been busy! A good number of these articles have been written by trainees, which I think is superb. I am always eager to encourage trainees to put fingers to keyboard. The Trainee Zone, under the guidance of its new Assistant Editor, continues to go from strength to strength, and hopefully will be of interest not only to trainees but also to more seasoned members. On top of all that we have a number of bursary and award reports, which will give an idea perhaps of how the ACP can support you; the columnists have been beavering away (we only feed them fish heads and stale bread, allowing them out once a month if they have written something): and there is the usual motley collection of curettings to brighten your day. Enjoy! As I sign off my mind turns already to the Winter issue and the currently empty table of contents. I’m hoping you’ll feel inspired to send me some copy!

“Erratum”: a repeated error? The Autumn 2011 issue of ACP news included an article by Dr Alison Finall titled “Ten top tips for floorless undergraduate tutorial teaching”. This excellent article was awarded the ACP’s Second Prize for Journalism in Pathology, as noted in the Summer issue this year. A reader has spotted this and raised these interesting questions: “Do you suspend them from the ceiling, in the hope that fear of falling improves the learning process? Should I seek to have the floor removed from all teaching areas?” In fact, the term “floorless” was deliberately chosen by the author and approved by the editor as a pun for what followed in the article.

www.pathologists.org.uk ISSN No. 0260-065X

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ACP news - Autumn 2012


Lead Articles Coroners’ post mortems and the National Hospital Service – Sidney C Dyke

Dr Sidney C Dyke was the founder of the Association of Clinical Pathologists

Following his death, the family of Dr Dyke kindly donated many of his personal papers to the ACP and they are archived in the offices of the Association in Hove. It is not possible to determine from the archive precisely when Dr Dyke delivered this speech, or to whom, but I present it to you, as it neatly shows that issues relating to coronial autopsy work have changed little in the last 80 years. I have transcribed it verbatim from its eight neatly typed, slightly foxed pages, adding in only some italics – Ed. In the year 1938, the last for which figures are available, 26,944 post mortem examinations were performed on the order of coroners; of the public money the sum of £71,035 was paid out in fees to medical practitioners performing these examinations. In 1930 the number of these post mortem examinations was 19,081 and the expenditure on fees to medical practitioners for their performance, £48,648. The yearly increase in the number of such examinations between 1930 and 1938 and the disbursement of fees in respect of them is shown below: Year

1931 1932 1933 1934 1935 1936 1937 1938

A B A @ 2 B @ 3 Totals Post Exams guineas guineas Mortem in nonInquest Inquest Cases Cases 11,069 10,796 11,561 12,054 11,728 11,972 12,771 13,180

8,458 8,873 9,647 10,745 11,058 12,069 13,212 13,764

23,235 22,561 24,278 25,325 24,629 25,141 26,819 27,678

26,645 27,950 30,338 33,847 34,832 38,018 41,618 43,357

49,878 50,511 54,616 59,616 59,170 65,159 68,437 71,035

To what extent the steep rise in the number of post mortem examinations and the consequent expenditure in fees may have been influenced by the war years is impossible to say; it is, however, safe to forecast that after the war the increase in both will continue, very possibly at an accelerated rate. Under present practice a large proportion of these examinations are made by medical practitioners having no particular skill or experience in this class of work; the results of the examinations are therefore in many instances of little value and the public money expended in this respect cannot be regarded as laid out to the best advantage. Under the Coroner’s Act of 1887 coroners may summon to perform a post mortem examination either (1) the medical practitioner who attended the deceased at death or (2) in cases where no practitioner was thus in attendance, a practitioner in or near the place where death occurred. The statutory fee for the performance of a coroner’s post mortem examination is two guineas and this is all that can be claimed by the practitioner summoned by the coroner. In section 22, para. 3 of the Amending Act of 1926 it is laid down that coroners may request specially qualified medical practitioners to perform post mortem examinations and to report to them, and that in such cases the statutory fee of two guineas shall not apply but that the fees shall be those prescribed in schedules to be drawn up by local authorities under section 25 of the Act of 1887 or by rules made by the Secretary of State under the same Act. Actually it appears that no such schedule or rules have ever been drawn up; in many parts of the country, however, coroners have adopted the custom of paying a fee of three instead of the statutory two guineas to medical practitioners having special skill and experience in post mortem work. Reference to the table shows the extent to which this custom has grown. In 1930 of the £48,648 expended on fees for coronial post mortem examinations, £23,842 was constituted by the two and £24,806 by the three guinea fees. By 1938 while the total of two guinea fees showed a rise of only 16 per cent to £27,678 those at three guineas had risen by 76 per cent from £24,806 to £43,357. The presumption is that the extra fee is only paid to practitioners having special qualifications for post mortem work and the deduction therefore that there is a growing tendency among coroners to entrust their post mortem work to those competent to perform it properly.

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Lead Articles This is certainly the case in many of the larger development of a truly national hospital service based towns in which coroners make it their practice always upon Key hospitals and covering the whole country there to employ the services of a trained pathologist. This will after this war be no area in which the services, not custom is, however, very far from being generally only of an individual pathologist but of the whole staff established throughout the country, and it is a fact that of a fully-equipped pathological department will not be a great number of post mortem examinations performed immediately available to all coroners. at the instance of coroners are still carried out by The vast majority of post mortem examinations practitioners having no particular competence in the performed at the instance of coroners are made for the work. Many coroners call upon a skilled pathologist purpose of ascertaining the cause of death in cases in and pay the extra fee only in cases which they judge are which there is no question of a criminal factor. Dr. Keith likely to be of unusual importance or difficulty, leaving Simpson of the Department of Pathology, Guy’s Hospital the remainder to be allocated to general practitioners Medical School kindly provided from his extensive without any special experience in post mortem work. practice figures showing the categories into which fell Partly this custom appears to arise from the assumption 10,000 examinations made by himself. These are as that it requires no special skill or knowledge to either follows: perform a post mortem or to interpret the findings and 1. Deaths from Natural causes that in cases presumed to be “ordinary” any medical (a) without recent medical attention ..... 5510 practitioner is competent to do this, and partly it appears (b) reported because of question of injury, to be due to a desire to save expenditure in extra fees. industrial exposure, crime, etc ..... 1388 Leaving aside the fallacious assumption that competence (c) Referred by registrar for some in post mortem work demands no special training or technical reason ..... 120 experience, the practice is open to condemnation on the grounds that until the examination has been performed it 2. “Anaesthetic deaths” ..... 592 is quite impossible to tell how difficult it is going to be to interpret the findings and to assess the cause of death. 3. Deaths from street, workshop or It is the prevalence of this custom that gives occasion to other accident ..... 1554 those instances within the experience of most practicing 4. Criminal cases – murders, suicide, criminal pathologists involving requests to identify the cause poisoning, criminal abortion, infanticide ..... 836 of death from the inspection of a pail of miscellaneous viscera or from information supplied over the telephone, -------requests to which the wise pathologist turns a deaf ear. 10,000 The Home Office Departmental Committee on Coroners of 1936 recommended (Chap. XI, para. 162) that “post mortem examinations shall be It will be seen that only in slightly made by pathologists with over 8 per cent of these cases “… many of special experience is there any question the mortuaries used by in that class of of criminal action. coroners are entirely unsuitable for work” and “that In over half the this must apply examination was the purpose to which they are put …” to all post mortem ordered because examinations made death had occurred at the request of coroners”. in the absence of medical Although in 1936 fewer hospitals than attention; in a substantial proportion it is now the case possessed pathological departments with was in reference to questions of industrial disease. skilled pathologists in charge, the Committee refused These figures make it evident that the proper (Para. 163) even then to accept the view that there was performance of coroners post mortem examinations any part of the country in which the services of a skilled demands experience in clinical medicine as well as in pathologist were not available. With the development post mortem room technique and the interpretation of of the E.M.S. Hospital Pathology Service and with the post mortem findings. The work can therefore best be advance of the voluntary hospitals this is now, in spite done by those pathologists in close touch with clinical of present restrictions on travel, still the case. With the work. These are already to be found attached to hospitals

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Lead Articles up and down the country and with the development of fall within the scope of the present discussion. the national hospital service their numbers will greatly The majority of coroners’ post mortem examinations increase. are at present performed in mortuaries under the These hospital pathologists would appear to be the administration of the local authorities with which the most suitable persons to deal with coroners’ post mortem coroner is concerned. Many coroners use a number of work. The 1936 Committee recommended (Para. 165) mortuaries scattered widely throughout the territory that coroners should normally be required to employ under their jurisdiction. As pointed out in the report of pathologists whose name appeared on a list to be kept the 1936 Committee many of the mortuaries used by by the Home Office and in the compilation of which coroners are entirely unsuitable for the purpose to which the Home Secretary should “be assisted by an advisory they are put; the committee received evidence from committee drawn from the Royal College of Physicians eminent pathologists that even in the London area many and the Royal College of Surgeons”. To put the coroners, of these lacked almost everything requisite for the proper post mortem service on a sound basis the first necessary performance of post mortem examinations. step would appear to be the establishment of such a panel With transport facilities as they were even before of pathologists and the second to restrict the performance the war and as they will certainly be immediately of this work to those upon the panel. If and when such afterwards there seems to be no reasons in this scattering a list is drawn up the hospital pathologists of of small mortuaries throughout the country. the country should figure very There is everything to be said “… until the largely in it. for concentrating the examination has been Those cases in which coroners’ post mortem there is a question of work of given areas performed it is quite impossible criminal action fall and it would appear to tell how difficult it is going to be into a somewhat reasonable to do so to interpret the findings and to special category; in the place where their number as it can most efficiently assess the cause of death.” pointed out above be performed. With the constitutes only a very small full development of the national fraction of those in which a post mortem hospital service this place will be the examination is called for by the coroner and many pathological department of the hospital serving the area. pathologists may go for years without being concerned That the body should go to the pathologist rather than in such cases. Although the hospital pathologist will be the pathologist to the body has everything to commend capable of dealing with the ordinary run of coroners’ it save the objection, which hardly seems to be serious, cases he may find himself in difficulties in the criminal that it might entail its temporary removal from territory case. This may demand an expenditure of time beyond within the jurisdiction of the coroner concerned. the capacity of the pathologist engaged in the practice The linking up of the coroners’ post mortem of a busy hospital and also investigations of which he service with the national hospitals would entail great may have no special experience and which may well advantages. Of these the chief are that it would ensure be outside the sphere of his department. In such cases that all examinations were carried out by those specially the services of specialists in forensic pathology should qualified by training and experience to perform them be available. These should be pathologists engaged and, if the suggestions made above were put into effect, continuously in this class of work. Their proper places under proper conditions. would be in Institutes of Forensic Medicine of which Further, this step would through the intermediacy few would suffice to serve the whole country; such of the hospital pathological service bring within the institutions have not been developed in this country but it purview of the national health services a very large is highly desirable that they should come into existence. amount of material now entirely lost to it, but susceptible How many will be required to serve the whole country, of being made of the greatest value, particularly in its under what auspices they should be developed and social aspects. maintained and where they should be located does not

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Lead Articles Political Engagement: how far can we go? – Eric Watts As charities, ACP and RCPath can’t behave like trade unions – but we can have a view and as responsible people we must have a view as only we really understand what we do and how it contributes to patients’ care. We have sapiential authority, i.e. the authority which comes from the thorough knowledge of our work and we as pathologists must promote our role. To be blunt, if we don’t who will? The College has made excellent progress with its strap line – “The Science Behind the Cure” and all the educational events in National Pathology Year that help to raise our profile. But what happens when the going gets tough and we feel the services we provide are under threat? Getting involved with politicians is best done if we can understand something of the dark arts. Starting with the Mr Nice approach one politician, who took an interest in blood transfusion, invited all hospital chief executives (CEOs) to comment on his plans to improve the lot of patients requiring transfusions. Most of the CEOs passed his letter to haematologists – some replied and were invited to a meeting in the pleasant and impressive

Taking a stand

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Dr Eric Watts is a retired Consultant Haematologist and a Vice President of the Association of Clinical Pathologists. Email: Eric.watts4@ btinternet.com

surroundings of the Palace of Westminster. He stated that he wanted to gather as many allies as possible to help to build his case. He had been advised by a company which produced erythropoietin that their drug could help prevent patients with anaemia from the inconvenience of attending hospitals for transfusions. We were able to advise him that the situation was a lot more complex than they had made out. We saved him the embarrassment of making a big issue for change without having the supporting facts. More recently a plan to radically transform the NHS was unleashed without any form of wider discussion with practitioners who could have introduced a measure of reality testing – the result is the longest passage of a Bill through parliament and the most changes (over 350 amendments) in parliamentary history. It took over a year and had hundreds of changes in the final few weeks; it became heated and we saw less of Mr Nice as email petitions gained momentum and the temperature rose further. It is now clear that the NHS will change but not as much as in the original plan – which shows the effectiveness of taking political action; the question remains how best to get our points across? When people disagree It would be a dull world if everyone agreed all of the time and we have several ways of resolving conflict, ranging from the polite agreeing to disagree to full blown argument where Mr Nasty may emerge and it ends up in a shouting match – both parties going away angry. Political arguments easily degenerate to opponents resorting to their personal philosophies, resulting in an impasse: was that the case with the NHS Bill – that we’re

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Lead Articles for or against the NHS and want to slug it out on that basis alone? It often seemed that way. Can we learn how to be more effective and get more of our views across with less effort? We can learn negotiating skills, the art of compromising on one or two issues (of minor importance to you) in order to get want you really want from the deal. We could also learn the art of concentrating on the achievable rather than wasting effort on a lost cause such as fighting the Bill as a whole in the last few weeks.

issues we discussed was motivation – how to get the best out of the workforce, discussed in much more detail in Charles Handy’s book Understanding organisations.

Hard nose or soft centre? There is a consensus amongst the top businessmen that people perform best when they are working for a purpose. The stronger the belief, the better they work together for a common goal – nothing too surprising there; “team spirit” is a vital ingredient in sports. But what did Want to make a difference? Learn the game surprise me was how much they used the NHS I’m a keen supporter of the NHS, as an example of a motivating this goes back a long time force. Using the language to my teens when I of management “… people perform best when was treated for a consultants, seeing they are working for a purpose. The neuroblastoma. how much has been stronger the belief, the better they work Illness can focus achieved by the the mind and NHS with its limited together for a common goal…” knowing the problems resources, they would that exist in other countries say “this is marvelous, how for people with prolonged illnesses, I do you do it? – if you can find the felt fortunate to be in a system which really did look after magical ingredient then bottle it and sell it!” people from cradle to grave. Then during the Thatcher Successful companies have had a core message, or years I joined the Labour party to do my bit to help mission statement to give their employees a sense of preserve what’s good about the NHS and also joined direction to aid cooperation, and some of the managers the National Health Service Consultants Association I’ve heard talking about “identifying our purpose, (NHSCA) dedicated to preserving the NHS. The NHSCA differentiating our product etc” are missing the point that has as a key message: we do know what we wish to achieve – health for all – and we did choose to work for the NHS for many reasons including the wish to work in a firm that embodies civilised values. Talking of values often provokes the response, “That’s soft!” Perhaps, but it can also be powerful if we are prepared to move away from the big stick school of management towards one that really does That explains my personal position (or baggage, some get the best out of people. would say) but I’m also aware of the dangers of sentiment and creating sacred cows; as head of department I had Why change a winning team? a budget to keep and was keen to learn the skills of The last government poured money into the NHS but management. I enrolled in the Keele course to obtain the productivity did not increase proportionately. However, Diploma in Healthcare Management, which was led by rather than being a sign of failure of the service this is Prof Roger Dyson who had been a member of Thatcher’s good evidence of the harm of creeping privatisation. think tank which produced the 1991 white paper that saw Much was spent on Independent Sector Treatment money following patients – the most radical change in Centres (ISTCs), privately owned and run, carrying out the NHS in 40 years. a limited range of services with the great bonus that they Professor Dyson had a clear political bias but could would not have any emergency admissions to disrupt rise above it, was intellectually honest and would enjoy planned surgery schedules. Also they selected the less robust debate – happy to acknowledge points scored complex cases and yet they were 12% more expensive against him (as no politician would) so it was a good than the NHS equivalent. This is not surprising when we learning environment. He introduced us to senior appreciate that these were companies out to make a profit managers, accountants and hard-nosed businessmen and the NHS does not. who were moving into hospital management. One of the How much profit should be made from healthcare? It

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Lead Articles depends on whether you see health as a business or as a right. As funds for healthcare are limited one argument is that any money that is lost from the system in profit to an external company is a lost opportunity to spend it on patient care. The opposing argument is that if a company can provide the same service more cheaply then more patients will benefit but the experience is that too often the NHS loses out through poorly negotiated contracts and short-termism. The classic example of short-termism is PFI, which is costing us dear and was described by the (Tory) chair of the Finance Committee as the “Unacceptable face of capitalism”. ISTCs are another example – we don’t pay the capital cost of building them but we pay handsomely to use them.

committed to supporting the NHS and some at the top of the party were talking of the NHS as if it were merely an insurance company, which would use any provider, favouring the private sector which was more efficient – a myth that still exists in the minds of some. There is information collected by the Healthcare Commission and benchmarking companies which is confidential but shows that there are many highly efficient NHS laboratories and it makes sense to see how they do it so we can generalise the best. I later heard Nigel (now Lord) Crisp, CEO of the NHS at the time, talk about ISTCs. Although the amount of work they did was “tiny” we saw a dramatic drop in waiting times because (he said) patients had been given the chance to go elsewhere and NHS hospitals suddenly realised they had competition and got to work. One example of An ISTC for my hospital? the sudden change, once DoH started promoting choice At Basildon we badly needed more space for our and competition, was cataract waiting times, which were haematology day unit and as our CEO advised that we two years in Surrey and four months in London. When would only get a new build by getting an ISTC, I agreed. the rules allowed the Surrey patients to go to London, the It would also provide a medical day ward and endoscopy Surrey hospitals soon increased their throughput. suite. The Trust placed the required adverts and the He gave that example of using competition to help to proposals came flooding in. It would have been hilarious induce a will to change within NHS hospitals that had if it had not been serious; we made it plain not responded to the call to cut waiting that this was to be a medical unit times or who had claimed it but we were swamped could not be done. He with proposals for also gave examples “Getting involved with politicians operating theatres. of improvements is best done if we can understand We had a shortlist by collaborative of suppliers, working within something of the dark arts.” consortia of building the NHS such as companies and private reducing the time to health companies and treatment with clot busters you could only admire their for patients with myocardial optimism and powers of self promotion. infarction. The waiting list Issue was a good They confidently sat down and told us they could example of judicious use of the private sector! We should provide what we wanted for a given price then showed not get complacent. they knew next to nothing of the services they had been In 2007 there was widespread concern about bidding for. A typical example was that as the service piecemeal privatisation. An amalgam of health unions would replace our day unit it would have to provide all launched “NHS together” and had a big march and rally of the current services including open access to patients in London. There I am with my home made placard with complications of treatment. “No,” they replied, setting off through the leafy suburbs and getting dirty “such patients will have to join the queue at A&E”, but looks from salesmen as I walked past the Jaguar and that is not the way to manage complex haematology BMW showrooms, but getting supportive comments patients who often do need direct access to haematology from fellow travellers on the train and tube. (Arriving units. Our endoscopists had a similar problem – the unit at the start of the march on the Embankment, I saw that would be closed at night, urgent GI bleeders would have everyone else with a placard had come in a hired bus or to join the queue. had had the placards taken there by van.) It was a good At that point we pulled the plug and developed the day out, meeting many new people but the rally was services in-house two years later. simply preaching to the converted. That dented my belief that Labour were truly I was puzzled and embarrassed by Labour’s position

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ACP news - Autumn 2012


Lead Articles so off I went to change it. I took a motion to my local branch calling for an end to a policy of increased privatisation and it was passed nem con with one abstention. I waited to hear how policy would change – it didn’t. I tried to find out what happened to motions from branches – it seems very little unless you’re part of a coordinated national movement. I spoke to our MP who was riding high in the party at the time and she got me into No10 – that’s me outside trying to look serious. I met Gordon Brown in the corridor, he was waiting to meet the Sarkozys, he directed me to an advisor who listened to me, thanked me for explaining the home truths and agreed they would do better next time. Would the Tories have been more responsive to medical advice? I had an interesting meeting with Tom Sackville, Minister for Health, when Virginia Bottomley was Secretary of State. As a cancer survivor I’m active in many cancer charities and at one meeting he had given an excellent speech with great aspirations of improving cancer care. I thanked him for the wonderful future he had displayed for us and invited him back next year so we could review progress. His reply? “Well I would very much like to but I can’t, as no politician knows where they will be next year.” So engaging with politicians is a long learning experience – they’ve heard it all before, they know what they want to do and they’ll humour you when they’re being nice and ignore you when they’re not. The best way to influence a politician? Find the Minister with the most marginal constituency and move there for the election. As an individual it’s hard to make a difference but as a group we should find it easier. Many colleges and medical associations made their views on the Health and Social Care Bill known and one of the most common themes was that the Bill would undermine the NHS through fragmentation, and that privatised services will be too selective to allow free services for all. Evidence of the benefits of integration has been published by Professor Chris Ham, current CEO of the King’s Fund. (Curry, N and Ham, C (2010) Clinical and service integration: the

Take it to the top

route to improved outcomes.) In particular they cite the Kaiser Permante’s move towards increasing integration. It is a simple truth that money is limited and therefore we should use the most efficient services but how do we measure efficiency? The World Health Organization has done it and published its league table in 2002. Although France and Italy faired better than the UK, we were at that time spending 6% of our GDP compared with 9% in most of Europe, and we were more effective than other large countries. Lord Carter acknowledged that UK pathology was good value by international comparison and most recently the Commonwealth Fund (a New York-based independent agency) commented that we out-perform other high income countries.1 One college which chose to lobby on the Bill both publicly and privately was the Royal College of Physicians, London (RCP) and in its commentary its president states that the RCP’s lobbying has led to a series of real improvements in the Bill, including: the inclusion of hospital doctors on the boards of clinical commissioning groups; ensuring the Secretary of State has responsibility for education and training; coordination of education and training at a national level; and a commitment that all providers will pay, via a levy, for education and training. Their lobbyist, at a recent meeting on global healthcare, talked about the value of lobbying, which sometimes has a poor image but is both legitimate and expected by

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Lead Articles on which to evaluate performance. politicians. In the UK the lobbying industry employs The major weakness of pathology is the behind the 14,000 people and has a turnover of £1.9 million. The scenes, backroom boy/girl image or mentality. Now, both lobbyist’s top tips for successful lobbying: be precise as individuals and collectively it’s time to get out and about what you want, be prepared to be challenged, ensure our colleagues and the commissioners know, not engage with as many people as possible, use local media only what pathology is but what good pathology is and to (your MP will), be prepared for the long haul and, above be sure that they get it. all be persistent and courageous. Lord Crisp spoke next How far can we go? It’s a matter of judgement and endorsed her comments adding that he paid and as an association we haven’t most attention to lobbyists who tried to test the limit. I don’t knew the practicalities of believe we have even their subject and had a “… engaging with politicians is tested the water. We good track record. a long learning experience – they’ve could make political In pathology we heard it all before, they know what statements but we have sweeping would need to find changes resulting they want to do and they’ll humour you ways of surveying from the Carter when they’re being nice and ignore the membership to Report and it would you when they’re not.” give a formal statement have been a political own of our position and this could goal to complain collectively be expensive. In the short term we about increased privatisation under can use our meetings to discuss topics and gauge this government if we did not under the last (at least I opinion, then as individuals we can advise our MPs that did my bit). A major problem with sweeping changes is we are seeing them in our position as constituents but that a lack of proper before and after evaluation. Doubtless meeting with fellow pathologists achieved a consensus the administration will prioritise one key performance view which we could then present. indicator that will trump the others when results are There have been informal discussion at ACP meetings announced – the smart politician will await the result, on the Bill. We also had discussions on Carter but I don’t see what’s come out best and trumpet that triumph. remember coming up with a collective response. So far One of the new features that will particularly affect we haven’t consulted with government; we’ve kept our pathology will be services provided by “any qualified heads down and got on with the day job. Next time a provider”. Experience with outsourcing such as during government plans wholesale reform, will we move faster the GP fund-holding years and the current round of outto form a view and communicate effectively? sourced ultrasound services is that the service may not Reflecting on the stance other organisations have be up to the standard of the local hospital and GPs will taken, at least we haven’t made any influential enemies request repeats, leading to increased costs. so, should we now choose to be bold, we can go into the next round unscathed! What next ? The key to the next round is commissioning. The College Reference is leading the way and I hope they will go further to 1. D Ingleby, M McKee, P Mladovsky, B Rechel. get the commissioners to review the performance of How the NHS measures up to other health providers against the contracts. I think we should promote systems. BMJ 2012; 344: e1079. 22.02.2012 benchmarking as a means of producing meaningful data

Doctor, doctor… I saw a man this afternoon, who came in and said: “I’ve got a cricket ball wedged up my arse”. “How’s that?” I asked. “Don’t you bloody start,” he replied.

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ACP news - Autumn 2012


Articles A Zambian interlude: leadership, management and kalamari – Simon Knowles

Dr Simon Knowles is a pathologist in the West Country. Email: simon.knowles. acpnews@gmail.com

So here I am sitting in a very crowded plane on the way back from Lusaka to London after a rather strange couple of weeks. The nice young chap next to me is enjoying a G&T, which is really unfair as I’ve decided to take a year off. Gin, not work. Anyway, I’ve been in Zambia teaching pathology trainees the rudiments of management and leadership so that when they get their specialist qualification, in their case a Masters of Medicine, they’ll be able to work as independent heads of service. And, believe me, independent – or at least entirely unsupported – is absolutely what they are likely to be. I’m tired and I could really murder a gin. You could be forgiven for wondering what on earth I’m doing here, given that there is more than enough work to go round, helping with the latest redisorganisation of the English (you can’t really call it National) Health Service. Well, basically, when I signed on to help Ken Fleming with putting a bit of leadership and management training into the MMed course, I was under the misguided impression that I would be doing a bit of computerbased curriculum work at my trusty desk in the West Country. It was only when I got an email from THET (the Tropical Health and Education Trust) asking me when the best time was for a trip to Lusaka that I realised that I’d been well and truly hijacked by the “voluntary” sector. So a short domestic discussion about how I should really be using

my annual leave and – hey presto – here I am, or rather there I was. In Lusaka after the dreaded Sunday night red-eye from Heathrow on what must be one of the oldest planes in the fleet. It’s not often you see a flush button stuck to the loo wall with black insulating tape. The Masters of Medicine courses at the University of Zambia are a really good idea, born out of both necessity and experience. Specialist doctors are necessary and in short supply. And long bitter experience has been that the majority of bright young doctors sent out of the country to train simply never come back. Hence a series of fouryear Masters degrees, roughly equivalent to postgraduate training for one of the Royal Colleges, delivered almost exclusively on a local basis, supported where necessaryby an international “faculty” of visiting teacher/trainers. Like me. The three courses being supported by THET are in anaesthetics, psychiatry and – as of this academic year – pathology. Country population at around 3.5 million souls. Anaesthetists? Eleven. And far fewer consultants in laboratory medicine. The fact that it is the inaugural Year One course may partly explain why my comprehensive terms of reference read something like “teach management and report back”. Anyway, that was my excuse for not having done much preparatory work before I arrived – better to suss out the

Dr Msonda takes us through a spaghetti diagram

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Articles This rather mature attitude to life may explain why the students, perhaps better described as subjects in an educational experiment, seem reasonably relaxed with a two-week course that was “modified” on a daily – sometimes hourly – basis. Although they did point out at the debrief yesterday that it would have been nice to have had a vague idea of what they were in for, so that they could prepare themselves; my own sentiments entirely, as it happens. Making it up as you go along is surprisingly hard work. Anyway, I’m playing with a timetable for next year which may help. For example:

The University Teaching Hospital, Lusaka

local scene and get a sense of background, culture and attitudes before launching into a programme that might be fit for purpose in Liverpool but not in Livingstone. We will return to cultural attitudes later. Relatively old dogs My four students are not exactly what you’d find in a UK pathology training programme. Medicine in Zambia propels its newly graduated medics head first into positions of significant responsibility. Two of my guys went out to provincial hospitals as “generalist” SHOs and found themselves working as Medical Superintendents and then Directors of a district service within a matter of months. Without any preparation or training as to what to do with an impending industrial dispute, how to manage a regional budget or, indeed, how to hose down an irritable head of nursing a couple of decades older and wiser (or not, of course). These experiences do not seem to have dampened their enthusiasm but have certainly given them a sense of purpose.

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Monday a.m.: Value stream maps, going to the gemba Monday p.m.: 5 whys, spaghetti and fishbone diagram Well perhaps not. So what have we been teaching and learning over the last two weeks? As it happens, my visit coincided

Specimen reception

ACP news - Autumn 2012


Articles with a flurry of administrative activity around a programme run from the WHO, called SLMTA (Strengthening Laboratory Management Towards Accreditation). At the moment the poor souls are doing all that “document control” stuff that is such a familiar component of tired old ISO 15189, the Box Ticker’s Charter. Mind you, this has served to remind me that there actually are some positive aspects to laboratory accreditation, not least the need to introduce at least a modicum of standard work into the complex process of result generation. The upside to this is that everyone in the labs in Lusaka is focusing on the ways that people work – a perfect environment to introduce some of the concepts of continuous quality and process improvement. In my book, as regular readers will know, this equates to using Toyota Production System methodology or “Lean”. So, instead of starting with leadership and management and working on to change and improvement, I did it the other way round. And it seemed to flow well: using continuous improvement as a hook from which to hang concepts such as change and conflict management, circles of influence and styles of leadership gave the sessions a strong practical purpose.

MMed students map the pathway for urine specimens

in some NHS establishments. Getting continuous quality improvement embedded into organisational culture is all about new tricks and old dogs. You can teach old dogs new tricks. The problem is getting them to unlearn the old tricks. Resource rich countries (and pathology departments) have learned to tolerate waste in the system and are finding the unlearning process painful. We can’t continue to throw money at the problem; there’s none And relatively new tricks left. Low income countries don’t have that baggage and At the end of the two weeks, the trainees have a they simply can’t afford to support wasteful processes. really firm grasp of the principles and tools of Lean And they know it. process improvement and we have had some energetic There are some caveats to my optimism, and the discussions about what you need personally to be able to first relates to the tricky relationship between nations successfully lead continuous change. Each student has rich and poor, generally referred to as “international a specimen pathway mapped out and development” or – worse – “aid”. Let ready to critically review us assume that first world “You can teach old dogs new and they’ve already efforts to help less generated some developed nations tricks. The problem is getting them interesting data are based entirely on to unlearn the old tricks.” and are signed up to a philanthropy and have fundamental truth – you can’t nothing to do with politics or improve what you don’t measure. Will anything trade; that there is no conscious paternalism in the I’ve started turn into practical change for the better? Not, I relationship; and that the vast bulk of capital (cash, goods suspect, without some significant support and a great deal or people) ends up where it is directed and isn’t top sliced of time. In which regard this is absolutely no different to or creamed off en route for “administrative” purposes. doing Lean stuff in the UK. Robust, sustainable changes Do the scales then tip in the favour of beneficence or are in culture – “the way we do things round here” – takes we doing relative harm? Well it depends, of course. But years not months. Perhaps in Zambia it will take even there are a couple of points. Firstly, a lot of development longer and perhaps it won’t happen at all. My personal aid inevitably and insidiously reflects first world dogma view is that it is more likely to succeed in Zambia than that may not even be fit for purpose in first world

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Articles

Rush hour in Lusaka

countries these days: the “old tricks” referred to above, especially throwing money – often in the form of flashy kit – at basic problems that should be managed through local solutions. At worst this is a waste of dosh. At best it is a continuing distraction from the main game. I am quite conscious that I may be guilty of this cardinal sin by suggesting that we throw Lean healthcare methodology – derived from first world manufacturing and refined in first world hospitals – at third world challenges. So whatever I am teaching needs to be given a particularly Zambian flavour, based on local needs, local culture, local usage and local learning. It’ll take a fair few learning cycles before we get that one right. The second point is somewhat paradoxical: it will only happen if we make it so. When we talk about cultural differences, my students seem to feel that local resistance to change will come more from entrenched public sector attitudes and a lack of knowledge about how things could be, rather than from an explicitly “African” approach to

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working life: people can’t aspire to improve without the knowledge of what may be possible. Funnily enough, I’ve heard a similar comment from Alison Trimble about working with communities in Tower Hamlets at the remarkable Bromley-by-Bow Centre. So there is an onus on us to act as catalysts and guides to help the labs work out for themselves what real success would look like; but with a view to developing long-term independent sustainability that will allow us to walk away. Job done. In this regard, Lusaka really is no different to Luton or Leamington: sustainable improvement will only come if there are dynamic leaders locally who “get it” and are ready to gently push things along on a daily basis. Anyway, right now at the University Teaching Hospital in Lusaka, there is a pressing need for a bit more measurement – you can’t improve on lab turnaround times if you don’t know what time a result is signed out of the lab. So my first measure of success will be when I get a bit of temporal data back from the pathways

ACP news - Autumn 2012


Articles

They treat the visiting lecturers very well in Zambia

we mapped during my visit. This is going to depend on getting the lab and clerical staff on side which is, in turn, a pivotal component of Lean. Our MMed students will need to lean heavily on their skills at influencing beyond authority. I’m quietly hopeful ... What doesn’t kill you makes you stranger … And tired. My neighbour on the plane is now onto his second G&T and the cabin crew have even popped in a slice of lemon. Well; see if I care. I’ll have another glass of water and tell him he’s a lucky man. That triggers a couple of hours of interesting conversation as he turns out to be a part-time optometrist and part-time lawyer who does a bit of eye stuff, a bit of legal stuff and quite a lot of third world stuff; and he’s a nice bloke into the bargain. Pretty cool for a 30-year-old. I wish I’d been that sorted at thirty. So what of the rest of Zambia, did I have a fab time on safari? Did I do the Victoria Falls?? Nope. I spent my time people watching and socialising with a motley group from the voluntary sector. And a thoroughly likable

lot they were too. Bizarrely, food up the road from my very basic hotel was about as good as you could ask for, including the absolutely best pan of kalamari, grilled in butter, that I have ever had the pleasure of demolishing. The bush, big game, malnutrition, malaria and the rest can wait for next time, if there is a next time. I rather suspect there will be. And if you want to help train some terrific young Zambians then contact Ken Fleming at the RCPath. End note Waiting in the afternoon sun for the car, after my final session with the students, a lanky local doctor strolled up and greeted me like a long lost friend. I must have looked a bit blank because he reminded me that we had both been at the same meeting discussing the nutrition programme the previous afternoon. I explained that I had been with my students all day and perhaps he was thinking of my colleague from THET. “Ah yes, that’s right” he said: “White, glasses, beard – I’m so sorry but you all look the same to me.”

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Articles The edible fauna of cambodia and other things: from the sublime to the amphibious – Ian Chandler

Dr Ian Chandler is a Consultant Histopathologist at the Royal Devon and Exeter Hospital Email: ianpchandler@ doctors.org.uk

“Look on my works, ye Mighty, and despair…” Ozymandias, PB Shelley In February I spent three glorious sunny weeks on holiday in Cambodia and Laos. Cambodia is famous for two things, Angkor Wat and the Khmer Rouge, both extreme examples of hubris and achievement in the magnificent and the depraved. I think the two are inextricably linked. Laos is probably most famous as a place most people have barely heard of and would struggle to locate on a map, although it is notorious for the statistic that it is the most heavily bombed country on earth, courtesy of the United States. I knew the obscurest fact that Alan Davidson, the author of the monumental Oxford Companion to Food, was inspired to write this while the British ambassador there. “Is it safe?” my mother asked. The answer is that as a haven of laid back tropical tranquility Laos can’t be beaten, and I didn’t want to leave. India gave it Buddhism and France gave it the patisserie, a blissful combination. On the menu… As anyone who has ever watched a Vietnam War film will know, the region is generally hilly. The Hueys are always having to fly round them. Cambodia bucks this trend. It is like travelling in Norfolk, only hotter and with more rice paddies and water buffalo. I can understand why someone would want to write an encyclopedia of food after a sojourn there. The fish of the Mekong were Davidson’s speciality, but on my tour group’s first full day in the country we came across a roadside stall selling fried frogs. I don’t think this was a French gastronomic import, I think they thought of this all on their own. The

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smallish frogs are killed, sundried (so would appeal to upmarket Islington types) and then shallow fried whole, while you wait, with a touch of chilli. There isn’t much meat on them, and they taste like chewy fried skin and bone, but with the chilli weren’t too bad. Preferable actually to the frog I had in Beijing, which had been prepared with a meat cleaver and was all bone shards and impossibly fiddly. But four-legged vertebrates are just the entrée. North of Phnom Penh is a town famous for its edible spiders. And not incy wincy spiders either, these are big black tarantulas which are hairy in a shaved velvety sort of way. The stallholder we found had a large bucketful on the ground and on top of this, keeping their compatriots in, was a big tray piled high with fried and ready to eat arachnids. The legs taste like thin black sticks of fried stick, and my victim had an abdomen full of eggs, which are beige and have a powdery slightly bitter taste that I didn’t really like. I wouldn’t have another. But I can’t

The Killing Fields mausoleum housing shelves of victims’ skulls just outside Phnom Penh

ACP news - Autumn 2012


Articles

Your intrepid author with a frog about to meet its maker

say that of the spider rice wine. We had a delicious home-cooked dinner that same evening, in an average one-room local house, that you would have happily paid good money for in a Chinese restaurant in this country. At the end of the meal, the cook’s husband produced a big glass jar half full of a murky yellow-grey fluid with the transparency of pond water. In the bottom of this was a good-sized helping of the same big black spiders. Plenty of houses in the region have a home still or know someone who has, and this makes a potent rice wine. So there was nothing for it but to grasp a shot glass and try said spirit. It is flavoured with honey, and the spider adds a certain proteinaceous je ne sais quoi, and it is actually quite nice. The honey makes it better than a lot of schnapps or other firewaters from around the world. I had a second glass, just to confirm my first impression. Angkor Wat Angkor Wat (or Angkor Wangkor as a friend’s daughter’s classmate said in his class show-and-tell) is claimed to be the largest religious building on earth. It is a colossal towering square stone representation of Mt Meru, the centre of the Hindu universe. It was built

in the 12th century as a temple and royal mausoleum at the zenith of the Khmer kingdom, just at the point when it was over-reaching itself through overpopulation and deforestation. In the following two centuries it was repeatedly sacked by Siamese armies, who burned all of the wooden houses to the ground. My two and a half days there are a bit of a blur of heat and sweat and crowds of other tourists; wonderful but not quite what I expected. Angkor Wat itself is a magnificent huge weathered stone temple complex like a rocket ship cluster surrounded by a wide moat and reached by a 190m long causeway. The weathering lends it a visual interest a pristine new symmetrical building would lack. Immediately to the north is a jumble of stone ruins of the old city centre, including the awe-inspiring Bayon, the pyramidal temple with 216 massive impassive regal stone faces staring out in all directions over the kingdom. Depending on your imagination, this either looks like nothing more than a huge craggy lump of limestone cliff or one of those black and white photos of gaunt shattered tenement blocks in Berlin in 1945. Scattered around the surrounding countryside for miles are numerous other temples, all different, from the famous tree root entangled Ta Prohm, smothered as though by pythons, to the finely exquisite Banteay Srei, reminding me at a distance of a red limestone Gothic country church nestling in the trees by its moat. The Khmer Rouge It is difficult to briefly convey the dark, deranged inhumanity of Pol Pot’s Khmer Rouge regime of 197579. It was a regime of combined communist and Buddhist ideological purity, renunciation of material possessions and suppression of the ego taken to its logically extreme limit in an entire country in one fell swoop. A regime whose express intention was to extinguish individual consciousness in the name of recreating the great Angkor nation of the 12th century which would overshadow its historic enemy next door, Vietnam. All towns and cities, including the capital, were forcibly evacuated of all citizens in a matter of days after the revolution in April 1975. This was to provide manual labour in the countryside for irrigation projects and rice farming. Children were separated from their parents to live communally; ownership of carts, bicycles and oxen was banned as encouraging individualism; and family cooking pots were outlawed to enforce communal living. But when this happens then lack of incentive, hunger and disease triumph. In this philosophy lack of success can only be due to lack of willpower. This means that anyone not

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Articles

Angkor Wat at sunrise

working hard enough or showing the slightest trace of independent thought is a hostile element to be expunged. Town dwellers too culturally remote from the countryside, technicians in factories and intellectuals are particularly prone to individualism or being susceptible to foreign agents. An estimated one and a half million people in a country of seven million died in four years. In January 1979 the Soviet-backed Vietnamese army invaded, not for humanitarian reasons but because it suited the Cold War politics of the Vietnam-Soviet axis. Pol Pot’s inner circle fled to a jungle exile just over the border in Thailand, and the Vietnamese didn’t leave until 1989. Pol Pot died of heart failure in internal exile in his remote camp in 1998, still leader of a tiny ineffectual rebel band. But why did Cambodian society allow such widespread cruelties to occur? That is clearly a complex question difficult to fully answer. Centuries of a sense of national humiliation and inferiority led to a regime modelled on a blend of the French revolution, Stalinism and Maoism at a time of the high water mark of world Communism. This combined with Buddhist fatalism and what observers have described as the Cambodian personality trait of bursts of intense vengeful anger and violence under a gentle carefree surface. Throw in American military carpet-bombing and the alienation that causes

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and you have a foul toxic mix. Communism was ill suited to a country without a big urban proletariat but three decades of French and American reprisals against Communist rebels drove people to the conclusion that maybe being a little poorer was a price worth paying to be a little freer. Administrators and soldiers in all manner of regimes can be persuaded by their superiors to do all manner of inhumanities when they are just “following orders”. Fascinatingly, in a morbid way, I met in Laos an elderly Austrian man who could be described as a Khmer Rouge holocaust denier. He was an experienced traveller in Asia and he said he was convinced the one to two million victims often quoted is a gross overestimate, a product of an American conspiracy to disguise their role in bringing the disaster about. This is certainly a minority view I have never come across before. Look forward, not back Over half of the current population of Cambodia was born since 1979 with an average of five children per family. I noticed that the time of the Khmer Rouge regime is referred to as “the three years and eight months” as though this precision somehow shortens and minimises it, making it sound more of a brief aberration, which it surely was. Cambodians appear to deal with the issue psychologically as far as I can tell by not dwelling on it. They concentrate on the present and look forward not back. Unlike a lot of countries with a history of conflict, they appear not to bear a grudge. Walking around another ancient city site, the local children following us blithely pointed out American bomb craters among the trees and ruins as though they were natural features of the landscape. At no time did I ever get the impression of a trace of anti-Western feeling. I counted 140 entries in the local A to Z drinking guide to Phnom Penh. There’s the California (biker friendly), the Cavern (no hip-hop), the Munich Beer Rest (a German-style microbrewery), the Nordic House (with Scandinavian treats) and Rory’s

ACP news - Autumn 2012


Articles (Irish pub with a great selection of whiskey). My personal favourite (not that I sampled all 140) was the Foreign Correspondents’ Club overlooking the Mekong, where you could get everything from a morning croissant to a sunset happy hour cocktail and a curry. I find Shelley’s “Look on my works, ye Mighty, and despair…” have a particularly haunting ring when taken out of their original ancient Egyptian colossus of a context and applied to Cambodia. This suddenly struck me while I was sitting on the top level of Angkor Wat trying to absorb the atmosphere. This was hampered by Chinese teenage girls pratting about as though in their local park and young backpackers in vests ignoring the fact that this is still a religious site. Angkor Wat, like the Khmer Rouge, to my mind is a huge monument to hubris. The king who commissioned it as his mausoleum, Suryavarman II, was killed on a campaign against the Vietnamese and was never buried there. A figure of 300,000 labourers working on it is widely quoted yet it was never completed, and within a generation the capital that surrounded it was sacked by the Siamese. There must have been a very strong central government with a personality cult to organise the enormous displacement of peasants that must have been necessary to work on such a project, backed by a powerful police force. Long days of labour either on the temple itself or on the supporting irrigation and rice farming would have been necessary. Hunger and disease probably followed as The towering centre of Angkor Wat, the symbolic centre of the the surrounding countryside was felled and Hindu Universe cultivated beyond what it could realistically produce. And very soon the kingdom was to go and try not to come back if you could help it. I met overrun by a more powerful neighbour. The irony of the parallels seems lost on modern Cambodians, who are still a senior Laos government health service manager on the proud of their country’s greatest cultural achievement. plane home. Imagine my disappointment when I learned But I can’t possibly end on a downbeat. Cambodia Laos sends its histopathology out to Bangkok. I took his and Laos are the most wonderfully chilled and laidcard – I’m sure I could do something about that! back countries and perfect holiday material (for an Asia lover like me anyway). Cambodia has awesome Further reading ancient temples, gorgeous beach resorts and the rare 1. Lewis, N. A Dragon Apparent: Travels in river dolphin spotting, as well as a generally low-key Cambodia, Laos and Vietnam. Eland, new edition 2003 friendly vibe. Laos has Buddhist monasteries full of 2. Short, P. Pol Pot. John Murray, 2005 orange-robed monks at every turn, animist hill tribes in 3. Swain, J. River of Time. Vintage Books, 1998 colourful costumes, elephant safaris, French cafes galore and dramatic mountain scenery. It’s no wonder Laos was considered the colonial staff posting to fight for, a place

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Articles A History of Leprosy – Michael Phipps

Mr Michael Phipps is a first year student doctor at the University of Sheffield Medical School Email: mjphipps1@ shef.ac.uk

Sometimes known as Hansen’s disease, leprosy is a chronic infectious disease caused by the rod-shaped bacillus Mycobacterium leprae. Characterised by the severe disfigurement caused to the sufferer’s skin, as well as by sensory loss due to the thickening of nerves, leprosy was one of the most feared diseases during the medieval period. This article traces the spread of leprosy across the world before charting the advances in the medical understanding and treatment of the disease. It also examines the social stigma that has surrounded the condition throughout history and which continues into the 21st century. The spread of leprosy For many years, it was thought that leprosy had been spread from India into countries of the Mediterranean by Alexander the Great’s armies returning to Greece during the period 327-326BC. Once integrated into southern and Eastern Europe, the Roman armies and Phœnician sailors may then have spread M. leprae into Western Europe. It is thought, therefore, that leprosy was first introduced into England in 60BC, due to the high incidence of the disease amongst the conquering Roman soldiers. Despite this, leprosy did not become epidemic in Britain until the 12th century, when the returning Crusaders brought back significant amounts of the bacillus. The traditional theory is supported by skeletal evidence that dates the presence of leprosy in India prior to 2000BC, the oldest evidence of leprosy. Research conducted in 2005 has, however, proposed East Africa as a different origin. By studying the genetic composition and mutation patterns of the different global strains of bacteria, scientists were able to identify four main types: “Most Central Asian strains were of the type-1

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variety, whereas type-2 predominated in Ethiopia, type3 in Europe, North Africa, and the Americas, and type-4 in West Africa and the Caribbean.”1 This evidence opposes the traditional theory. If the disease was ultimately transmitted from India to Western Europe, several mutations would have been necessary from type 1 to 2 to 3 which, according to Stewart Cole, is not feasible due to the genetic stability of the bacillus.1,2 Research also highlights the role of colonialism and the slave trade in the spread of leprosy. As a result of the genetic similarities between type-3 and type-4 leprosy, North African or European migrants are likely to have been responsible for spreading the disease into West Africa. In addition, the presence of type-4 leprosy in West Africa, as well as in countries of South America suggests that the 18th century slave trade may have been responsible for transmitting the disease across the South Atlantic. Furthermore, the presence of type-3 leprosy in North America as well as in Europe, indicates the role of the old world migrants in the spread of the disease. Indeed, there is a positive correlation between Scandinavian migration to the midwestern states of America and the prevalence of the disease there during the 18th and 19th centuries when significantly there was an epidemic of leprosy in Norway. Advances in medical understanding Medieval physicians had a primitive knowledge of leprosy and, as such, often confused it with other skin complaints. For instance, the often-cited Chons’ swellings of around 1550-1350BC, translated by academics as leprosy, are completely dissimilar. Many early physicians also believed leprosy to be as much a moral condition as a medical one. The mode of transmission of leprosy was also disputed. Throughout the Middle Ages, it was believed that the disease was highly contagious. This view was challenged in 1847 by the Norwegian scientist D.C. Danielsson who claimed that the disease must be hereditary due to the failure of physicians to contract the condition, despite spending considerable time amongst its sufferers. The first advancement occurred in 1874, when a Norwegian researcher, Armauer Hansen, isolated the bacillus responsible for causing the disease, M. leprae. Hansen observed “yellow granular masses” within lymph nodes and skin nodules of leprosy patients and

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Articles concluded that these “small staff-like bodies, much resembling bacteria”3 may be responsible for causing the disease. Despite the discovery of M. leprae, however, progression remained limited due to the slow growth of the bacteria, which takes 13 days to divide. This problem was overcome in 1960 when it was discovered that M. leprae could be cultured on the footpads of mice as well as in the nine-banded armadillo, allowing sufficient quantities to be harvested for analysis. By comparing M. leprae with the closely related M. tuberculosis, it was discovered that its genome had reduced significantly through evolution, resulting in severe metabolic constraints, therefore helping to explain the bacteria’s slow growth. It is now accepted that leprosy is an infectious disease, transmitted by droplets exhaled from the respiratory tract. The bacillus is not highly pathogenic, however, meaning that prolonged and repeated close contact is necessary for it to be transmitted.

resistance has been encountered.

Social Attitudes Attitudes regarding leprosy have their origins in the Old Testament of the Bible. Indeed, those who suffered from “tsara’ath”, a terrible skin condition considered an early form of leprosy, were deemed unclean. Leviticus further describes how lepers should be ostracised, stating that “All the days wherein the plague [leprosy] shall be in him he shall be defiled; he is unclean: he shall dwell alone.” Confirmed lepers were no longer protected by the law and were forbidden to marry or to bequeath their possessions. They were also forced to wear special clothing and to carry a type of instrument, such as a rattle, to warn others of their approach. As the disease became epidemic, leper hospitals, known as leprosaria, were established to contain affected individuals and by 1250 most English towns had a leprosarium. Due to the continued fear of the infectiousness of the condition, these establishments were built downwind from town to prevent transmission The evolution of treatments Throughout the medieval period, leprosy was an via the wind. incurable disease with the only policy being that of The campaign against the unclean continued into isolation to prevent further spread. Indeed, before the the 14th and 15th centuries. For instance, in 1346 and 19th century the only proposed therapies were spiritual. in 1472 royal letters demanded the removal of lepers Some considered that alchemy could cure the disease, as from the streets of London. This stance is confirmed by could the earth from an anthill. The Bible also reported records indicating that a leper, John Mayn, was forcibly that submerging oneself in the River Jordan seven times removed from London in 1372. would arrest the condition. This negative interpretation of The first chemotherapy leprosy survives into the 21st “Medieval physicians treatment for leprosy century, as a result of had a primitive knowledge of began in 1941, with the images presented the discovery of the leprosy and, as such, often confused by artists and poets. drug dapsone. Despite For instance, Richard it with other skin complaints.” curing tens of thousands Cooper’s work of 1912 of patients, however, entitled “Medieval villages this mono-drug treatment scrambling to get away from encountered several problems. Indeed, a leper” depicts a leper in traditional the treatment often had to be continued throughout the costume and with deformed facial features. As a sufferer’s life, causing difficulties in ensuring long-term result of this modern day stereotyping, leprosy is now compliance. The use of a mono-drug therapy also led to diagnosed by its alternative name, Hansen’s disease, to the growth of dapsone-resistant bacteria by the 1960s. alleviate the stigma that may otherwise surround the To reduce this risk, the World Health Organization individual. (WHO) proposed the use of multidrug therapy in 1981, following the discovery of two further drugs: rifampicin The eradication of leprosy and future policy and clofazimin. The recommended treatment now In 1991, the World Health Assembly targeted the includes a mixture of all three drugs taken over tworeduction of leprosy to less than one case in 10,000 to-three years. To emphasise the success of multi-drug people by the year 2000 – effectively eliminating the therapy, the WHO reports that since its introduction, 14 disease. This target was achieved, with the incidence of million sufferers have been cured and that no bacterial leprosy falling by 90% in the 10 year period.1

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The disease remains relatively common throughout the Tropics, however, where there are approximately 800,000 new cases per year. If leprosy is to be completely eradicated then significant funds will be needed to pay for the recommended multi-drug treatment approach. This is problematic as multi-drug therapy is expensive – costing US$50 for the prescribed two years of treatment. The stigma surrounding leprosy also makes sufferers reluctant to seek medical attention and this, combined with a lack of education in third world communities, makes early diagnosis and intervention difficult. Governments must, therefore, remain committed to the challenge of changing people’s misconceptions of the condition and providing effective local health services. Conclusion Leprosy is regarded as one of the most horrific diseases in history, surpassing both the Plague and the Pox. From its origins in India, or perhaps East Africa, the disease spread across the majority of the civilised world. The

success of multi-drug therapy, however, led to leprosy being declassified by the WHO as a public health problem in 2000. If the disease is to be eradicated in the future, however, then according to the WHO: “a new environment, in which patients will not hesitate to come forward for diagnosis and treatment at any health facility, must be created.” In other words, the global stigma that has surrounded leprosy for approximately a 1,000 years must be changed. References 1. Grimm D. Global spread of leprosy tied to human migration. Science 2005; 308: pp 936-937. 2. http://news.nationalgeographic.com/ news/2005/05/0512_050512_leprosy_2.html Accessed: 16.10.2011 3. Tan SY, Graham C. Armauer Hansen (1841-1912): discoverer of the cause of leprosy. Singapore Medical Journal 2008; 49: pp 520-521.

ACP Alumni Reunion 2013 The reunion of ACP Alumni will be held at Scalford Hall, Leicestershire from 21 to 24 May 2013 with three night’s private dinner, bed and breakfast at a special ACP rate of £99.00 per double room and £79.00 for single occupancy. We plan to visit a local brewery, Isaac Newton’s home, Barnsdale Gardens and take a reservoir cruise. We will have an after-dinner speaker from Anglian Water to talk about Rutland water with maybe “Albert and the lion” on the last night. Other visits are optional. Full details will be circulated later. Enquiries and expressions of interest to Hugh Mackay at hugh.mackay@talktalk.net

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Membership catagories 2013 No increase for 2012/13 & New Trainee rates Ordinary and Extraordinary members (UK & Ireland) (This category is for medically qualified pathology consultants and career grade pathologists. Membership benefits include the Journal of Clinical Pathology (monthly), ACP news (quarterly), Programme of Postgraduate Education and access to grants and funding) Online Journal only

£127

£104

Trainee members (UK and Ireland) (This category is for medically qualified pathologists in SHO and SpR posts Membership benefits are as shown above) Online Journal only

£25

First Year Consultants (UK and Ireland)

£95

Online Journal only

£80

Overseas Ordinary, Extraordinary and Trainee members (All overseas members pay this rate, with the exception of Retired Overseas members. Membership benefits are as shown above) Online Journal only

£50

£147

£124

Retired Members (no Journal) (All retired members who are no longer in remunerative practice can opt to take this category of membership. Retired Members will continue to receive all publications with the exception of the Journal of Clinical Pathology)

£34

Retired Members with Journal (Retired members who wish to continue to receive the Journal of Clinical Pathology pay this rate. These Members will continue to receive all publications listed above) Online Journal only

£107

£84

Members may opt out of printed Journals and take on-line access only at a reduced rate, as shown above. Please contact Central Office to take advantage of this reduction. Members who have already opted to take on-line Journals need take no further action. For further details contact ACP Central Office Email info@pathologists.org.uk

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Bursary and Award Reports ACP Career Development Award: Rhode Island Hospital, USA – Anna Piskorski The first MDT is listed for 06:45. I’m skeptical; I decide to go to the 07:00 lecture. The 15 minutes make all the difference and I arrive on time, caffeinated and awake. All the residents are already there chatting about their schedule and what the on call over the weekend was like. On call? My interest is piqued. There are two residents on call over the weekend; one covers the equivalent of histopathology while the other covers a mixture of haematology, microbiology, biochemistry and anything else that falls into the general territory of the laboratory. My interest is no longer piqued. I am flabbergasted. My observership at Rhode Island Hospital has begun. I arrived on 7 May 2012 for a four-week attachment. Rhode Island Hospital is a tertiary care centre and the principal teaching hospital for Alpert Brown Medical School. The hospital is located in Providence, Rhode Island. Rhode Island, is the smallest state in the union, teetering on the edge of New England between Connecticut and Massachusetts. The state has a rich maritime history; Newport, a city south of Providence, was a major 18th century port and a hub of pirate activity until the 1720s where the British authorities hanged the criminals and buried them on nearby Goat Island. Modern day Newport offers some of the best preserved colonial buildings and mansions in New England. It is also the city in which John Kennedy wed his future first lady, Jacqueline Lee Bouvier. Providence was Rhode Island’s first settlement founded in 1636. It is now a vibrant university town in part due to the Ivy League Brown University, Rhode Island School of Design and Johnson & Wales University, whose culinary school is world-renowned. The city is reported to have the highest number of restaurants per capita in the country. I can attest and recommend some of the fine Italian eateries dotted around Federal Hill, a historically Italian area of the city. Scrubs The Rhode Island Hospital perhaps is best known for its immortalisation in the US sitcom, Scrubs. It is here that Dr Jonathan Doris did his internal medicine training. His anecdotes and stories provided his friend, Bill Lawrence, with enough material to create the hit US TV show. I learned that life did not imitate art and no wheelchair races took place in the corridors of the hospital but this did not prevent me from an engaging four weeks at Rhode Island Hospital.

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Dr Anna Piskorski is a ST2 Histopathologist at Dewsbury District Hospital Email: a_piskorski@ yahoo.com

I decided to spend four weeks in the States to widen my histopathology horizon and see what pathology training is like overseas. I am originally from Connecticut and jumped at the chance for an extended stay in New England. This is how I ended up sitting in a conference room on the 12th floor of Rhode Island Hospital, while a resident explained an interesting case she had seen over the weekend. She then continued, to my horror, to show a peripheral blood smear. I cringed trying to remember what a megakaryocyte looks like. Pathology training, US-style I parted with my bleep two years ago. It has been an easy transition to pushing glass for a living. I am surprised to hear that our US counterparts keep their bleeps and use them often. The training scheme is different in the United States. It is divided into two components: anatomic pathology and clinical pathology. A training program is either an exclusive three-year program with only anatomic pathology or clinical pathology, or a four-year combination of both. Trainees are encouraged to do both anatomic and clinical pathology with dual board certification in order to be more marketable for consultant jobs. Anatomic pathology is the equivalent to Histopathology. Clinical pathology comprises Clinical Chemistry, Cytogenetics, Haematology, Microbiology, Molecular Diagnostics, Transfusion Medicine and any other subject which falls into the domain of the laboratory. After the initial training scheme most residents go onto a year-long fellowship or two. These fellowships can be

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Bursary and Award Reports divided into different subspecialties like neuropathology, paediatrics, haematology, GI pathology or simply surgical pathology, which covers most surgical specimens a consultant will see in his practice. After the lecture, I meet Dr Mark LeGolvan who will be overseeing my stay at Rhode Island Hospital. I’m pointed in the general direction of the laundry to pick up some scrubs. I have another foundation training flashback and tuck my scrub top into the trousers. I meet the two residents I’ll be shadowing for the next four weeks, Dr Ralf Sams and Dr Michael Chaump, in the surgical suite (cut-up room) which is located on the floor above the operating rooms. Throughout the next four weeks I come to realise that the vicinity of theatres encourages surgical staff interaction. The surgeons frequently follow behind their frozen sections and sit at the multiheader microscope whilst the consultant pathologist reports the case. Dr Chaump takes a small pot sent for a frozen section and pops it open: it’s a lymph node. He’ll do two smears. He hands me one of the slides to stain and I gently tell him that I’ve never done that before. He shows me the rack of stains and off we go. I’ve now made my first slide. The consultant arrives and the slide is reported before the cover slip dries. Things move fast. Four more frozen sections arrive in the lab that day as we try to squeeze in six cancer cases through cut up before finishing around 5:30 pm. There’s still some evening left to look at the slides for the next day. Before we leave the laboratory Chaump grabs two surgical caps and we wander down a flight of stairs to theatres to check the fridges for any specimen that needs to be put in formalin overnight. We find a foot and carry it back upstairs. I tell him we rarely cut up ischaemic limbs. I don’t mention the laboratory staff that would’ve potted the specimen. There are 15 residents in the Brown pathology residency and three fellows. The year is divided into attachments where each resident will spend a set amount of time in each discipline in order to cover the curriculum for anatomic and clinical pathology. In order to finish the residency program the residents have to do at least 50

autopsies throughout their training. This autopsy practice includes an on-call service which covers the weekends. There is a yearly exam that each resident takes in order to demonstrate progression from year to year throughout their residency. There is no formal ARCP or portfolio to submit. However, a conference does take place where the consultants can discuss and raise any concerns about each resident. Busy busy The next day starts with a morning slide checking session which is called sign out. I try to point out nothing is signed out and we’re checking the slides with the consultant. I’m not sure I convinced the resident or the consultant. We check till noon. I take a lunch break while Dr Chaump dictates the cases and amends the reports. After lunch I meet him in the surgical suite where we will spend our afternoon in cut-up. There’s a consensus meeting every day at 2pm which the consultants and residents attached to anatomic pathology attend. The meeting offers a chance to see rare cases and learn something new. My four weeks at the hospital went by fast, despite or maybe because of the 80 hour working week. One of the first things I learned as a ST1 was to never touch the microscope after 4:30pm. on a Friday afternoon; nothing good would come of it. To my dismay this silent rule was unheard of in the States. In addition to their work commitments, the residents were encouraged to participate in research. They also had plenty of opportunities to do presentations; at a grand round, a journal club or resident’s hour, which is a self-directed teaching, the residents lead each Friday. I tried to participate in as many of the resident’s activities as possible and had the chance to present and write up a rare case of carcinosarcoma of the oesophagus. Overall, I enjoyed my time at Rhode Island Hospital and would recommend it to any trainee. I would like to thank Dr LeGolvan and all the residents for a welcoming and informative stay at the hospital.

Random So I met this gangster who pulls up the back of people’s pants. It was Wedgie Kray. I was having lunch with Garry Kasparov and there was a check tablecloth. It took him two hours to pass me the salt. I went into Millets to buy camouflage trousers but I couldn’t find any.

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Bursary and Award Reports ACP Incentive Prize for Junior Doctors 2012: Are we learning enough pathology in medical school to prepare us for our postgraduate training and membership exams? – Emma Marsdin

Miss E. Marsdin is a CT2 in Surgery in the Oxford Deanery and won a £100 ACP incentive prize. Her supervisor was Miss S. Biswas Email: emmamarsdin@ doctors.org.uk

Many medical schools in the UK responded to the first publication of Tomorrow’s Doctors in 1993 by reducing didactic teaching and increasing problem-based and selfdirected learning1,3. This was a requirement of the General Medical Council, that was concerned that undergraduate medical curricula had become factually overloaded. As the number of facts that medical students needed to learn was reduced, the teaching of some subjects was abbreviated and curricula became integrated, merging clinical sciences imperceptibly with clinical medicine to the point that students are unable to recall attending a dedicated taught course in the subject. Pathology (especially histopathology) and clinical pharmacology are two such examples. Several changes in undergraduate education, departmental funding, NHS and a decline in academic pharmacology and pathology conspired to produce a generation of junior doctors who knew less pathology and clinical pharmacology than their colleagues before them. Though not all students were affected, there has been a well-documented increase in prescribing errors4 and a perception amongst clinicians that junior doctors know less about the pathological basis of disease than they once did. Pathology experience We sought to ask junior doctors how useful they thought their undergraduate teaching in pathology had been in their early postgraduate career and in preparation for their membership examinations. A questionnaire study

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was undertaken between January and March, 2011 where 70 consecutive trainees within one UK deanery (Oxford) were handed a single page questionnaire to complete in the hospital where the author works and at regional teaching sessions. Each potential respondent was asked where they had completed their undergraduate medical training and only graduates of UK medical schools were asked to complete a questionnaire, as we sought to evaluate undergraduate Pathology teaching in the UK only. Although almost every doctor, n=61 (96%), thought that pathology formed a major component of their postgraduate exam, most, n=47 (67%), thought that their undergraduate teaching left them unprepared for their postgraduate careers and that they had to learn basic principles as they revised for their postgraduate exams. In their postgraduate learning, few used pathology texts to aid their learning. Most doctors, n=64 (91%), relied on question and answer revision resources for exam preparation. The pathology section of e-Learning for Healthcare (e-LFH) the web-based educational resource delivered in partnership by the Royal College of Pathologists and e-Learning for Healthcare (e-LfH)5, useful for postgraduate learning and revision already available at NHS sites, were also underutilised. Discussion Our findings are similar to those previously published 2,3,6,8,9 which show that the decline of pathology teaching in medical schools since the 1993 publication of Tomorrow’s Doctors (and other factors resulting in the decline) has adversely affected today’s junior doctors in both their academic and clinical work. Reintroduction of clinical pharmacology and pathology teaching within medical schools, and subsequent revisions of Tomorrow’s Doctors have sought to address this. Some doctors remain at a disadvantage. As revision materials are so widely used in postgraduate learning, we suggest that collaboration with academic institutions to produce high quality questions and answers of significant learning value may result in deeper learning and utilisation of these resources as an adjunct to clinical training rather than last minute exam revision tools. Although some written and online materials are available, this might be an opportunity for pathologists, deaneries, the royal colleges and publishing houses to

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Bursary and Award Reports work together in the preparation of good quality written and online material readily accessible to junior doctors in the clinical workplace. 5) References 1) General Medical Council. Tomorrow’s doctors. Recommendations on undergraduate medical education. London (UK): GMC, 1993: 1-28 2) Marshall R, Cartwright N, Mattick K. Teaching and learning pathology: a critical review of the English literature. Med Educ. 2004 Mar; 38(3): 302-13. Review 3) Mattick K, Marshall R, Bligh J. Tissue pathology in undergraduate medical education: atrophy or evolution? J Pathol. 2004 Aug; 203(4): 871-6 4) Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, Tully M, Wass V. An in depth investigation into causes of prescribing errors by

6)

7) 8)

9)

foundation trainees in relation to their medical education – EQUIP study. London: General Medical Council 2009 http://www.e-lfh.org.uk/projects/epath/index.html (Last acessed 22 March 2012) O’Shaughnessy L, Haq I, Maxwell S, Llewelyn M. Teaching of clinical pharmacology and therapeutics in UK medical schools: current status in 2009. Br J Clin Pharmacol 2010; 70(1): 143-148 Aaronson JK. A prescription for better prescribing. Br J Clin Pharmacol 2006; 61(5): 487-491 Gray TA, El-Kadlki A. Filling the gaps in undergraduate teaching of clinical biochemistry. J Clin Pathol 2010; 63: 99-101 Freedman, DB. Is the medical undergraduate curriculum ‘fit for purpose’? Ann Clin Biochem. Jan 2008 45: 1-2

Busted David staggered home very late after another evening with his drinking buddy, Steve. He took off his shoes to avoid waking his wife, Kathleen. He tiptoed as quietly as he could toward the stairs leading to their upstairs bedroom, but misjudged the bottom step. As he caught himself by grabbing the banister, his body swung around and he landed heavily on his rump. A whiskey bottle in each back pocket broke and made the landing especially painful. Managing not to yell, David sprang up, pulled down his pants, and looked in the hall mirror to see that his butt cheeks were cut and bleeding. He managed to quietly find a full box of Band-Aids and began putting a Band-Aid as best he could on each place he saw blood. He then hid the now almost empty Band-Aid box and shuffled and stumbled his way to bed. In the morning, David woke up with searing pain in both his head and butt and Kathleen staring at him from across the room. She said, “You were drunk again last night weren’t you?” David said, “Why’d you say such a mean thing?” “Well,” Kathleen said, “it could be the open front door, it could be the broken glass at the bottom of the stairs, it could be the drops of blood trailing through the house, it could be your bloodshot eyes, but mostly … it’s all those Band-Aids stuck on the hall mirror.”

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Bursary and Award Reports ACP Incentive Prize for Junior Doctors 2012: Bowel Cancer Screening Programme: an audit of histology reporting at University Hospital of North Staffordshire – Alyn German Dr Alyn German is the winner of the ACP Incentive Prize for Junior Doctors 2012 and an F2 Doctor at University Hospital of North Staffordshire, Stoke-on-Trent Email: alyngerman@ gmail.com

The Bowel Cancer Screening Programme (BCSP) was introduced in 2006, and since then has had a major impact on the early stage diagnosis of bowel cancer, leading to a better prognosis for patients. The aim of this audit was to assess whether the consultant pathologists at the University Hospital of North Staffordshire (UHNS) were reporting BCSP specimens using the minimum dataset as advised by the NHS BCSP, and also to assess whether the turnaround time (TAT) met the target of 90% of cases being reported within 7.0 days. Method and data sample The data sample covered two three month periods, JulySeptember 2011 and OctoberDecember 2011. This allowed us to compare data between these periods, before and after the UHNS committed to pilot the NHS BCSP minimum dataset in October 2011. This covered a total of 109 patients, and 217 different specimens. The laboratory codes were input into Masterlab, the histology reporting system at UHNS, to view the completed histology reports and obtain the required audit data.

Cancer identification rate During the six month period covered, 17 adenocarcinomas were identified, of which 11 were identified as tumours at endoscopy, and six were reported as polyps. Of the 17 adenocarcinomas, 11.8% were reported as polyp cancers, 52.9% were classified as Dukes A or B, and 35.3% as Dukes C on resection. There were no Dukes D cancers identified during this timeframe. Fifteen of the cancers (88.2%) were identified in the descending colon, sigmoid colon and rectum. Use of NHS BCSP minimum dataset Prior to the introduction of the NHS proforma, the Audit found that polyp site and type were always documented; however, other items were inconsistently recorded. Post introduction there was found to be 100% completion rate of all aspects of the proforma. Turnaround time Analysis of the two three month periods showed an improvement in the department’s TAT from 4.18 days to 3.86 days. 88.9% of cases were reported to be within the target TAT between July and September, and 89.1% between October and December. A total of 12 specimens were reported to be beyond the seven day target over the six month period. The timings in

Completeness of a minimum dataset

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Bursary and Award Reports

BCSP proforma (example data)

these cases were therefore reviewed. This identified three cases which were reported within 7.1 days, two cases that were reviewed by more than one consultant, one case that required two sets of extras, and one case where it took four days for the specimens to arrive at the laboratory. Another interesting finding One finding highlighted through this audit process was that out of the four GI-Pathologists in the department, one consultant was reporting 41% of all BCSP specimens, in stark contrast to another who was reporting only 8%. Conclusions The achievement of 100% compliance with the BCSP proforma was excellent. Although the turnaround time has improved (marginally), it is still slightly below the Government target of 90%; therefore the investigation of why specimens were beyond the target would potentially improve the turnaround time further. Recommendations Following this audit a number of recommendations were

put in place within the department. The first recommendation, given the aim of the audit, was to maintain use of the BCSP minimum dataset to continue to achieve the excellent 100% adherence rate. Secondly, that if consultants were awaiting extras they should authorise the report and state that a supplementary report will be issued to clarify the results (e.g. if awaiting extra levels to check for excision completeness, or awaiting review by another consultant). The supplementary report should then be issued as soon as possible. The next recommendation was that slides should be distributed equally between consultants to ensure that the workload is evenly spread. Regarding the distribution of specimens, the slides should also be placed on top of consultants’ trays – routine cases should not be put on top of any BCSP specimens. Following a previous audit, all specimen cards already contain a large BCSP stamp for easy identification. Consultants should use voice recognition software to dictate reports directly onto the system. These reports can then be authorised and released immediately. This significantly reduces the turnaround time. The turnaround time also requires continued monitoring. If a specimen is reported after 7.0 days, it is necessary to understand why, along with any further steps which could be taken to identify further areas for improvement. A further audit is to be undertaken to identify delays in delivery of specimens to the laboratory, as this can have large implications on the turnaround time. These recommendations were presented to all the pathology consultants, firstly so that the GI-pathologists were aware of the recommendations put in place, and secondly to allow other pathologists to have an input into any further changes which could be implemented within the histopathology department.

More from the weird and wonderful world of Dr Chris Allen‌ There was a u-shaped scar in the airline approximately 6 cm in length and on the eye right forehead. Mild-moderate focally actinic colitis

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Meetings Reports Hot Topics/Current Issues Management Day: the Liaison and Branch Officers Meeting, February 2012 (A trainee’s perspective) – Zena Slim Dr Zena Slim is an SpR in Histopathology in the Wessex Deanery Email: zenaslim78@ yahoo.co.uk

The annual “Hot topics / Current issues Management day” is a well-anticipated feature in the Pathology meetings calendar. A chance to have the most contemporaneous topics in pathology and the broader medical politicomanagerial world distilled into a couple of hours with a decent lunch and plenty of good banter thrown in. This year was no different. A civilised kick-off time of 10:30 at the Institute of Physics, greeted with coffee and cake made for a happy receptive audience. Delivering the QIPP challenge Following the welcome from Dr Marion Wood, Honorary Secretary of the ACP, the first speaker of the day was Dr Janet Williamson. Dr Williamson heads up the NHS Improvement Centre and gave her talk on “Delivering the QIPP challenge”. For those that don’t know, QIPP stands for Quality, Innovation, Productivity and Prevention. This programme constitutes the Department of Health (DoH) national strategy of quality improvement and cost-cutting. Its mission statement is “to improve the quality and delivery of NHS care while reducing costs to make £20 billion efficiency savings by 2014/15. Savings will be re-invested to support the front-line”1. As with every good management homily, Dr Williamson set the scene by giving an overview of the political and economic “drivers for change”. She reiterated Sir David

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Nicholson’s (Chief Executive of the NHS and NHS Commissioning Board) assertion that “it is vital that we continue to deliver on quality, finance and performance, as well as make the required productivity savings of £1520 billion” in his letter Equity and Excellence: Liberating the NHS, Managing the Transition2. She outlined and gave examples of her department’s activities in supporting NHS providers in implementing QIPP, shaping national policy and supporting commissioning through research and data collection. NHS Improvement has set up pilot sites across the country to implement cost-efficiency initiatives, including clinical pathway re-design, in key areas including Cancer and Diagnostics. Within pathology, Dr Williamson highlighted case studies of her team providing service improvement and redesign expertise, including Lean and Six Sigma methodology. QIPP ‘work-streams’ and pathways offer the framework to implementing these changes. “Walking the specimen walk” and “Go and See” are some of the many ways that teams can get to grips with what is really happening in their labs.1 Dr Williamson was frank in acknowledging that QIPP initiatives focus on short-term objectives without looking at fundamental system re-design. Furthermore, the real

Dr Marion Wood

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Meetings Reports

Prof A Street

challenge was turning paper exercises into reality and in disseminating good practice beyond pilot sites. This starts with good leadership and willingness to change (neither of which is in abundant supply in an over-stretched and reform-weary NHS, I may add). Other challenges to achieving QIPP karma were tight timelines, thinking on a departmental level rather than along the “care pathway” model, and the difficulties in quantifying the impact of changes, particularly on “lateral” and “downstream” services. A comment from the audience highlighted the difficulty in involving managers in this process as “they lack relevant knowledge” and “are paralysed by the task of cost-saving”. Our Dear DoH, to this end, aims to drive these changes forward and silence enemies of QIPP with its publication Innovation, Health and Wealth, Accelerating Adoption and Diffusion in the NHS.3 A “document with teeth” it sets out “a delivery agenda that will significantly ramp up the pace and scale of change and innovation”. This will include financial penalties if NHS Trusts are not seen to implement QIPP policies. Whoever said that “top-down” management in the NHS was passé?

A fairy story for pathology folk Next up, Dr Marion Wood presented us with the experience of “Pathology Transformation in the East of England”. Her talk “A fairy story for pathology folk” was a comprehensive and interesting account of the journey of developing the Pathology Network across the East of England (AKA the Middle East amongst certain circles). Set against the “Carterian” landscape, the story was keenly received as most of us will be somewhere along the tumultuous path to pathology networking and reconfiguration. Every story has a dark side and the set timescales, onerous data requests and political and bureaucratic process involved were alarming even from the warmth and safety of our lecture theatre. The reality of how commissioner- and commercially-focused the process is, was driven home. The involvement of management consultants, collaboration with independent sector, and GPs and Commissioners as “customers” are all new concepts that will be the norm in the not too distant future. So what to the future? This Brave New (Pathology) World, according to Dr Wood, will see a reduction in the number of providers, efficient onsite “hot” hubs, consolidated services, independent sector involvement and a progressive move towards independent Pathology Trusts. Some of the questions that follow “will this story have a happy ending?”, are; “how much cherry-picking of services will happen?”, “what effect will this have on acute Trusts’ incomes?”, “how will cost savings be realised and reapportioned between PCTs and Trusts”, and “will commissioners look at quality measures or just cost when “purchasing” services from competing AQP (Any Qualified Provider)?” Watch this space. Productivity Street Professor Andrew Street swiftly transported us to the relatively calmer waters of health economics with a talk on “Measuring NHS Productivity”. As Professor of Health Economics and Director of the Health Policy team in the Centre for Health Economics, and Director of the Economics of Social and Healthcare Research Unit (ESHCRU), he also serves as a committee member for the Department of Health’s analytical sub-group for Payment by Results. An excellent speaker, he illuminated the subject in a way that even most stats-averse members of the audience (myself included) could understand. He lucidly explained the way that inputs and outputs in healthcare are defined and the complexity of factors that impact on these two measures. One of the many revelations made were that the Office of National Statistics is flawed in its recent assertion that productivity in the NHS has

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Meetings Reports

Dr Anne Thorpe

fallen. He demonstrated that whilst expenditure on capital and staff has increased in the last decade, productivity in the NHS has actually been constant. Another salient point discussed was the regional variation in the cost of care and how a “one size fits all” solution cannot be applied across the various localities. He went on to illustrate how by cutting costs across the board, you are penalising the best performers and not focusing on poorer performing Trusts. In the face of increasing healthcare demands, he made the argument for constant productivity to be the primary aim and for the “incentives reform” to be the sensible model rather than wholesale reorganisation that is constantly distracting us from patient care. He explained how Payment by Results is a good way to change an organisation’s perspective on how they manage resources. There are still not enough incentives for primary care practitioners to reduce acute care admissions. Furthermore, with the increasing commercialisation of healthcare, he emphasised the need for transparency of data to enable us to build a reliable evidence base to effect the necessary changes.

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Six simple steps And then it was lunch-time. A delicious hot buffet served in the cool white interior of the Institute gave us a chance to catch up with colleagues and reflect on the morning’s topics. After lunch, Dr Steven Wilkinson’s talk “Revalidation 2012 – The Value of 360˚ Feedback” set the record straight, in no-nonsense antipodean style, on what multi-source feedback (MSF) should represent. He debunked the myth of MSF as a scientific tool and warned us of the hazards of employing expensive companies to administer them. He gave us a simple sixstep approach to developing our own in-house survey and generously offered his support in setting one up. Next, Dr Anne Thorpe, Consultant Histopathologist, current member of the College Specialty Advisory Committee for Histopathology, a member of the BMA’s Consultants Committee and chair of its Pathology subcommittee, was eminently qualified to talk to us on job planning. “Pathologists are Special” gave us an invaluable and advice-packed final talk of the day. The Q & A session rounded up the afternoon and involved a good discussion on “How to get hospital Excellence Awards Committees to value external professional activities such as peer review assessors and EQA scheme organisation”. The speakers covered a broad scope of important issues and no doubt enthused people to implement some changes in their own workplaces and careers. As a trainee, it offered me the opportunity to learn about the current management issues in pathology and medical politics in the wider NHS and helped translate the jargon du jour. All in a very digestible format. Thank you to Dr Marion Wood and Rachel for organising the meeting and to Abbie Pugh for playing paparazzi for the day. I would whole-heartedly encourage consultants and senior trainees to attend the 2013 meeting. References

1. http://www.improvement.nhs.uk/Default. aspx?alias=www.improvement.nhs.uk/qipp 2. http://www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/documents/digital asset/dh_117406.pdf 3. http://www.dh.gov.uk/prod_consum_dh/ groups/dh_digitalassets/documents/digital asset/dh_131784.pdf

ACP news - Autumn 2012


Meetings Reports The ACP National Scientific Meeting, The Royal Institute of British Architects, London 28-29 June 2012: Abbie Pugh, Eamonn Trainor, Bill Simpson and Eric Watts

Dr Abbie Pugh is a Histopathology Trainee at The Royal Orthopaedic Hospital, Birmingham Email: abbiepugh@ doctors.org.uk

Dr Eamonn Trainor is a Microbiology Trainee at The Royal Liverpool University Hospital

Dr Bill Simpson is a Consultant Chemical Pathologist at NHS Grampian

Dr Eric Watts is a retired Consultant Haematologist and recreational athlete

Email: eamonntrainor@ nhs.net

Email: bill.simpson@ nhs.net

Email: eric.watts4@ btinternet.com

The National Scientific Meeting (NSM) 2012 was held over two humid days in June at 66 Portland Place, the home of the Royal Institute of British Architects (RIBA) in London. The impressive 1930s Art Deco architecture and minimalist interiors provided an interesting backdrop to the day. The building itself was opened in 1934 and was one of the earliest “modern” buildings to be listed (Grade II) on the grounds of historical and architectural importance. Why is this relevant? Well, when Abbie began snapping away with my camera, she was quickly asked to stop. Was she blinding the speakers? No (well yes, maybe). Apparently, there is a rather sensitive sprinkler system that has been triggered in the past by camera flashguns. Whether this is true or not remains open to debate but we’re not sure the room full of consultants would have been impressed by an indoor rain shower triggered by a trainee! Although the NSM has traditionally involved just a couple of pathology specialities, this year it was decided that it would aim to be as multidisciplinary as possible, with sessions organised for histopathology, chemical pathology, microbiology, haematology and forensic pathology. This year’s theme was iatrogenic disease, and the ACP president, Professor Tim Stephenson, commenced proceedings with an overview. We learned that “iatrogenic” is derived from the Greek word iātrós

The Royal Institute of British Architects

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Meetings Reports meaning “healer” and refers to a condition or effect resulting from medical treatment. It is thought to be the third biggest killer, after heart disease and cancer. We routinely encounter iatrogenic conditions in all disciplines of pathology. Many iatrogenic conditions are a trade-off for treatment of more serious conditions, rather than negligence or avoidable error, and the phrase primum non nocere (first, do no harm) is an important reminder of our duties as doctors. Histopathology – Abbie Pugh The first day kicked off with professor Neil Shepherd from Cheltenham (who assures us we haven’t got too long to wait for the new edition of Morson and Dawson!) discussing iatrogenic disease of the gastrointestinal tract. He emphasised the importance of trimming and reporting specimens from post-operative complications to a high standard for medico-legal reasons and to support your Trust in the event of a complaint. Drugs were the main theme of iatrogenic pathology in the GI tract, particularly NSAIDs, Gold and antibiotics. Professor Shepherd answered his own question on the numbers of eosinophils required to diagnose eosinophilic oesophagitis (no idea, his registrar does the counting). Dr Judy Wyatt (Leeds) followed with iatrogenic conditions of the liver and reminded us that paracetamol toxicity is not always a result of deliberate overdose. It has been reported recently that chronic “mild” non-deliberate overdose is increasingly observed in the elderly, especially in the frail or underweight patient, and can have detrimental effects on the liver. After coffee, Dr Alexandra Rice (Royal Brompton) systematically reviewed the alphabet soup of interstitial lung disease and the histological clues to different drug reactions before discussing iatrogenic causes of airway disease, vasculopathy and malignant conditions. The morning ended with Dr Griffiths and Dr Leonard discussing iatrogenic pathology of the urological tract and skin. Professor Tim Stephenson gave the presidential address on iatrogenic disease of the endocrine system but before delighting us with the iatrogenic conditions of Worrisome Histological Alterations Following Fine needle aspiration of the Thyroid gland (WHAFFT) and Worrisome Histological Alterations Following Fine needle aspiration of the Parathyroid gland (WHAFFP). He explained (whilst nearly falling into the cupboard) the symbolism and meaning behind the ACP coat of arms.

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Professor Tim Stephenson wearing his presidential badge of office

During the lunch break various poster presentations had been exhibited throughout the foyer with a wide range of topics, including some rather gruesome autopsy photographs. The prizes were awarded after the presidential address. Dr Eamonn Trainor received the

ACP news - Autumn 2012

Dr Trainor with his prize-winning poster


Meetings Reports Research Prize for his poster “A 5 year retrospective review of patients with norovirus infection: factors associated with prolonged viral shedding” and Dr Bibi Leila Roofeida Ahmed (FY2 at Russells Hall Hospital, Dudley) received the Audit Prize for her poster “Audit on Clostridium difficile testing: before a positive result”. Prize winners receive a £100 Amazon voucher and all poster presenters get their course fee refunded, so it’s well worth participating (submit before the end of April 2013 for next year’s NSM). Thursday concluded with iatrogenic conditions of haematopathology by Dr Bridget Wilkins of St. Thomas’, who concentrated on post-transplant lymphoproliferative disorders, and Professor Glenn McCluggage from Belfast taking us through the myriad of iatrogenic gynaecological conditions, including metaplastic changes secondary to biopsy and the effects of hormones and intrauterine devices. With the lectures over for the day the Annual General Meeting commenced, which included handing over the presidential badge of office to Dr Mike Galloway. On Friday, presentations were scheduled for the morning only as many histopathologists enjoy attending the forensic pathology session in the afternoon. Professor Mary Sheppard showed us how to identify healed ablation sites and took us through the main culprits of toxic cardiomyopathy. Iatrogenic conditions of soft tissue were compartmentalised into intra- and extraabdominal by professor Cyril Fisher who discussed

Dr B Wilkins delivering her talk “iatrogenic conditions of haematopathology”

post-irradiation lesions and the abdominal cocoon of sclerosing encapsulating peritonitis, which can be seen as a consequence of continuous ambulatory peritoneal dialysis. Lastly, but by no means least, Dr Chas. Mangham concluded the histopathology meeting by giving us all a useful overview of how to describe bone and the principles of Wolff’s law, before taking us through the fundamentals of iatrogenic bone pathology. We learned the history behind “phossy jaw”, osteonecrosis of the jaw, diagnosed in “match girls” working in the match industry but now seen in prolonged bisphosphonate therapy.

The left mandible of a 19th century male showing changes of “phossy jaw”

Forensic Pathology – Abbie Pugh Friday afternoon’s forensic pathology lectures were also attended by histopathologists and perhaps a couple of people from other specialities hoping for a glimpse of some gory photos. Dr Alistair Gascoigne, a consultant in intensive care and respiratory medicine from Newcastle shared with us some interesting case histories, including a nasty case of necrotising fasciitis post-tattoo. He emphasised the importance of hand washing and reminded us that poor hygiene within the medical setting and its consequences may be considered an iatrogenic disease. He told a delightful tale of surveying hand washing of people using the toilets at a medical meeting. I don’t think you want to know the outcome of that – it is disturbing indeed. Anaphylaxis and the autopsy was the title of the next presentation, given to us by Dr Pumphrey – an immunologist. His opinion of the ability of pathologists to correctly diagnose anaphylaxis at autopsy was low (and possibly justifiably so) and proposed that this was due to misinterpretation of tryptase levels and insufficient attention to the clinical history. Dr Pumphrey terrified us with reports of anaphylaxis deaths due to wasps lurking

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Meetings Reports An engaging presentation on pseudomonas, the water supply and hospital environment was given by Professor Kevin Kerr (Harrogate and District NHS Foundation Trust/Hull York Medical School). This area has received significant media attention over the past year, with high profile outbreaks of P. aeruginosa infection in neonatal units in Northern Ireland and recent guidance published by the Department of Health (DoH). Professor Kerr presented compelling evidence for the role of hospital water in the epidemiology of P. aeruginosa infection in vulnerable patients on augmented care units – including the Dr R Pumphrey delivering his talk “Anaphylaxis and the Autopsy” perils of portable water dispensers! The difficulty of interpreting results in boots and gloves; nearly a quarter of anaphylactic from intermittent water sampling as suggested by the deaths are due to stings. He then urged us to remember new DoH guidance was discussed as well as the need novel/hidden antigens such as sterilising agents and that for further research to identify robust, cost-effective EpiPens may not be effective in today’s “horizontally technological solutions to this problem. challenged” population, due to the short needle size Dr Peter Jenks (Derriford Hospital, Plymouth) gave a resulting in ineffective injections into fat rather than presentation on healthcare workers (HCW) as a source muscle. In the last session of the day, Dr Patrick Gallagher of MRSA. This is always a controversial area and it was discussed post mortems after cardiovascular procedures useful to hear Dr Jenks’ experience in Plymouth, which and emphasised the importance of checking correct included establishing a multidisciplinary staff screening sitings of lines and other devices. Remember never to advisory panel consisting of representatives from the pull at a stent with forceps – they are very stretchy! relevant clinical area, infection prevention and control, the occupational health department and local/joint staff Microbiology – Eamonn Trainor negotiating committees. A stimulating and topical microbiology session chaired by Dr Marina Morgan included a varied programme providing an up-to-date overview of important aspects of iatrogenic infection which sparked debate and discussion among the audience. Dr Peter Muir (HPA Bristol) delivered an excellent presentation on the management of EBV infection in the immunocompromised patient. For those of us who could be best described as virologically challenged (myself included), Peter succinctly provided a coherent overview focusing on important practice points, including the diagnosis and management of post-transplant lymphoproliferative disease. The carefully arranged black and white mugs at coffee

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Meetings Reports Other highlights included a presentation on the management of HCW with group A Streptococcus, and puerperal sepsis – new guidelines, by Dr Marina Morgan who discussed practical difficulties in the diagnosis of puerperal sepsis and the management of real cases – as well as a review of recent NICE guidance on neutropenic sepsis by Dr Rosemary Barnes, for which we were joined by our haematology colleagues. I certainly left the day feeling renewed and updated and have no doubt that many of the areas discussed and debated will allow me to reflect upon and change my future practice. Chemical Pathology – Bill Simpson In the Chemical Pathology session, the role of the laboratory was explored in different contexts of iatrogenic disease; either directly through the actions of laboratory clinicians, or where laboratory results led directly or indirectly to a diagnosis of iatrogenic disease. The contribution of standardisation was considered and specific problems with immunoassay discussed. The morning concluded with some thoughts to the future with the potential contribution of IT. The afternoon took a more macabre twist, looking at more “direct” examples of iatrogenicity – nosocomial homicide, where “caring” professionals had directly caused the deaths of patients, and concluded with a comprehensive multidisciplinary session considering doping in sport, just in time for the Olympics (are we allowed to use that word?). Haematology – Eric Watts A wide range of subjects showing the breadth and diversity of modern haematology. One effect of the improvement in treating malignancies is that there are now 2 million people alive who have been treated for cancer, with the number of survivors expected to reach 3 million by 2020. Late effects are increasingly being recognised, particularly endocrine and cardiac. This is being studied in detail in Sheffield, which has produced good evidence for formal assessments of survivors. The emotional impact of the illness is becoming better understood and there are many small scale research projects to help patients, to prevent post traumatic stress and to enable rehabilitation. One project involves art in medicine and their website – www.mapfoundation.org – provides a vivid illustration. Haemovigilance, i.e. the detailed analysis of all morbidity, errors and near misses associated with blood transfusion, is showing good results with transfusion transmitted infections now very rare and a “back to basics” approach ensuring each of the many steps

A sculpture at the Royal Institute of British Architects

involved in the transfusion process is done properly, showing transfusion is becoming even safer. In the changing world of infections in immunocompromised patients molecular diagnostic techniques can help to guide treatment. Doping in sport is highly topical and requires attention to the three phases of clinical pathology: pre analytical – is this an uncontaminated sample?; analytical –have we a good standard for the substance we’re testing for?; and post analytical – will our result stand up in court? Next year’s NSM is on the 6-7 June 2013 at RIBA and the theme will be “Screening”. Thanks also for the support of Blackwell’s Bookstore who exhibited at the NSM. Acknowledgements The image of Phossy Jaw is reproduced with kind permission of the Museum of London Archaeology, and appears in their forthcoming monograph “He being dead yet speaketh”: excavations at three post-medieval burial grounds in Tower Hamlets, east London, 2004–10

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Meetings Reports 31st Annual Meeting of the British Association of Ophthalmic Pathologists – Caroline Graham The 31st Annual Meeting of the British Association for Ophthalmic Pathology (BAOP) was held on 29-30 March 2012 in Sheffield, hosted by Dr Hardeep Singh Mudhar. There was a varied programme, which included case reports, research papers and guest lectures. The case reports included such rarities as primary apocrine adenocarcinoma of the eyelid, Lisch epithelial corneal dystrophy, IgG4 related sclerosing disease (affecting the orbit and even the myometrium!) and a granulocytic sarcoma of the conjunctiva. Among the research papers were a well illustrated retrospective study of ocular surface squamous metaplasia, and an account of the role of elastin, oxytalan, collagen and inflammation in floppy eyelid syndrome. One study detailing how to improve immunohistochemistry results and preservation of morphology in corneal specimens prompted many of the delegates to encourage the use of this technique (employing boric acid) in their own laboratories. Dr Fiona Roberts gave an elegant talk linking ocular pathology with pulmonary pathology. There were two talks with a veterinary flavour. One

Dr Caroline Graham is a Consultant Cellular Pathologist at Buckinghamshire Healthcare NHS Trust and Secretary of the BAOP Email: Caroline.graham@ buckshealthcare.nhs.uk

included a report of globe proptosis secondary to a dog fight. The other was a comprehensive account of normal and pathological irises in cats and dogs. The veterinary iris lecture complemented magnificently the BAOP lecture delivered by Professor Iain Rennie, entitled “Heterochromia and other disorders of the iris”. The other BAOP lecture was a fascinating update on the genetics of uveal melanoma given by Dr Karen Sisley. Professor Ian Cree told us about the NIHR (National Institute for Health Research) and the mechanism for the successful application for research grants.

BAOP delegates 2012

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Meetings Reports

Meeting dinner, with host Dr Hardeep Singh Mudhar second from the left

Robson, together with the usual controversy surrounding certain cases. The AGM was chaired by the BAOP President, Dr Peter Smith. Delegates came from as far afield as Nova Scotia, Washington DC, Amsterdam, Cork and Dublin. As ever this educational and informative meeting retained its warm, family type atmosphere, as evidenced by the lively chatter during the coffee breaks and meals. Next year’s meeting will take place on 18-19 April 2013 in the beautiful setting of the University of Cork. Readers interested in participating in this or future meetings, or who would like to learn more about BAOP, should contact Dr Graham at the email address above.

A number of presentations were given by trainees and for the first time in the history of the BAOP a prize was awarded for the best trainee presentation. A panel of eminent judges decided that the trophy should be given to Dr Anu Maudgil, trainee ophthalmologist in Sheffield, for her talk “Improving the interaction between the ophthalmology and histopathology departments – an audit”. Aside from this prize, an unofficial prize of best title has to go to Professor Catherine Keohane for her talk entitled “Is that a twinkle in your eye?” about the Twinkle helicase protein, a mutation of which is implicated in mitochondrial myopathy. There was the usual EQA presentation by Dr Keith

Vacuum cleaner jokes… I awoke in the night and saw the Grim Reaper standing at the end of my bed. Luckily, I fought him off with a vacuum cleaner. Talk about Dyson with Death... *** I spent last night waiting in the Emergency Department to see the Urologist. Turns out our new Dyson Ball Cleaner wasn’t what I thought it was!

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ACP news - Autumn 2012

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Meetings Reports Trainee fringe session at the 58th Scientific and Standardisation Committee (SSC) meeting of the International Society on Thrombosis and Haemostasis (ISTH) Liverpool, 26 June 2012 – Gill Lowe The idea of having a session targeted at trainees for this year’s ISTH meeting in Liverpool first started during the 2011 conference in Kyoto, Japan over coffee and a friendly chat. Little did I know how much it would develop and how huge an undertaking it would become! ISTH is the leading worldwide organisation dedicated to the advancement of understanding, prevention, diagnosis and treatment of thrombotic and bleeding disorders. International congresses are held on a yearly basis and happen in the UK approximately once per decade. The location of the meeting in Liverpool thus represented a great opportunity to include an event focussed at UK trainees. This was strengthened by the fact that the overall meeting had an educational format with “Hot Topic” plenary sessions. Thrombosis and haemostasis is a large part of any haematology trainee’s workload, and we wanted to provide an interesting and stimulating day focusing on key areas within this specialty. Our aim was to keep registration free for this event in order to encourage attendance and to promote haemostasis and thrombosis as a career option for haematology trainees. We originally had 80 registered delegates, but actually ended up with approximately 130 attendees as many people arrived on the day and asked to attend.

Inside the Albert Dock Convention Centre

Dr Gillian Lowe is an Academic Clinical Research Fellow at the Institute of Biomedical Research, University of Birmingham Email: g.c.lowe@ bham.ac.uk

Although the event was mostly aimed at UK trainees we did have several international delegates, and also attracted some attendees who were biomedical scientists. We decided to split the day into two main sessions – the morning was targeted on “Trainees in research”. After an introductory talk on the basics of laboratory coagulation testing, this session discussed several aspects of trainees in research, including the logistics of obtaining research fellowship funding, how to get published and possible ways of integrating research into a clinical career. The afternoon session was entitled “On call Issues in Haemostasis and Thrombosis” and comprised a series of talks discussing commonly encountered practical problems within various areas of this specialty, such as Obstetric Haematology and Inherited Bleeding Disorders. The pitfalls in interpretation of laboratory tests were frequently discussed and were very much appreciated by the audience. After a long and thought provoking day we finished with a Trainee Reception on a terrace overlooking the docks, which was attended by delegates, speakers, and members of the ISTH Council. Everyone appreciated the chance to discuss the day’s events informally and to look forward to the rest of the meeting and spending time in the energetic city of Liverpool!

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Meetings Reports

The trainee reception at the end of the day

We were lucky to have a fantastic complement of speakers who supported the event from the very beginning and gave huge amounts of their time and enthusiasm – without them the day would not have been possible. We would like to thank the ACP very much for their generous support of this meeting. We received overwhelmingly positive feedback from delegates after the event, many of whom said that they hoped that a trainee day would become a regular feature of ISTH meetings. We are currently planning the development of a mentoring system for trainees who are interested in pursuing haemostasis and thrombosis as a career option, as those who attended felt this would be very helpful.

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In conclusion, the incorporation of a trainee day to the ISTH meeting was a huge success and was great fun to plan; we hope this will now become a regular feature of the meetings. Thanks to all the speakers, sponsors, ISTH council, staff at the Albert Dock Convention Centre and delegates. Acknowledgements The Trainee fringe session was sponsored by the Association of Clinical Pathologists and organised by the Trainee Day Organising Committee – Dr Gill Lowe, Dr Jecko Thachil, Professor Cheng Hock Toh, Mr René Haller and Mrs Gayle Halford.

ACP news - Autumn 2012


Meetings Reports Problems in Tumour Pathology – Su Enn Low Every Spring, the Christie Hospital in Manchester customarily holds a day of lectures concerning problematic areas in diagnostic pathology. This time, the focus was on mediastinal pathology. We were honoured to have revered international speakers Dr Cesar Moran and Dr Mark Wick flying in from America to join us. As it was a Saturday, and very early in the morning, we all arrived (or rather, I arrived) looking like something the cat dragged out of bed. And if I am absolutely honest my cat more or less did so, giving me a well-timed thump on the face with his paw at the crack of dawn to remind me it was breakfast. It was thus very welcome to find that there was plenty of hot coffee and tea available before the course started, which was promptly at 9am. Professor Cesar Moran kicked the day off and gave us a riveting account of the status of thymomas and the convoluted progress in its classification. Or regress rather, as it would appear that, some 60 years on, and despite supposed advances in classification, we appear to be back to the drawing board. After coffee, Professor Moran followed on with a lecture on haematolymphoid lesions in the mediastinum. Dr Patrick Shenjere continued with a couple of intriguing lesions.

Dr Su Enn Low is a Consultant Histopathologist at Pennine Acute Trust and an Assistant Editor of the ACP news Email: preciousdumpling @doctors.org.uk

By this time, immersed in spellbindingly difficult cases everyone had lost track of time only to be reminded that lunchtime was nearly over by one delegate’s noisily rumbling tummy. Thankfully, we were allowed lunch, albeit slightly shortened. Lunch was buffet style, so there was no real queuing involved as we dashed down several flights of stairs to get at the food. Paul Bishop (of the immunohistochemical vade mecum fame) was given the unenviable task of reminding everyone that time was up and they had to come back up for lectures. However, he was to learn, from his postprandial fate after he had climbed the several flights back up to the lecture theatre. After lunch, Professor Mark Wick lectured us on mesenchymal tumours affecting the mediastinum, which segued into a discussion of several difficult cases. Dr Daisuke Nonaka finished the series of lectures with several interesting cases. Overall it was a useful educational day, which was also pretty entertaining. I for one would never be able to diagnose a plasmablastic variant of Castleman’s disease with concurrent Kaposi sarcoma in a lymph node and so I will be taking Professor Moran’s advice: “when you don’t know the diagnosis, make it someone else’s problem”.

Professor Mark Wick lectures on the finer points of tailoring

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Trainee’s Zone Leisure time in Oxford with the BDIAP – Monika Beauchamp Dr Monika Beauchamp is an ST3 in Histopathology in Truro Email: beauchamp. monika@gmail.com

Introduction I am sure that, like me, you are often asked what you do in your leisure time. You may then give countless examples of how original and versatile you are when, in truth, your time is mostly spent working. I thought that this would be my bold and honest answer but since I did not feel entirely happy with it I decided to rediscover what my pastime pleasures were, and I came to some conclusions while attending the most recent British Division of the International Academy of Pathology (BDIAP) meeting in Oxford. I really enjoy histopathology courses. They create a lot of mayhem in my life but overall the experience is positive.

A pathologist’s walking tour of Oxford

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Journey Departure involves cooking for as many days as the course in question is going to take, laundering in advance and hiding my clothes from interception into any prospective washing that is going to happen at my absence, unless my desire is to let them turn grey. Then comes the feeling of guilt because I will be leaving those loved ones that allegedly cannot function without me. This is emphasised by a tearful drama at the train station. Finally, I am on the train. It is not the first class coach but it is still comfortable enough to allow me to do some reading. My indispensable backpack contains ambitious reading options for different moods. I have Bill Bryson, good as a traveller’s companion, a dermatopathology atlas and Diagnostic Histopathology. I also take my iPod with some movies to catch up with. I will let you guess which item gets the most attention. Entertainment Oxford is beautiful. I realised that my first and true reason for booking myself a place at this year’s BDIAP spring meeting was that I wanted to have an excuse to visit the place. Each day I walked pass the Museum of History of Science and read on the posters the names of those many intellectuals who performed in Oxford. I had the impression that my IQ rose only by virtue of my being there. I wandered between the walls of all the old buildings that emanated the knowledge of centuries. Professor Ian Roberts helped us to engage with English history. He took us on a popular walk around Oxford, describing intriguing executions and medical students’ autopsy adventures over almost a millennium. It used to be pretty difficult to get a cadaver to practice on, especially as the entire town used to be hostile towards the notion of dissection. Professor Roberts described quite a few bloody battles between “town and gown”. People preferred to chop a dead body themselves rather than let the students anatomise it. Executions

ACP news - Autumn 2012


Trainee’s Zone were a legal source of bodies. He proved to be an amazing storyteller in, for instance, an account about Anne Greene and her unjust death sentence. In 1650 she was hung for alleged infanticide. She had a very strong neck and the tightening wire loop did not kill her. To shorten her suffering her family hit her on the head and she was finally taken to the dissection room. There, she was found to be still breathing. She could not be punished again for the same crime. She went on with her happy life and had many children. We also learnt what was entertaining in preserving bodies when formaldehyde was yet to be invented. The anatomy school kept the whiskey business flourishing. In the end I bought myself “A short history of England” to cover gaps in my knowledge. The book is now awaiting its time allowance, perhaps after “Little Nicholas” and Sternberg bedtime reading. I planned to impress my husband with my intellectual exploits but the only information that he acknowledged was the fact that Harry Potter was filmed there.

New College

My post-Oxford resolution is to get myself on a bicycle

Symposia The Spring BDIAP meeting amalgamated the trainees meeting with a dermatopathology symposium. Both of them were time well spent. The Autopsy day was deliciously packed with information and reality. The talks varied from toxicology, imaging techniques in post mortems to common standard autopsy dilemmas and the Coroner’s perspective. The Coroner’s standpoint was clear and justifiable. Although he understood our desire to investigate precise causes of death and make tissue diagnoses, he is not always prepared to foot the bill for histology. We did not discuss the Human Tissue Act. The day finished with a heart-lifting presentation from Professor Sebastian Lucas, who himself was trying to prove that the Objective Structured Practical Examination component of the FRCPath autopsy exam is passable. It is taken after the successful outcome of the first component of the exam, which is a “simple” post mortem performed at the candidate’s training hospital and assessed by a local consultant familiar to the them and an external pathologist. Why is the new format of autopsy exam better than the old one? First of all, it is fair by being the same to everyone taking it. It consists of 16 stations, some with photographs of gross specimens, others with real time microscopy slides.

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Trainee’s Zone Moreover, candidates are quizzed on advanced autopsy scenarios and asked to interpret toxicology reports or other laboratory data. For the fact that non-invasive investigation of cause of death is on the way to being implemented in daily practice, there are going to be more radiology questions. New specialty training for a pathology radiologist could emerge. The dermatopathology symposium was world class. Most of the cases exceeded my comprehension but the material was made available in PDF format on the website, for revision purposes. Lectures presented systematic approaches to working out dermatoses and some malignancies. I found the lecture on vasculitides very useful. Others gave an update on emerging new entities. Professor Scoyler from Australia was thanked by Professor Shepherd for introducing the youngest BDIAP meeting participant, a six-seven year old boy, his son, who in a very well behaved manner indulged himself in some computer game entertainment in the back row.

Summary Refreshed and educated I arrived home late. The next day I discovered that the inhabitants had not only survived my absence but had also overcome their common colds. Also, I realised that I had been missing all my household chores. I returned to the Department, too. I came to a conclusion that seeing routines and making short code diagnoses, as opposed to identifying case reports, gives me satisfaction and has a soothing effect on me. This histology course was a great fun. I learnt so much on so many subjects, met fascinating people and I did not need to travel far. I got time for myself to rediscover I am a lucky person, who while pursuing her career can see and do wonderful things. Also, having had a break in my day-to-day routine made me understand that my little, I used to think tedious, activities give me a lot of fulfillment.

Meet the Trainee Members Group Name: Eamonn Trainor Job: Medical Microbiology ST3, Royal Liverpool University Hospital, Mersey Deanery TMG position: Vice Chair TMG/ Microbiology Trainee representative TMG role: Represent trainee interests at council meetings; help the Chair run the TMG. Promote the ACP to microbiology trainees, and increase awareness of the management courses and other benefits of membership. Medical School: Liverpool Email address: eamonntrainor@nhs.net Hobbies/interests: Travel, entertaining, art, music, running Favorites: Non-medical book: The Bell Jar, Sylvia Plath Medical book: Kucers, The use of antibiotics Film: The Hours Food: Indian (hotter the better!) Music: Eclectic tastes, Ladytron, Madonna, Tori Amos,

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Pet Shop Boys Quotation/saying: Can we get a MIC on that isolate! Place: Nice, France Alternative career if it all goes belly-up: Interior designer If I won the lottery I would: Go on a long, long‌ holiday Any pets? No, too messy!

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Book Review

Clinical pathologists are faced with a plethora of pathology-related books to choose from to assist in their training and continuing professional development, to accompany their undergraduate teaching, and for their own amusement and enjoyment. The review section is here as your guiding light and presents brief critical reviews of up and coming books (and perhaps one or two you thought you knew) in the realms of pathology, medical education and medical history.

Diagnostic Techniques in Hematological Malignancies Wendy N Erber (Ed) Cambridge University Press, 2010 ISBN 978-0521111218 £75 348pp Haematology is a rather under-taught area of the undergraduate medical curriculum; almost labyrinthine in potential diagnoses and available tests. This book gives some insight into understanding the inner workings and principles behind haematological investigations in order to best utilise them. The book is split into two parts – the first part details the many techniques used for diagnosis and includes chapters on immunohistochemistry and flow cytometry. In these chapters, the basic principles of clinical and laboratory haematology are addressed. Of note is the first chapter which enthuses upon blood and bone marrow microscopy as an integral part of diagnosis, rather than as an adjunct, despite the many laboratory modalities currently available. The second part focuses on the diagnosis and management of the wide range of clinical disease, including disease monitoring, and also highlights the role of prognostic markers. The book is quite user friendly and comes well illustrated with clear tables and diagrams. The plentiful radiological and microscopy images add a welcome splash of colour. Whilst quite readable, this text will probably prove more useful for trainees as a background to clinical and laboratory practice. In diagnostic histopathology terms, it is a bit on the brief side and shouldn’t be mistaken as a working reference text. For the histopathologist, however, it is a useful refresher on clinical aspects of haematological disease, alongside the usual histopathological tomes. Dr Su Enn Low

Readers wishing to become book reviewers for ACP news should contact: Dr Alex Freeman, ACP news Book Reviews, Department of Pathology, University College London Hospital, Rockefeller Building, University Street, London WC1E 6JJ, Email: alex.freeman@uclh.nhs.uk. Please specify which areas of pathology/ medical education/medical history you would be prepared to review books on. Non-histopathologist reviewers with an interest in chemical pathology, medical microbiology, haematology, neuropathology, forensic pathology, and the history of medicine are especially welcome. Reviewers may keep the book and are asked to submit their review within 4-6 weeks of its receipt. Reviews are requested to be 200-250 words long, but space restrictions mean some reviews may need to be cropped by the editors. We welcome suggestions for titles to be reviewed, but regret that unsolicited reviews cannot be accepted.

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Columnists An Apple a day… – Kevin Kerr Professor Kevin Kerr is a Consultant Microbiologist and Honorary Clinical Professor of Microbiology at Harrogate District Hospital Email: kgkerr@hdft.nhs.uk

English in its written and spoken varieties is the subject of seemingly never-ending debate and is a favourite topic for columnists in this esteemed organ. It seems to be a staple for Radio 4 and the network has an excellent programme about English, Word of Mouth. Use of the language is often wheeled out for discussion in news programmes, too, usually around the time that the list of new words to be added to the Oxford English Dictionary (not to be confused with I’m Sorry I Haven’t a Clue’s superb Uxbridge English Dictionary) is announced. The formula is that pundit A in the English-language-is-aliving-thing-which-evolves-constantly-and-new-wordscan-only-enrich-it blue corner is pitted against pundit B in the English-can’t-be-preserved-in-aspic-but-we-shouldstill-be-careful-with-it red one. There then follows a debate about whether we should follow the French and establish an equivalent of the Academie Francaise with both pundits agreeing that we shouldn’t. Everyone goes home, the OED gains some handy publicity and the arguments are put back on the shelf until they are dusted down for the following year. Personally I find the new additions to the dictionary desperately contrived neologisms and I’m pretty sceptical as to whether many of these words will achieve any sort of longevity. Take a current neologism, “staycation”. A favourite of the media at the moment but neither I, nor anyone else I’ve asked, has ever heard this word used in a real life conversation. If my experience is typical and no one actually uses the word then this tiresome construct should disappear as quickly as it has appeared. For years the IT industry has been trying to persuade us that, what everyone else calls a “laptop”, is really a “notebook”. Thankfully this has never caught on, although Apple seem to have had a bit more success

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with their MacBooks, presumably because the phrase “my MacBook” means only one thing, whereas “my notebook” would almost certainly lead to confusion. So is this the way forward then; do we, the punters, just refuse to adopt a word or better still ridicule its use whenever it appears in conversation? I just wish we could and one word at the top of my list for the chop would be leverage. I have just finished reading an article in a journal in which the authors argue that a particular technique could be “leveraged” to reduce infection rates. According to my dictionary leverage is a noun and most certainly not a verb. No-sirree! What is wrong with “used”? Perhaps it doesn’t sound “sophisticated” enough for a scientific publication and presumably to those who are busy leveraging stuff, sounds better than the almost as bad “utilised”, which in turns seems to have replaced “used”. This kind of claptrap along with abominations such as “garner”; “facilitate” and “prior to” could be stamped out with little in the way of effort if we all just said “no”. [Can we add “nauseous” (when people mean “nauseated”) to the pile? – Ed] And speaking of words, how about skeuomorphic? No, me neither. Apparently this refers to an “object that retains ornamental design cues to a structure that was necessary in the original, even when not functionally necessary”. Skeuomorphism is one of the reasons that I never hankered after an iPhone. So to accessing an e-book you would tap an icon that looks like a bookcase from IKEA.

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An apple a day


Columnists Those dinky little icons were just a bit too Fisher Price for me, but after I’d seen a relative watching a feature film on his iPhone I realised that I had to have one. This would be an indispensable tool I told myself as I handed over my plastic to the whey-faced loon in the mobile phone shop. Lots of apps to organise my professional life (sadly in my mid-fifties I am in no need of any sort of app to organise what passes for my social life these days). Diary and contact lists would be synched seamlessly and all would be hunky dory. I would be wowed by Apple’s approach to technology. Straightforward, simple, easy to use, all wrapped up in cutting edge design. Everything would just “work”. So, buoyed up on a tide of enthusiasm I bought an iMac and, grits teeth, MacBook, so that I could enter a state of IT Nirvana and free myself from clapped-out, bloated, five-minutes-to-boot-up, virusridden Windows (apart from my PC at work, of course). Straightforward and elegantly simple. OK, so let’s look at synchronisation. Yep, that’s easy, it’s done through iTunes, which is, er, a music program, sorry, app. Which our IT people at work don’t let you have on your PC. And when I attempt to sync the phone with the iMac and the laptop? Surely straightforward and elegantly simple? Apparently not. Stern messages that if I sync with this, it’ll replace with that. Or is it that with this? The same with music: and here my ancient second generation iPod enters the digital fray. Attempting to synch between devices brings up a flurry of warnings about authorised and deauthorised computers and the familiar invitations that this will be replaced by that

and that by this. Frankly I couldn’t be arsed and resigned myself to listening to different music on different devices and just stopped buying stuff from iTunes altogether. But, I hear the Apple devotees chorusing, iCloud!” Ah yes, the iCloud. Buy anything from iTunes and it will appear on all your devices. Other things can be synched through iCloud, too. Hang on; isn’t this something like the MobileMe (I’m sorry about these daft names) account I signed up for? Yes it is, but Apple is closing MobileMe and you need to move to iCloud. Fine, except it doesn’t work with my iMac. “That’s because it’s running Snow Leopard (another daft name), squire. You need to upgrade to Lion. That’ll be 21 quid from the App Store”. And then I read the dire reviews of Lion on the App Store and wonder whether I really want to take the risk. Or I could wait for the release of Mountain Lion later this year (What next, Lenny the Lion*?). So with this impenetrable thicket of authorised and unauthorised computers and devices, non-synching synchronisation and different versions of the same operating system which don’t work with each other, can anything be simplified; say merging my iTunes account with the one I use for iCloud? You can probably guess the answer to that one. Apple: straightforward, elegantly simple and stuff that just works. Yeah, right. Will I be buying the new iPad? Probably. * For younger readers Lenny the Lion was a puppet operated by ventriloquist Terry Hall (not to be confused with the singer from The Specials, Fun Boy Three and The Colourfield) who appeared regularly on television in the late fifties and sixties.

Food of our time – Mike Harris Eating in is the new eating out, or so they say. There are probably a number of reasons for this, not least of which would be the current “credit crunch” (or perhaps in this respect we might refer to it as credit al dente). However, I think what lets many restaurants down is the poor quality of their food compared to what you can buy in the supermarkets and cook for yourself at a fraction of the price. And don’t even get me started on the quality and price of restaurant wines! Some of the supermarket ready meals are quite good as well, although I gather you need to watch the salt content. I can particularly recommend the do-it-yourself

Dr Mike Harris is a consultant histopathologist and a former editor of ACP news Email: mdharris@ doctors.org.uk

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Columnists The “vindy” as we know it was born and, provided it crispy duck pancakes available from M&S (others also is done properly and is not just restaurant code for their do a version, but I think M&S are the best). When he bog-standard curry sauce with extra chilli, it still contains was younger, my son would sometimes share half a duck vinegar and potato. with me, although I wished he would use the hoisin sauce And what about that Chinese carbohydrate staple, the provided and not tomato ketchup. noodle? Historically, noodles have much in common with Conversely, chilli con carne in ready meal form never spaghetti pasta, although the Chinese and the Italians, as seems to pass muster and more often than not tastes like well as some Arab nations, all a lightly spiced mince and bean “Perhaps the deep claim to have invented it. stew. In my experience, Whoever might be correct, packet mixes and jars fried Mars bar may yet catch on doesn’t everyone know of sauce are not much outside of Scotland.” that chop suey is an American better. In fact, most restaurant concoction? Or was it? Some sources state chillies I have had have not really been up that this leftovers dish had actually been around in China to much. Something had to be done and I was just the long before immigrant chefs in the States claimed to man to do it. have created it. At least everyone can agree on one thing: When it came to chilli con carne, I knew the basic the fortune cookie is a purely American invention! “form”, but not the details. Most of the chillies I had tried But did you know that balti, a kind of stir fried curry to cook as a student were mouth-blistering failures that named from the pan or wok in which it is cooked, has it was only possible to eat with the aid of gallons of ice less to do with Baltistan than it has with the Pakistani cold beer (although that doesn’t sound too bad actually) community in Birmingham? Or that, although pizza [Sour cream and guacamole, along with cooking it the itself came from Italy, the deep pan variety has its home day before, help – Ed]. Anyway, for supper one day I in Chicago? It seems that the Belgians were the first to decide to consult the modern oracle that is the internet. start putting mayonnaise on their chips, but this has now The “net” is a great source for recipes and a good way to been adapted in Britain using salad cream (yeuch!), as start is to type the name of the dish you want into Google devoured by my daughter and her chums when they were or Wikipedia. I was soon cooking up a decent chilli, this teenagers. Perhaps the deep fried Mars bar may yet catch time edible without the aid of a fire extinguisher. As well on outside of Scotland. as chilli powder and Tabasco, or even just Tabasco alone, Actually, I think that this kind of “fusion cuisine” has the secret to a good chilli is cumin – and plenty of it [and much to recommend it. As with the examples above, fresh chillies – Ed]. Surprisingly enough, a little dark food travels well and can be adapted to local tastes by chocolate or cocoa powder also goes well in there. But those to whom it is introduced. That is how food has being a bit of a sad geek, I actually got more interested evolved in the past, so why stop now? For example, in exploring the histories behind this and other foods, Chinese cooking goes rather well on fresh pasta shapes, particularly the ways in which their original composition which are easier to eat and often of far better quality than and geography differ from our views of them today. traditional noodles. And how about curry and chips? This Chilli con carne is marketed as Mexican, but it is dish, which rather bizarrely was popularised in the UK apparently virtually unknown in Mexico, outside of by Chinese takeaways, is perhaps not to my own taste, tourist areas. In fact, it is an American dish which but some swear by it. Chicken tikka masala, created in originated in Texas as an easy meal on the cattle trail, Britain and now some would suggest our national dish, where beef was cheap and readily available. It consisted is really a kind of homecoming for the curry as we know of meat, suet, salt and hot chilli pepper. The addition of it, which in its present form originated in the days of the beans and tomatoes came much later and would still be British Raj (the Empire rule of India). considered sacrilege by some purists. Maybe in years to come the origins of regional cuisines Then take the vindaloo, now there’s a proper traditional may become even more unclear in an increasingly Indian meal if ever there was one. Well, not quite. In fact, globalised world. In the future there may be less value the original was a Portuguese dish, vinho de alho, mostly placed on authenticity and tradition, and more on a kind made with pork cooked in wine vinegar (vinho) and of “if you like it, do it”. Perhaps then my son’s creation garlic (alho). When this was taken to Goa by Portuguese of crispy duck pancakes with tomato ketchup, or my merchants, spices were added and somewhere along the daughter’s chips with salad cream, may not seem so line (possibly after the tenth pint on a Saturday night) strange to future generations after all! alho became the Hindi word aloo, which means potato.

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PhotoCurettings Editorial & Curettings

Love, love me do – Spotted by Dr Sarah Johnson in an incidental papillary thyroid microcarcinoma. Don’t you just love endocrine pathology?

A haunting odour – Spotted by Hannah Gibbs

Try not to gouge out your eyes – Spotted by Hannah Gibbs

Rather vampiric coronary vessels – spotted by Mike Biggs

Romanes eunt domus A Roman Centurion walks into a Manhattan cocktail bar and says to the barman, “Give me a Martinus!” The barman says, “Don’t you mean a Martini?” “If I wanted a double, bud, I’d have asked for it”, replied the Centurion.

One, none or more of the curettings in this issue have previously appeared on www.doctors.net.uk

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