The Association of Clinical Pathologists
What do people want from pathologists? Histopathology in the financial wasteland How to fail FRCPath Part II exams NHS â€“ RIP?
Association of Clinical Pathologists Officers
Calendar of Forthcoming Meetings DIARY DATES FOR 2011
President Dr R Reid President-elect Professor T J Stephenson Vice-Presidents Dr A Galloway Dr E Watts Chairman of Council Dr W J Fuggle Secretary Treasurer Dr D Bareford Editor/Publications Secretary Dr Julian Burton Assistant Editors Dr E Carling Dr S Enn Low Postgraduate Education Secretary Dr M K Heatley Management Course Organisers Drs A and M Galloway Secretariat The Association of Clinical Pathologists 189 Dyke Road Hove, East Sussex, BN3 1TL Tel: 01273 775700 Fax: 01273 773303 email: email@example.com http://www.pathologists.org.uk
Date 2011 & Organisation
24 February Association of Clinical Pathologists
Hot Topics Management Day ACP Liaison & Branch Officers Meeting
Institute of Physics Rachel Eustace 76 Portland Place 01273 775700 London Rachel@pathologists.org.uk
2 March Association of Clinical Pathologists
Basic Management Course
Copthorne Hotel Newcastle upon Tyne
Alison Martin 01273 775700 Alison@pathologists.org.uk
16 – 17 June Association of Clinical Pathologists
ACP Annual Scientific Meeting
RIBA 66 Portland Place London
Alison Martin 01273 775700 Alison@pathologists.org.uk
28 – 30 September Association of Clinical Pathologists
ACP 25th Management Course
Hardwick Hall Hotel Sedgefield
Jacqui Rush 01273 775700 Jacqui@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.
General Administrator Ms A A Martin Administrator – Finance Mrs R Eustace Editorial Assistant Miss J Rush (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 2010 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 Ed Carling is Assistant Editor of ACP news and Locum Consultant Histopathologist
Dr Su Enn Low is Assistant Editor of ACP news and Consultant Histopathologist at Pennine Acute Trust
ACP news Winter 2010 Contents P4 P5 P7 P7
Invitation to contributors Editorial Style Guide Letters to the Editor
LEAD ARTICLES P10 Peace of mind for non-religious patients: chaplains and pathologists in common cause. Rev David Hoskins P11 What people want from their pathologists: a patient’s perspective. Mr Tom Grew P14 What people want from their pathologists: a general practitoner's perspective. Dr Trefor Roscoe P15 Histopathology in the financial wasteland: a nightmare for the future. Dr Ed Carling ARTICLES P17 Key quality indicators for cellular pathology. Dr Tim Helliwell P19 Pathology ‘Modernisation’ – A good thing? Dr Su Enn Low P21 Doing things differently in the North. Dr Julian Burton
p13 The mask
BURSARY REPORTS P24 The Laboratory paralogues. Mr Lovesh Dyall P28 Using digital pathology to assess the superficial anatomy of the colon. Mr Peter Brown TRADECRAFT AND MEETINGS P30 NHS – RIP? The 24th ACP management course. Drs Chris Carey and Mike Galloway P33 Report of the ACP alumni meeting. Dr David Winfield P35 British Association for Opthalmic Pathology (BAOP) 29th Annual Meeting. Dr Margaret Jeffrey TRAINEES ZONE P37 How to fail the FRCPath Part II examination in Histopathology. Dr Ed Carling
p28 Bursary Reports
BOOK REVIEWS P41 Another positive book review THE COLUMNISTS P42 Password protected! Dr Carl Gray P44 SLOW SLOW QIPP QIPP SLOW. Dame Dorothy Dixon P45 Facebook and I. Dr Mike Harris P46 Travel is supposed to broaden the mind, but it’s getting to be so much hassle. Prof Tim Reynolds P48 Motivation: everybody’s doing it. Dr Simon Knowles P50 Sunday evening paranoia. Dr Su Enn Low CURETTINGS P51 More of the weird and wonderful spotted by readers
p37 How to fail
ACP news - Winter 2010
All alone and finding oneâ€™s way in a clear blue sea. Rather like becoming an editor.
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. 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. Columns (600 words): Regular and irregular columnists exercise their thoughts. Please feel free to rant. Pathological creative writing: All literary forms, including short stories, serials, surrealism and even poetry. Appreciations (1000-1500 words): We prefer appreciations on retirement, rather than obituaries. Please discuss these with the editor before submission. 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! Trainees: Trainees are especially encouraged to submit material in any and all of the above categories. These will normally be placed in the traineesâ€™ section. Appointments committees in particular value publications in ACP news. Editorial Policy: The editor would particularly encourage overseas contributors, material from trainees, material from nonhistopathologists, commentary on current affairs in pathology, occasional columnists, innovations in pathology, humorous writing on pathology-related topics, and anything downright cantankerous. Format: The ACP news style guide has been revised and appears in this issue on pages 7-9. 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. All suggestions are welcome; however, the editorâ€™s decision is final. ACP news is published quarterly. Regular publication dates are: Issue SPRING SUMMER AUTUMN WINTER
Publication month February May August November
Copy date 5th December 5th March 5th June 5th 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 firstname.lastname@example.org
ACP news - Winter 2010
Editorial Everyone take one step back It’s that special time again when the editorial blue pencil is passed from one hapless victim to the next. Well you might wonder how such an honour is bestowed. According to Domhnall Macauley, Clinical Editor (Primary Care) with the BMJ “You don’t become an editor because you’re normal”. You may well suspect that every two to three years the entire profession is invited to take a swift step backwards: the slowest person becomes the editor of ACP news. In fact, the honour of choosing the next editor falls to the outgoing incumbent. Over the years several of the editors have tried to persuade me to pick up that oh-so-heavy pencil but I have always politely but firmly declined. Dr Knowles threatened bodily harm and so here I am. Actually, it occurred to me that as horrifying as being asked to be the next editor may be, it might be worse not to be asked. I’ve been told that there actually isn’t much to editing the ACP news, but I have already discovered that when you start to pull an issue together there are an awful lot of blank pages to fill. There is also a steep learning curve, filled with excitements such as discovering publishing formats, deadlines and (a highlight) training on what editors do and how they do it. I’d tell you about the secret initiation ceremony that took place in an abandoned pathology museum but the formaldehyde fumes have destroyed most of my memories of it and in any case I have been cursed with a lifetime’s tenure if I give away too much. Anyhow, it seems that the role of the editor is primarily to variously beg, plead and threaten people to write material to fill the pages. While some of the content comes from our esteemed regular (and irregular) columnists, most comes from you dear readers. While I hope fervently for some controversy that will spark debate in these august pages your articles, musings, travel reports, commentaries and curettings will always be most gratefully received. In November the ACP sent me to Oxford to attend a Short Course for Medical Editors, run by Pippa Smart. Surrounded by the editors of many learned journals from around the world I learnt some of the tricks of the trade. It set me wondering what ACP news is all about. I think that this publication has a multitude of purposes. Its formal purpose is to communicate news about the Association of Clinical Pathologists and to bring its members together. What else? Well, the ACP news is a safe place to spark debate, voice opinion and concern and to share practice. This is a light-hearted publication, and so one of the purposes of ACP news is to entertain. I realise that we’re competing for your leisure time (or the time you spend on the toilet – but let’s not go there).
Dr Julian Burton is Senior Teaching Fellow at the University of Sheffield and a Coronial Pathologist at the Medico-Legal Centre Email:email@example.com
I hope that under my tenure the ACP news will be able to live up to those aims. I am lucky to inherit the wonderful work of the previous editors who, I am sure you will agree, have done a sterling job. I doff my cap to all of them, and only hope that I can live up to and maintain the high standards that they have set. You will be pleased to know that the format of your favourite periodical hasn’t changed too much but I have exercised my editorial prerogative and revised the style just a little. The biggest change that I have made is to the title of the publication. Shamelessly I have turned my back on approximately 25 years of tradition and changed acpNews to ACP news. I hope that no one is left unable to sleep at night because of this. Letters to the Editor expressing your unbridled joy or dismay will of course be welcomed. You can find the revised style guide on pages 7-9. Almost all change – please mind the gap ... The editorial panel consists of the editor, wonderfully supported by a team of assistant editors and columnists. While in the past there have been three assistant editors, I am hopeful to establish a team of four. Pat Twomey and Kevin Kerr have stepped down after years of dedicated and exemplary service, and as I stepped up four vacancies for assistant editors became available. I am pleased to
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Editorial introduce the newest members to the team, handpicked from a cast of thousands. Su Enn Low is a consultant histopathologist at the Pennine Acute Trust and will be familiar to all of you as the author of a column that is largely inspired by her cat. She positively begged to become an assistant editor. I feel somewhat responsible as she approached me for advice as to whether or not she should embark on a career in pathology many years ago. On the understanding that we are treated to only one cat-related item per issue (unless she chooses to write about cat-scratch fever) she is warmly welcomed onto the team. Ed Carling is a locum consultant histopathologist and he tells me that he will report cases for food. That leaves us with two vacancies. If you’d like to fill either of them I’d love to hear from you. Assistant editors must read each issue of ACP news from cover to cover (hardly a chore) and contribute or commission at least one article per issue. Clinical chemists, haematologists or microbiologists would be especially welcomed. Elsewhere in this issue The current state of the nation’s finances is clearly causing people to worry about the impact that this will have on
Cert no. TT-CoC-002420
pathology services. Our new assistant editors share their thoughts on this, and Tim Helliwell gives us some suggestions on how we might assure the quality of our work in the difficult times that no doubt lie ahead. As well as considering what we want our service to become, it’s worth asking what those we work with and for want from the service in the changing healthcare landscape. To that end, Tom Grew and Trefor Roscoe give their views on the impact that pathology services have on their lives as a patient and general practitioner, respectively. David Hoskins demonstrates the importance of peace of mind. In dark times a kind word and thoughtful ear take on a special value that is not to be underestimated. The ACP offers financial assistance to students to support their academic studies, and we learn from Lovesh Dyall and Peter Brown how some of that money has been put to good use. If you want to fail the FRCPath examinations it’s never too early to start your preparation. Ed Carling offers some valuable advice but the ACP news accepts no responsibility if you manage to accidentally pass. Finally, of course, there is the usual selection of meetings, reviews and even a bumper crop of columns from our regular and irregular columnists. Enjoy!
www.pathologists.org.uk ISSN No. 0260-065X
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Letters to the Editor Dear Sir I liked the Unmasked Pathologist’s piece in the Autumn 2010 issue. I have to say I was only offended by his spelling of ‘fetal’. How on earth did ‘foetal’ get past the editorial pen of Dr Knowles?
I refer, natch, to the word fœtus. What was hœ thinking of, your prœdœcessor. Has hœ no fœlings? I tell you, hœ’s gone right down in my œstimation mate. Tell you what – youse’ll nœd to have a word in his œr next time he writes something about Lœn Pathology eh? Hooroo
Disgusted of Bangor (Name and address supplied)
Dorothy Dixon, Dame
Ed:I do not know how this happened either but the former editor has been sent to a lonely island to contemplate the error of his ways. Readers unduly traumatised by this lapse are advised to lie down in a darkened room until the throbbing in their temples stops. Dœr Editor My bœdy eyes nearly popped out of my fluffy head when I caught a glimpse of the F word in your estœmed mag. Gobsmacked would come close but bœksmacked would be nœrer the mark.
Dear Editor Your correspondents have every right to their outrage. I am utterly mortified. I have not knowingly misspelt this word since training in *fetal* pathology in the 1980s. I regard *foetal* as a complete blot on the etymological landscape. It is not just incorrect, it is utterly, revoltingly wrong. Yours in shame, Simon Knowles Lonely Island
ACP news Style Guide – Julian Burton This guide builds upon and replaces that produced by Dr Mike Harris in 2005. As well as guiding authors, this will assist in editing and proof-reading, in particular to remind the editor of what he decided on previously regarding any given question. ACP news generally follows the house styles adopted by the Journal of Clinical Pathology and the British Medical Journal. However, its more informal approach inevitably means a more relaxed attitude towards deviation from guidelines. Journal titles The format of the title of this publication has changed. ACP news is now normally written with ACP in upper case and news in lower case. There is a space between ACP and news. When referring to the Association, ACP appears in upper case. In common with the titles of all journals, books, films, TV programmes and what pass for newspapers in the British press, it is printed in italics. Government reports and papers are also italicised, but acts of Parliament are not.
Authors Authors are generally referred to by first and last names at the start of their articles, e.g., “Henry Jekyll” or “Edward Hyde”. For doctors a more formal approach is taken within the body of an article, e.g., “Dr Henry Jekyll is ...”. Authors’ qualifications are not normally given as this may seem like showing off and they may have more than the editor. Abbreviations Abbreviations may be used without explanation if their meaning would be clear to the readership, such as “NHS”, “RCPath” or “BMJ”, also “USA”, “EU” and “UK”, and obviously “ACP”. However, please bear in mind that whilst other abbreviations or acronyms may be familiar to you and others in your field, they may not be so to the wider readership, who will therefore not have a clue what you are on about. In such cases the convention of spelling names out in full the first time they are used, with the abbreviation in brackets, should apply.
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Style Guide Punctuation and grammar Avoid excessive capitalisation. Titles such as “consultant”, “professor”, or “president”, will normally be given lower case, as are “government” and “department”; this prevents them from thinking they are too important. However, you should capitalise bodies such as the “Department of Health”. The ACP may be referred to as the “Association” and the RCPath as the “College”. However, when used non-specifically do not capitalise, e.g., “royal colleges”. When in doubt do not capitalise, unless it looks wrong not to do so. At the end of the day it is not worth getting too bogged down in this as the readership are unlikely to notice, unlike a misused apostrophe which will probably attract correspondence in the letters section for a number of subsequent issues. Try where possible to use “he or she”, not “s/he”, which looks ugly. If no alternative is possible, the non-gender specific “they” can be used as both singular and plural. (English does not have any other satisfactory non-gender specific third person singular, apart from “it”, which might appear rude.) Do not over-use commas. These should be placed where needed for clarification, or where they mark a natural pause in speech. The same applies to hyphenation, which should be used for words preceded by non- and followed by -like, as well as compound words like think-tank, or where the meaning may otherwise be ambiguous, such as little used car as opposed to little used-car. Do not hyphenate no one (not never, no how). Double or single dashes should mainly be used as an alternative to brackets, and not as a substitute for a comma, semicolon or colon, which is just lazy. Similarly, the ellipsis, i.e., “…” (bet you didn’t know that is what it is called), should not be over-used. Where it is used, it should always be three dots, whether in the middle or at the end of a sentence. Some pedants would say four dots if it also includes a full stop, but the editor thinks this is excessively anally-retentive. Punctuation is in some respects a matter of individual style; however, the current editor prefers the use of semicolons and colons to link phrases, rather than several very short sentences, although over-long sentences should also be avoided. Exclamation marks should be used sparingly and normally should be single (no “!!!”, and especially no “!!?!?!?”). Question marks should only follow a direct question, not otherwise, so “Can you help?” but “I wondered whether you could help.” Double quotation marks are normally used for all purposes, single quotes being reserved for quotes within quotes. In quoted speech the comma, full stop, or other final punctuation mark normally comes before the closing
quotation marks; however, this is not so if a quote that is not direct speech falls at the end of a phrase or sentence. Foreign terms, including Latin, should mostly appear in italics. Terms such as ad hoc are italicised. The exceptions are Latin phrases which have effectively become anglicised, such as in situ or in vitro, which are not hyphenated. Latin medical terms are similarly not italicised. Some medical terminology evolves and the most up-to-date form should be used wherever possible, for example Down syndrome rather than Down’s syndrome. For numbers, single figures are normally written, e.g., one, two three. Double figures are given as numerals, e.g., 10, 11, 12. Roman numerals, such as I, II, III, should be avoided. The exception to this would be if it might look odd to do so. Editorial interjections will normally be italicised and appear in square brackets. [Like this – Ed.] They are best kept to a complete and separate sentence. The abbreviations “e.g.”, “i.e.” and “etc.” should be avoided where possible and phrases like “for example” are preferred. Often “etc” at the end of a list is superfluous. When used they should appear with full stops between the letters and are usually followed by a comma or full stop (e.g., etc.). Always use the English spelling rather than the American, for example organise not organize and capitalise not capitalize. An exception to this might be where the editor uses “Americanize”; here he is being ironic. Also avoid American terms and say “biscuits” rather than “cookies”, eat “crisps” not “potato chips” and wear “trousers” not “pants”. This is particularly a problem with curettings found on US websites and, although an argument might be made for keeping to the original form, the editor would prefer it if these were translated into proper English. A developing mammal after the embryonic stage and prior to birth is a fetus, rather than a foetus. Where possible, language should be kept simple. Inflated words and phrases should be avoided. Thus, pay is preferred to remuneration and improve is preferred to affect in a positive way. Paragraphs should not be over-long as this tires the reader; however, one sentence paragraphs should be mostly reserved for children’s books. Variation in both paragraph and sentence length makes a piece more interesting and this is felt to be no bad thing. Article and author titles In the titles of articles on the cover the nouns are normally capitalised; unsurprisingly this is called “title case”. The
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Style Guide title on the article itself should be in sentence case and this is how it will also appear on the contents page. Authors are normally referred to by name only at the beginning of an article (such as Joe Soap) and with title in the body of an article (Dr Joe Soap – note no full stop after Dr). Authors’ qualifications are not given as they may have more than the editor. References Acp news is a professional rather than an academic publication and references should be kept to a minimum. Articles typically have six or fewer references and a list of recommended or further reading is preferred. Where given references should be in the Vancouver style and will appear in the text in superscript, with spaces between numbers, without commas (for example,5 6 7) When the title of a talk or paper is given in full in the body of the text this should be in plain text and in double quotation marks, but not normally preceded by a comma or colon. Submitting text Submissions should ideally be received as Word documents in Times New Roman font, 12 point, single line-spaced and left-aligned. A single space should follow all commas, semicolons, colons and full-stops. Do not use a double space after full stops, as this is a relic from the days of typewriters and is unnecessary in a wordprocessed document. Articles in any other format will normally be converted to the above before they are checked and sent to the printers. Where possible, avoid bullet-points and other formatting, as these are anyway lost in the strange and mystical process of conversion from a Word document in Windows to Quark Express on a Mac, as used almost universally by the printing industry for reasons clear to itself, but to no one else. Most pieces, whether articles or reports, will be returned
to the author after editing, in order that they may carry out a final proof-read and correct any errors the editor may have unintentionally introduced. When correcting an article, authors should do so by modifying the text, but they should not use the “track changes” option in Word as this also causes problems when the files are converted onto a Macintosh at the printers and can turn the most carefully edited and proof-read article into total gobbledygook. Submitting images All submitted articles should be accompanied by a mug shot of the author(s). Images that illustrate the submission are welcomed. Images should be sent as uncompressed JPEG or TIFF files, or similar universally readable format. Pictures and other figures are preferred as separate files. Please do not embed images in Microsoft Word documents or Microsoft PowerPoint as this results in file compression and reduced image quality when published. Images should be in colour and of a high quality (mug shots that accompany an article need to be at least 200Kb). Figures and tables will be referred to as such in the text (in lower case). When there is more than one, these will be referred to as figure 1, figure 2, etc. If images are sent as photographic prints, authors should indicate whether or not these are to be returned. Further information For further reading see the BMJ’s house style advice at: http://bmj.bmjjournals.com/advice/stylebook/basics.shtml or refer to Eats Shoots and Leaves by Lynne Truss and The Economist Style Guide. In instances where no clear guidance exists, the editor will make something up under the guise of “editorial policy”. His decision is final.
Siamese twins ... Siamese twins walk into a pub in Ontario and park themselves on a bar stool. One of them says to the innkeeper, “Don't mind us, we’re joined at the hip. I’m Mike, he’s Jim, we'll have two Molson Canadian beers, draft please.” The innkeeper, feeling slightly awkward, tries to make polite conversation while pouring the beers. “Been on holiday yet, boys?” “Off to England next month,” says Mike. “We go to England every year and hire a car and drive for miles, don't we, Jim?” Jim agrees. “Ah, England,” says the innkeeper.” Wonderful country ... the history, the beer, the culture ...” “Nah, we don’t like that British crap,” says Mike. “Hamburgers & Molson’s beer, that’s us, eh Jim? And we can’t stand the English – they’re arrogant and rude.” “So why keep going to England?” asks the innkeeper. Mike replies, “It's the only chance Jim gets to drive.”
ACP news - Winter 2010
Peace of mind for non-religious patients: chaplains and pathologists in common cause – David Hoskins Reverend David Hoskins is the Chaplaincy Team Leader at Harrogate District Hospital Email: David.Hoskins@ hdft.nhs.uk
Adrian Sudbury died on August 20 2008. He was twenty-six years old. He was not religious, yet he said that it was the hospital chaplain (Mark Newitt, Sheffield Teaching Hospitals) who was of enormous help to him. How does that work; and in days when the National Secular Society have hospital chaplains firmly in their sights for elimination from the NHS payroll, what is the role of us NHS Godbotherers, especially for the vast majority of our patients who are secular? It might be helpful to dispel some common myths. When I turn up on a ward, dog collar proclaiming my religious background, what do patients think? “Good God I must be sicker than I thought!” “Is this bloke here to convert me?” I am not there to convert or condemn, even though I can understand why some people might think that. The Church does not have a blameless record in this department. Some of the most demanding encounters I have had have been with non-religious patients. The religious bits are quite easy; say a prayer, a blessing, give Holy Communion. Those who have no particular faith and who wonder why they have been smitten with this disease or that are a much tougher challenge, and more of a chaplain’s time is spent with this kind of dilemma than doing religious things. Perhaps that is why I love working in the secular world of the NHS more than the religious world of Church. The Reverend Dr Chris Swift who writes extensively on Hospital Chaplaincy says: “It may be that spirituality represents a flight from religious authority, from the idea that religion with a capital ‘R’ requires an outward conformity, which is inauthentic to inner belief. Is spirituality simply the religion of our time?”
Now to get back to the theme of this article, peace of mind for non-religious patients. Adrian Sudbury said that although he was not religious he was certain that the chaplain greatly contributed to his wellbeing. In an email sent the month before he died of leukaemia he said of the chaplain: “It is difficult to quantify exactly how I was helped … for an hour or so we could talk about football, running, the state of the church, world politics … there is no one else who could have provided a service or range of conversations to match this … I loved these chats, and they were always something that left me feeling better and with a renewed determination to keep battling on. It was a service that made one of the most difficult times of my life substantially more bearable.” (If you Google Mark Newitt you will get the whole article. British Medical Journal April 2009). Then there was the lady who shouted at me loudly from her hospital bed, “You will not want to talk to me; I am an atheist.” What I think she was really saying was, “Please talk to me.” An old boy like me picks that up and runs with it. This lady was dying, afraid of what was happening to her, and deeply anxious. The value of chaplaincy for her was more than just a listening ear. It was respect for her views, an unpacking of what troubled her, and an opportunity to deal with problems from the past that could be tackled. It is this kind of work that typifies a chaplain’s day and is at the heart of what we do. Peace of mind might sound a rather grand claim, but time and again it is found. We human beings are wonderful and mysterious creatures. We recognise we are part of creation, are aware of our history, have hopes for the future, know we are mortal. We ask questions. All of this shapes our search for purpose in our lives. Most of us might not be religious, but we are spiritual beings. It is when we are threatened by ill health that issues like these can fill our thoughts. We can lose our peace of mind. It is then that I so often hear the words, “I have not even told my wife/husband this but …” and out comes some anxiety or fear, long suppressed, which surfaces when our mortality is under threat. If we are providing good holistic care in the NHS these fears and anxieties need addressing. Who has the confidence, expertise, and nerve to tread this awesome ground and help bring peace of mind? Not only that, we are obliged to help bring that peace of
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Lead Articles mind by addressing these concerns. From Lord Darzi’s final report, High Quality for All, to Standards for Better Health, we are asked to ensure that “Patients receive effective treatment and care that takes into account their individual requirements and meets their physical, cultural, spiritual and psychological needs and preferences”. I think there is one area at least where chaplains and pathologists have common cause. Post mortems. Many families do not want their loved ones to have a post mortem. This deeply atavistic feeling is hardly surprising. Having witnessed several as each new colleague of mine arrived at our hospital, I know it can help to bring peace of mind when we can tell families what happens, and that we are beautifully put back together. I am in awe of your work. Many pathologists seem to have a dark sense of humour and it can help enormously with those of us who deal with life and death issues daily. We are constantly reminded of our own mortality and that can be testing too. We hardly think like that in our twenties and thirties, but as the ageing process gathers pace it crosses our minds more often. How often is the person in the coffin or on the slab younger than me? Who helps us with our peace of mind? My line manager is a pathologist! I know it is anecdotal but I have a box with hundreds of
letters and cards in it from patients and family members who tell stories of how such encounters helped to bring peace of mind. It is difficult to measure the value of that in financial ways but for those involved it is invaluable. Finally, I recently read of a group of Americans attending a creative writing course. Each was asked to write a short piece on something that had changed their lives. One chap wrote that when he was a teenager he and two other boys who were slightly drunk on beer and had a minor grudge against the local sheriff, climbed the town’s water tower and painted in large letters, SHERIFF BROWN IS A S O B. The two other boys were caught immediately but the writer was not. Twenty years later, and still feeling burdened by the event he looked up Sheriff Brown in the phone book and called him. “Sheriff Brown. I am the boy who wrote those words on the water tower 20 years ago.” “I knew it,” said the sheriff, “and I am really glad you have called me. It must have been very hard for you these last 20 years.” They say confession is good for the soul. How often have I been able to say to a dying patient, is there anything I can do for you, and they tell me a story like this one, or something more dramatic, and they want to put things right. Peace of mind can be worth more than riches.
What people want from their pathologists: a patient’s perspective – Tom Grew I had never been sure what I wanted to achieve in life, especially with regards to a career. It had been my grandfather reminiscing about the Second World War when I was a child that had inspired me to study History at university – and so it began in September 2003 at the University of Sheffield. I had refrained from taking up the option of a gap year and so was instantly drawn to what I saw as the frenetic lifestyle of Sheffield (I was originally from rural south Derbyshire). By the end of 2003 I had also begun to be drawn to the ever increasing (although it did fluctuate considerably) “lump” on the right hand side of my neck. The worried expression on the face of my GP as I told him that the swelling had been present for 18 months, since contracting a severe infection (thought to be EBV but unconfirmed), was instantly mirrored by myself. Following my referral, the majority of the medical professionals I spoke to did not
Mr Tom Grew is a 2nd Year Student Doctor at the University of Sheffield Email: mda08tjg@ sheffield.ac.uk
seem too concerned, especially as the painless swelling was my only symptom – the ENT surgeon who dealt with me felt confident that it was a branchial cyst. After surgery he did not continue with this line of thinking and
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Figure 1: Tom Grew is somewhat effaced
Figure 2: Tom Grew Reacts to CD15
two weeks later he told me that it was “Hodgkin’s Disease” (figures 1 and 2), although he pointed out that while “serious”, it was “not cancer”. Luckily I had a Macmillan nurse on hand to explain things a bit more thoroughly. So began the next “chapter” in my life. Many clichés seem to be used when speaking about cancer, but there was absolutely no possibility that my life could ever have been the same again. My haematologist was incredibly surprised but relieved to inform me that I was “only” at Stage 1A (although he placed an X next to that to recognise the bulkiness of disease present in my neck). Six sessions of outpatient chemotherapy followed. Nausea/vomiting and myelosuppression are most commonly associated with that particular regimen (ABVD) – the former being the hardest to cope with. Severe anticipatory symptoms exacerbated this, as medical professionals that I had never met before injected me with drugs that could make me infertile and made my hair fall out, all in an effort to treat a cancer that had actually only ever given me one symptom. That, the psychological aspect of cancer, was by far the hardest part to deal with – the most difficult stage peaking around 18 months after treatment. (Later I was diagnosed with an anxiety disorder centring around fear of recurrence. A psychologist subsequently stated that she felt that I also had elements of PTSD.) Six years on and I actually have follow-ups for my psychological well-being more frequently than for the Hodgkin’s itself. A CT scan after chemotherapy was extremely positive, but radiotherapy once a day for 20 days followed to minimise the chances of recurrence. After the severity of the side-effects from chemotherapy, this seemed easy – the hardest part lay in having a mask fixed down over my
head to ensure that the targeted field remained consistent throughout treatment. Upon completion of treatment, I was asked if I wanted to keep my mask and so I did – it lay undisturbed in a cupboard for a number of years but now has become one of the many symbols of my illness that I want to embrace and share, and certainly not hide away in a cupboard with my memories (figure 3). Throughout treatment I had discovered that knowledge was the key to my understanding, and ultimate acceptance of my illness. I would be that awkward patient with a list (literally written down) of questions to ask my consultant with regard to everything from Reed-Sternberg cells to the cost of the drugs being used to treat me. My consultant did his best and actually is one of the two main people (the other being my GP) that have inspired me to arrive at my location today. By the end of the History degree I was already contemplating medicine – hesitant for a while due to the fear of debt/time/generally knowing very little about science, I plucked up the courage to ask family, friends and those that had treated me for their thoughts. An almost unanimous “yes” was received and so, on the advice of a distant relative who is a GP, I successfully applied for a job in a hospital pharmacy, in Burton-on-Trent – where I had the chemotherapy side of treatment (I had also entered the world there back in 1985). Two years later I had qualified as a Pharmacy Technician and was fortunate enough to gain a place back in Sheffield – this time over the road from the History department and in the Medical school. My initial foundation year was at a college and included all of the basic sciences that I had not taken at A-level. Now in my second year of the MBChB programme I can only ever imagine working in medical oncology – this also being inspired by my work with various streams of cancer
ACP news - Winter 2010
Figure 3: The mask
research, mainly in London. At a Macmillan conference at the end of 2008 I met a Nurse Consultant from Weston Park Hospital in Sheffield and she invited me to join their National Cancer Survivorship Initiative test site as a user representative. This has led to so many opportunities opening up for me – I now also help to represent the views of all teenage and young adult cancer patients and “survivors” (the use of this term being one of the hot topics of debate) across the country for the National Cancer Research Institute. This has involved speaking at national conferences and running workshops, but most rewarding is communicating with other young people who have shared that almost unique experience – the importance of this connection can never be underestimated. During treatment and for over four years posttreatment I had only heard of and received help from Macmillan Cancer Support. I later found that this was one of the major negatives of being treated at a smaller hospital. At the time I felt that my treatment was fantastic, but now I have experienced larger teaching
hospitals and met some of those responsible for organising policy on a national level, I am acutely aware of how a different postcode could have shaped my care so dramatically. I completely missed out on age appropriate care – there is now an increasing recognition of the necessity for 13-24 year olds not to be split into paediatric and adult settings but to be recognised as a distinct group with individual needs.1 The Teenage Cancer Trust are leading the way in this field – this being another charity that I now have been able to work with, frequently realising how their specialised units and holistic care packages would have benefited me enormously. Thankfully, my health is currently agreeable – I was completely discharged from Burton-on-Trent this summer and recently attended my first appointment at the Late Effects Clinic at the Royal Hallamshire Hospital in Sheffield – a service established in recognition of the specialised supportive care needs that long-term survivors of cancer may require.2 Hopefully I won’t have to access their resources too frequently in the future – the issue of my fertility is still a question that I will probably need to resolve. However, studying medicine has only deepened my understanding of my illness and this has led to further acceptance of what happened and renewed determination to work in the field of oncology. I have recently requested and obtained the histology slides used in my diagnosis – the next step is to have them enlarged, framed and hung on the wall at home. I felt that I lost so much control over my life for such a long period that my decision to study medicine, and now to frame my cancer, has been an extremely liberating one – to take back some control over my life and future. Some have certainly raised their eyebrows when I tell them my plan for the slides, but not only does it make an excellent conversation starter, I actually think my cancer looked quite pretty. References 1. Marris S, Morgan S, & Stark D, ‘Listening to Patients’: what is the value of age-appropriate care to teenagers and young adults with cancer? European Journal of Cancer Care. doi: 10.1111/j.13652354.2010.01186.x 2. Armes J, Richardson A, Crowe M, Colbourne L, Morgan H, Oakley C, Palmer N, Ream E & Young A. Patients’ supportive care needs beyond the end of treatment: a prospective and longitudinal survey. Journal of Clinical Oncology 27(36): 6172-6179
ACP news - Winter 2010
What people want from their pathologists: a general practitioner’s perspective – Trefor Roscoe Dr Trefor Roscoe is a General Practitioner in Sheffield. Email:Trefor@medicallegal.co.uk
as to be clinically important, the laboratory service usually telephones the results through with suitable advice on further management and sometimes we need advice on interpreting the combination of high and low values in the report. We appreciate that without full clinical details laboratories are unlikely to be able to provide a detailed interpretation, but in the vast majority of cases all that is needed is for the laboratory to give the normal ranges. It is our responsibility, having seen the patient or being in charge of their long-term care, to match up the results with what we already know. Systems are in place to flag up abnormalities and these work very well. It is only very rarely that either the clinical picture or the pathology report is so unusual as to require contact with the pathologist. Advice is on occasions also needed before tests are done to suggest exactly what tests to request and again this is most easily done by telephone call, something that in my experience has always resulted in a satisfactory discussion. Keeping up-to-date with all aspects of medical practice can be quite difficult and GPs are always interested to hear via a note on a particular report or in some sort of circular, new ways of investigating problems or new tests to help diagnosis.
One of the first things I do every morning after switching on my computer and logging on, is to check my inbox for pathology reports that have come in since the last log-on. Most of these are routine blood tests that have been generated by the chronic disease management done by the nursing team in our practice. The rest are results that I have specifically requested while managing newly diagnosed patients, or patients who have yet to be diagnosed. On average, I have about 25 such reports every day. This is probably slightly below the norm because the management of the diabetic patients in the practice is done Sometimes things are not straight forward by two of my partners and it is the diabetics that generate An unusual situation may lead to the need to have a the largest numbers of laboratory requests. One of the discussion with one’s consultant colleagues. An example things I have slightly more of is histopathology reports of this occurred a few years ago when a patient of mine because I perform most of the minor surgery in the who had been admitted with a stroke was found practice. This activity generates two to have evidence of cerebral or three specimens per week. metastases. The hospital An individual General doctor asked if the “It is only very rarely that either the Practitioner’s use of patient had had the laboratory is any moles clinical picture or the pathology report therefore only a tiny removed in the is so unusual as to require contact with past and this was fraction of what is the pathologist.” being processed daily, confirmed by the particularly as more of a family. Unfortunately, workload must come from the suggestion was made that secondary care. The procedure of receiving the mole that had been removed may have electronic reports is now so routine in Primary Care that been the source of the patient’s cancer. This led the family we probably do not think of the complexity of the process to complain that I had mismanaged the patient but I was that leads to the report being delivered to our inboxes. able to contact the laboratory and ask them to confirm that So what do General Practitioners’ need from pathology the original histology report that they had given me was services? We need to know when an unexpected abnormal correct. Within a couple of days, I had a further detailed result or an unusual result has been obtained. Obviously report of examination of the original sample, which if this is about results that are so far from the normal range demonstrated that there was no sign of malignancy. This
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Lead Articles enabled me to refute the complaint that the pathologist or I had missed something. Feedback is good Such events are rare but being able to get hold of a consultant to discuss this sort of case is one of the most important features of the interface between GPs and pathologists. Looking at it from the other side we are well aware in primary care of the need to ensure that samples are properly labelled so the correct patient is identified and linked to the sample throughout the process. It would also be useful if, when there seems to be some discrepancy in the numbers of samples or tests being requested, this could be fed back to practice. Increasingly,
samples are being taken and sent off with every box on the form ticked without thinking. I am sure that some laboratories do such audits but perhaps they should become more widespread. All good practices would be happy to have such feedback. In conclusion, pathology services are like any other secondary care opinion that we seek from General Practice. We are asking for help in diagnosing or managing the patientâ€™s condition. We try not to bother too many of our consultant colleagues but there is always a place for closer dialogue with grossly abnormal unexpected or unusual results or in situations like that described above.
Histopathology in the financial wasteland: a nightmare of the future â€“ Ed Carling Dr Ed Carling is a Locum Consultant Histopathologist and Assistant Editor of ACP news. He will report cases for food. Email: edcarling@ doctors.org.uk
At the time I write, the government comprehensive spending review looms over the next fortnight, and my nightmares about the future of histopathology seem if not real, then certainly more vivid. The media is full of apocalyptic predictions of the end of the welfare state as we know it, each report painted with a slightly darker shade of grim concrete grey. The health sector, we are promised, will be spared the evisceration that awaits some organs of the state. Nevertheless, hospital accountants can be seen huddled around their spreadsheets, eyes heavy and faces gaunt as they try to plot survival of the coming financial famine. All expenditure, from magnetic resonance scanners to magnetic paperclip holders, is scrutinised. Always the questions are the same: Do we really need that? Can we do this on the cheap? Inevitably,
their gaze will fall upon the Department of Histopathology. Once, in better times, we could have scared them away with bottles of foul fluids and rooms with even fouler smells. Not now; they are too desperate. They will come, and they will dissect our budgets, examining each cost, however microscopic. There will be meetings, more meetings, and meetings about more meetings. Then, the edicts will come: Spend less, Be more efficient, Innovate, Do more with less. We will of course protest, citing reams of regulations, pathways and guidelines. They will not listen. Again, they are too desperate. Budgets will be cut, broken equipment patched together with duct tape, and ill or retired colleagues will not be replaced. Eventually, it will dawn on us, first as small groups then as associations and larger gatherings, until we all know that things will never be as they were before. Like a young parent in the summer of 1939 we will look around and know that this is as good as we will ever know, and that our future is of increasing toil for decreasing reward. We will change, individually and as one. We will have no choice. The first change will be our outlook. A job we were once proud to enjoy will become first a drudge and then, as the workload ever increases and our equipment grows geriatric, a dull grind. The superspecialists will be the first to fall, knocked from their perches by colleagues unable to tolerate proclamations of best practice that seem ever more unachievable. We will then gradually become more
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Lead Articles uniform, as staff shortages become new optimal staffing levels, and specialisation a luxury we can no longer afford. The Generalist will have returned with a vengeance. Next, we will be rationalised, that is shunted from our individual departments to form an amalgamated factory in an unremarkable iron frame building on an industrial estate somewhere close to the motorway network. A battery farm of hot-desking microscopy will fill this former go-cart track or food packaging facility 24 hours a day, 7 days a week, 365 days a year. Efficiency will demand it. Communication with our former hospitals will be by videolink and e-mail at allotted times only. Finally, we will be outsourced, or at least our work will. The technologies of infinite data storage and transmission will transform our former slides to virtual fodder for global megalaboratories in India or China, where even our fall from hospital grace to cheap warehouse would seem idyllic. I doubt we can avoid these changes, or if we can I do not know how. The collected ranks of taxpayers would no doubt welcome the savings, and when I see my tax bill I would often agree. I am of course a hypocrite, at once
ranting against my occupation being globalised, whilst regularly buying all manner of cheap goods no doubt produced in the worldwide industrial slum. The collectivist alternative, a perfectly equal and fair society isolated from the changes of the world, gives me even worse nightmares, usually involving Gordon Brown. Perhaps our only hope of avoiding either nightmare is to become almost invisible, withdrawing our profession from the world into our own closed secret society. The ACP could transform into an almost Masonic organisation, jealously guarding our hidden knowledge. The Hermetic Order of the Golden Microscope? The Worshipful Company of Thanatologists? Our trainees designated from Zelator to Adeptus Minor as they learn the mysteries of the sacred trichromes, passing only to the level of Magus after a ritual involving hallucinogenic mushrooms and a set of heavily stained liver specials? We could wear hooded silver and purple robes that double as ritual lab coats, and recognise each other in public by a slowing rotating secret handshake that symbolises the great focusing dial of the universe. Perhaps not; it would be an even worse nightmare.
Fairy godmother So, there’s this yellow toad wandering around in the forest kinda pissed off because he doesn't want to be yellow. Life would be easier if he were brown like the other toads ... He’d sure be less visible to predators for one thing. Anyway, this yellow toad bumps into a fairy godmother. “Fairy godmother, please make me brown like the other toads,” begs her. “I’m hacked off being so visible to predators. The stress is like, killing me, you know?” “Okay,” says the fairy godmother, who whips out her magic wand and goes: “Abracapokus! You're brown!” The toad looks down and sees that he is brown ! Except ... for his weenie, which is still yellow. “Hang about lady,” he says to the fairy godmother, “my pecker's still yellow!” “Yeah, well I don't do weenies,” she says, “you'll have to go see the Wizard of Oz for that.” So the toad thanks her and hops off on his way. There is also a purple bear wandering about the very same woods. As luck would have it, he encounters the very same fairy godmother (yes okay it’s a coincidence, but it’s true). “Fairy Godmother! You're just the person I need!” says the purple bear, “I can't pull any bearesses cos they don’t want to be seen with me on account of the hunters. They can spot me from a mile off.” Being a fairly nice fairy godmother, she takes out her magic wand. “Oh for goodness sake, what is the matter with you lot round here," she says. And with that, she yells: “Pokuscadabra! You're brown!” The bear looks down and sees that he is, in fact, brown. Except for his goolies, which remain purple. “Hold up sweetheart!” he says to the fairy godmother, “my goolies are still purple!” “Yeah, well I don’t do those goolie things,” she replies, “you'll have to go see the Wizard of Oz for that.” “Well that's just dandy, innit?” the bear replies, “how the hell do I find the Wizard of Oz?” “Easy,” says the fairy godmother as she flew off ... just follow the yellow-dick toad!!”
ACP news - Winter 2010
Key Quality Indicators for Cellular Pathology – Tim Helliwell The article by Simon Knowles in the autumn edition of ACP news1 emphasises the challenges faced when clinical pathology laboratories need to persuade commissioners and consumers that laboratory services are “fit for purpose”. In general terms this means getting the right report on the right patient to the right place at the right time to allow decisions on management and prognosis to be suitably informed. This article describes an approach to defining the quality of cellular pathology services that is being promoted in Merseyside and Cheshire. More detailed background information is provided in publications by the Royal College of Pathologists.2 3 Scope of a cellular pathology service Cellular pathologists provide diagnostic expertise and advice for clinical colleagues, and work in clinical teams that care for patients. The main output of the cellular pathology service is a clinical opinion based on microscopic examination of the submitted material and is fundamentally no different from the clinical opinions expressed by other health professionals. Pathologists work in partnership with biomedical scientists (BMS), clinical scientists and pathology managers to provide the best possible cellular pathology standards and service. Cellular pathology laboratories deliver: • Diagnostic histopathology and cytopathology reports on biopsies taken in the hospitals and general practice. • Clinical advice to surgeons and physicians on an ad hoc basis and through participation in multidisciplinary team meetings. • On-site support for rapid access diagnostic clinics where fine needle cytology specimens are obtained, assessed for adequacy and, depending on the clinical setting, an immediate report produced to guide patient management. • Autopsy work for the hospitals and coroners. • Multidisciplinary audits and postgraduate teaching within and outside pathology. • Undergraduate medical and dental teaching, and training for biomedical scientists. • Support for clinical trials and tissue banking and, in some settings, direct involvement in research for patient benefit. • Involvement in service management at Trust, Network or National levels. While the volume of activity and time taken for each of
Dr Tim Helliwell is Reader in Pathology at the University of Liverpool and Consultant Histopathologist at the Royal Liverpool University Hospital Email: firstname.lastname@example.org
these headings can be quantified and provides an indicator of the cost of the service, such information does not necessarily inform the likely impact on clinical outcomes. Nevertheless, the content of a biopsy report is an important determinant of whether further investigations and treatment are necessary. A positive biopsy report indicating the presence of cancer, for example, underpins the complex treatment pathways required for successful management. A benign biopsy report avoids overinvestigation and inappropriate treatment. The quality (clinical accuracy) of the report is therefore critically important.
Quality of the Service The quality of a cellular pathology report depends on the
ACP news - Winter 2010
Articles Table 1: Proposed Framework for Quality Assurance in Cellular Pathology
Quality component Structural components Service is provided from a CPA(UK) accredited laboratory(s) Pathologists participate to a satisfactory level in relevant, accredited External Quality Assessment Schemes Pathologists keep up to date Ongoing audit of clinical practice
Measurable components Attendance at multidisciplinary team (MDT) meetings Turnaround times for fine needle aspiration cytology Turnaround times for diagnostic biopsies Turnaround times for resection specimen
List of EQAs schemes in which pathologists participate and evidence of satisfactory performance
All pathologists achieve satisfactory performance in relevant EQA
List of CPD points accrued during each year by each pathologist List of audits completed with summary of conclusions and actions taken
All Pathologists participate in RCPath CPD scheme (250 credits over a rolling five-year period) Completion of audit cycle
Records of attendance
Lead pathologist attends >50% MDTs. Levels for other pathologists are subject to local agreement 80% cases reported within 24 hours (modified by agreement with local clinical teams) 90% cases reported within five working days (modified by agreement with local clinical teams) 90% cases reported within 10 working days (exceptions for some specimens e.g. bone) (modified by agreement with local clinical teams)
Calculated turnaround time
Calculated turnaround time
Calculated turnaround time
training and experience of the pathologist and the quality of the technical laboratory services that provide suitably prepared material for microscopy. As clinical pathology opinions are inherently subjective, assuring the quality of this work relies on a framework of criteria, none of which in isolation is an adequate measure of quality. The components of this framework (table 1) should form part of an annual report that informs commissioners on the quality of the service delivered. Some elements of the quality framework can be recorded for each specimen, while others are essential features of the structure of a pathology service without which it is unlikely that a high
quality service can be delivered. Some information is specific to cancer pathology but the generic criteria can also be applied to other diseases. Where there are nationally agreed measures for the pathological evaluation of a specimen, these can be added to the generic quality components, for example, hormone receptors and HER-2 status of breast carcinomas; lymph node retrieval in colorectal carcinoma resections. Measures of the quality of technical work within the laboratories are included in the standards required for laboratory accreditation (usually by Clinical Pathology Accreditation UK). These include internal quality control
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Articles procedures used on a daily basis, external quality assessment of the technical quality of the work through participation in schemes run by NEQAS, and an effective quality management system.
relevant to an individual pathologist’s practice is essential; this in turn requires that the EQA schemes should perform to the standards required by accrediting bodies such as CPA.
Can the framework be delivered? Clearly, the proposed quality framework does not cover all aspects of the service in detail, and individual services may wish to amend the criteria through negotiation with their clinical colleagues and commissioners. All of the information suggested should be readily available to laboratory managers and most data will be collected for the annual performance review of the laboratory quality management system. The demonstration of satisfactory performance in interpretative EQA schemes that are
References 1. Knowles S. Why we need key quality indicators for clinical pathology yesterday. ACP news Autumn 2010, 19-21. 2. Code of Practice for Histopathologists and Histopathology Services www.rcpath.org/resources/pdf /g030codeofpracticehisto2009_jan10.pdf 3. Quality Assurance in Histopathology and Cytopathology Reporting Practice www.rcpath.org/ resources/pdf/g082_qahistoreporting_feb09.pdf
Pathology ‘Modernisation’: A good thing? – Su Enn Low Dr Su Enn Low is a Consultant Histopathologist and an Assistant Editor of ACP news Email: email@example.com
“There will be a zero per cent uplift in national tariff prices and the uplift for the following three years will be a maximum of zero per cent. This uplift in 2010/11 includes an efficiency requirement of 3.5 per cent. A key area to drive efficiency will be to consolidate pathology services as above to deliver annual savings of up to £500 million.”1 Gulp. And as the implications of the recession sink in, the Treasury are now keen to realise the £500 million savings outlined by Lord Carter, under the guise of an apparent “patient centred” need to modernise and improve the efficiency of pathology services. 2 Collecting cost and activity data from NHS pathology pilot sites in England (whence wide variations between sites were found) the Carter Review made a case for consolidation and reconfiguration citing the brainchild of the Pathology Modernisation; the hub and spoke (managed networks) model. This expounds a main lab
processing all routine pathology tests and performing specialist testing, with smaller labs on acute hospital sites. Fundamentally, this is to provide an integrated service with a single management structure across a defined geographical area to reflect the needs of users, patients and stakeholders. One hundred and sixty current services are envisioned to be reduced to between one and three in each Strategic Health Authority. There are benefits indeed – currently, small labs with “low” volumes of complex/specialist work lead to high costs per test/case. The above network model exhorts concentration and achieves better utilisation of equipment, which in turn works out to be cheaper on a cost per case basis. Rationalisation of buildings, facilities and equipment helps to make savings. In cellular pathology at least, better outcomes can be achieved with increased workload and specialisation, leading to a faster and more responsive service and enabling delivery of targets. The resultant high volume of cases helps facilitate junior doctor training, which is all the more important as as time spent in training is reducing. Consultant “cross-cover” and peer support occur naturally and locum cover is provided for each other during absence. Coverage of a larger population achieves a necessary “critical mass” to justify local testing. Common guidelines and protocols can be implemented to encourage consistency of practice. Standardisation of pathology IT services allows smooth service delivery. In the test based directorates (e.g. clinical
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Articles chemistry), common analyser platforms enable standardisation of reference ranges and test costs can be harmonised. A few such networks are already in play e.g. Kent and Medway, and savings of £4-5 million have been recorded by this network. On a pessimistic note, reconfiguration leads to considerable staff anxiety, uncertainty and a resultant loss of morale. When superlabs are built away from hospital sites for cost reduction, this effectively forms “off site production line facilities” which can lead to staff feeling “detached” from patients. Also, clinical problems may develop; for example, a four-year audit of GP-requested potassium tests in London found as many as one in five were false positives at certain times of the year, because of the effects of cold weather.3 The researchers predicted the problem would get worse with consolidation of pathology services and potential further transportation of samples. Other niggles include soaring transport bills and delays due to batching of specimens prior to transport to keep costs down. Will there be employer contributions to the costs of (further) travel and potential relocation? What about time lost from specialist staff having to attend MDTs across sites? Video-conferencing is not always ideal and suffers from problems related to reliability, technical complexity and technical support. And what of the spoke labs? Ultimately these labs will end up staffed with a skeleton crew. With removal of various aspects of workload, this will impact unfavourably on training and maintenance of skills, and will present a future recruitment difficulty. And finally, as the NHS pathology market is valued at around £2.5bn per annum and with demand for diagnostic tests growing at around 8-10% a year, in come private companies. Serco is one example; a service company which apparently “improves services” by effective management of people, processes and assets. At the time of writing Serco has won a $300 million contract to
provide pathology services to King's College Hospital NHS Trust. Serco already has a contract with Guy’s & St Thomas’ Trust (forming GSTS) and has recently formed a partnership with Bedford Hospital Trust to run its pathology services for the next 10 years. GSTS Pathology also offers pathology services for other NHS organisations, the private sector and for customers outside of the UK. A key question is how will private companies factor in their profit margin and reconcile this with service provision? Might this entail undercutting the in-house cost of service provision and perhaps even paycuts and changes to leave entitlement and pensions? And what happens if friction ensues – will there be a toss-up between business and quality? Quite frankly, no one knows what is going to happen. Over the past 62 years, a lot has changed and the NHS frequently undergoes upheaval and reorganisation for the purposes of modernisation. So how long will centralisation last? Good intentions or not, trying to change a part of a process frequently has a knockback effect on other parts of the chain. Pathology services although not frontline are still important clinical services. But once centralisation (and privatisation) has spread its web, can the tangled skeins then be undone?
References 1. DoH - Operational Framework 2010/11 http://www.dh.gov.uk/prod_consum_dh/groups/dh_ digitalassets/@dh/@en/@ps/@sta/@perf/documents/ digitalasset/dh_110159.pdf 2. www.dh.gov.uk/en/Healthcare/Pathology/DH_075531 3. Thurlow V, Bailey I, Payne N. Centralised Pathology Services. Br J Gen Pract. 2008 April 1; 58(549): 278–279
Reportisms “Sections show a composed naevus with a very largely regressed dermal component.” “Ulcer antrum pythons biopsy x 6.” “These include papillomas and columnar cell change with a sputum from usual type hyperplasia to atypical ductal hyperplasia.” Submitted by Christopher Allen (Christopher.Allen@worcsacute.nhs.uk)
ACP news - Winter 2010
Doing things differently in the North: a visit to Trondheim, Norway – Julian Burton
Dr Julian Burton is a Coronial Pathologist, Medical Educationalist and Editor of ACP news Email: firstname.lastname@example.org
With a population of approximately 180,000 people, one-sixth of whom are students, Trondheim is of a similar size to Chesterfield. It is Norway’s third largest city and fourth largest urban area. The city is centred around the Nidelva where it flows into the Trondheimsfjorden and therefore enjoys a cool but sheltered climate (figure 1). I was invited to give lectures about the external examination and the value of the autopsy on the Short course on autopsy, cause of death and non-neoplastic neuropathology held at St Olav’s Hospital in February 2010. On arrival at the airport I was met by Professor Ivar Nordrum, Professor in Forensic Medicine at the Norwegian University of Science and Technology (NTNU) (figure 2). After a drive on roads which we Brits would consider impassable he took me to see his department, and one has to say it is impressive. St Olav’s hospital is modern and well-appointed. One arrives to find that the pathology department is in a big airy building with a large atrium that has plenty of room in which students can gather, and which affords space for students and staff to mix freely together. There was an atmosphere of quiet studiousness, accented by numerous art installations (which are a requirement in any public building under Norwegian law). The pathology department had the expected consultant offices, cut-up area and laboratory but the autopsy suite was something truly impressive. I have long thought that pathologists are ideally positioned to help in the delivery of anatomy, and to help
Figure 1: A view across the Nidelva
students make the transition from appreciating normal anatomy to understanding macroscopic pathology if only there was time in the day (which for most pathologists in the NHS there isn’t) and suitable facilities. In Norway it is a reality. The mortuary is well-designed and has a
ACP news - Winter 2010
Figure 2: Professor Ivar Nordrum
Figure 3: St Olav’s autopsy demonstration room
significant caseload. Attached to it there are a number of different teaching rooms. First and foremost among these is a dedicated autopsy demonstration room with a large demonstration area (figure 3), audiovisual equipment and viewing gallery which allows students to witness autopsies and to get up close and personal to the action. The last 10 years has seen many universities in the UK dispose of their pathology museums, or relegate them to dark and dusty storerooms, perhaps never again to see the light of day. In Trondheim the trend seems to be occurring in reverse. Attached to the mortuary there is a well-equipped lecture theatre with an adjoining pathology museum. The space is open, bright, modern and has space for pathology specimens and private study or tutorials. The specimens include the traditional fixed tissues in pots as well as more modern plastinated specimens, which can be handled with ungloved hands, and some photographs (figure 4). The collection is actively growing. Pride of place is given over to a fixed whale’s heart which floats in a large clear tank of fixative. In the UK many medical students
will now learn their anatomy without the aid of cadaveric dissection although a few universities, Sheffield included I am pleased to say, still have their students undertake dissection. Walk through the pathology museum in Trondheim and you come to the anatomy dissection room (figure 5). Articulated skeletons are present down the centre of the room, with cadavers for dissection on either side. Trondheim admits approximately 120 students each year, and so the ratio of living students to deceased subjects is not too high. The juxtaposition of anatomy dissection room and pathology museum allows medical students to compare normal with abnormal from an early stage in their training, which I think can only be a good thing. (Of note in Sheffield our pathology museum collection is now housed in the Medical Teaching Unit – the formal name of our anatomy dissection room – for the self-same reason.) It might seem strange to have a professor of forensic medicine working in a hospital histopathology department but things are different up north. In the UK autopsies are performed by non-forensic and forensic pathologists. In Norway this distinction is not made and
ACP news - Winter 2010
Figure 4: St Olav’s pathology museum
Figure 5: St Olav’s anatomy dissection room
histopathologists engaged in autopsy practice will deal with homicides as well as natural deaths, suicides etc. I gather that Norway doesn’t have separate training to specialise in forensic pathology though many pathologists who perform autopsies will take the specialist examinations afforded by other countries. After the tour I was taken to my hotel (which was excellent) and so had time to recover from a long day before setting out to explore the city. Trondheim is a superb city to explore on foot, though if you go in winter it will be cold and walking boots are a good idea as the ground will be slippery and treacherous. There is plenty to see in what is a very picturesque cityscape, but be sure not to miss the Stiftsgården (The Royal Residence in Trondheim) or Nidaros Cathedral (figure 6). Norway is generally thought of as being an expensive place to visit, and I am afraid that that is true. Eating out and shopping are not cheap but if you steer clear of unhealthy food, alcohol and tobacco, things aren’t too bad. Certainly it shouldn’t be a reason not to visit this wonderful country. My short stay was most enjoyable and hospitable. My only
Figure 6: Nidaros Cathedral, Trondheim, Norway
disappointment was that Trondheim is perhaps just a little too far south for you to be able to see the Aurora Borealis, but you can’t have everything.
ACP news - Winter 2010
The Laboratory Paralogues – Lovesh Dyall Mr Lovesh Dyall, a student On August 31 2009, armed with my copy of “At the doctor at the University of Bench” by Kathy Barker, a freshly ironed white lab-coat, Leicester, was awarded an ACP two pens and the hardbound lab book, I stepped with Intercalated BSc Scholarship trepidation into the Laboratory – my battlefield for the in Pathology worth £2,500 in following nine months. 2009-2010. A battle it truly was. From the first couple of weeks, Email: Ld81@le.ac.uk where I had to quickly get to grips with military, sorry laboratory, terms, such as buffer, aliquots, concentrations ... and learn how to pipette with the same accuracy as the laboratory technician (whom I soon referred to as the was not the solution. I was now officially an intercalated magician), to finally sitting down and writing a cohesive BSc student working in the laboratory. piece of literature which condensed nine months of work It was not until two months down the line that I could into 12, 000 words. confidently say I understood my project. This was in part In the first couple of weeks there was a basic quick due to the fact that I had to present my work to the introduction to working in the laboratory from a rather Generals (the department staff), and I had been warned short but sweet laboratory technician, with the magical that I would be expected to answer some rather harsh powers of trouble shooting! It was evident from the outset questions from the “enemy” (the molecular biologists). that good organisational skills, and a good night’s sleep, My project was titled: “Using were key to having a successful day Chromosomal Instability as in the lab. With a folder of a Diagnostic Marker Standard Operating “Paralogue Ratio Tests and Dual in Melanoma”. The Procedures (SOPs) aim was to design to learn from the Loci Ratio Tests are promising novel a molecular tool lab, I moved on to techniques in the detection of which would be my next battle: the first meeting with my chromosomal copy number variations” able to differentiate objectively between wise supervisors to benign naevi and cutaneous receive another shelling of terms, melanoma (CM) lesions. Although the like Paralogue Ratio Tests, PubMed, NCBI, diagnosis of naevi from CM is generally easy both Human Genome Browsers, Quantitative PCR (q-PCR). clinically and histopathologically, there exists a significant So much for having a good night’s sleep! I soon realised minority of equivocal lesions for which the classification that the work that I would be carrying out was novel, and is not obvious. Thus, the ultimate aim of the project running to the textbooks, as many medical students do, (which has been running as a series of BSc projects in the department) was to use my molecular tool to address the need to classify these ambiguous lesions. My approach was to use q-PCR to detect chromosomal copy number variations (CNV) in a set number of melanoma and naevi cases. The normal ‘healthy’ genome contains a diploid set of each chromosome, Figure 1: Diagram showing a PRT between Chromosome (Chr.) X except for the sex chromosomes. The and Chr. 13. Only one pair of Forward and Reverse primers is needed to hypothesis, therefore, was that as naevi amplify both Chr. X and Chr. 13, whilst a green fluorescent probe is used to differentiate Chr. X amplicons from the red labelled Chr. 13 amplicons in a are benign growths, they are likely to harbour fewer (if any) chromosomal q-PCR reaction. This gives rise to the Chr. X|13 PRT. copy number aberrations, compared to
ACP news - Winter 2010
Figure 2: Diagram showing the amplification plots for the Chr. X|13 PRT when assayed on a female and a male tonsil samples. The amplification plot for both targets in the female sample overlap, as the copy number is diploid for both. The amplification plot for the Chr. X target in the male sample is delayed due to the lack of a diploid X status (remember, males are XY!).
melanoma lesions, which are malignant growths. Therefore measuring the degree of CNV in a melanocytic lesion can be an objective indication of malignancy. Paralogue Ratio Tests (PRT) and Dual Loci Ratio Tests (DRT) were the two methods that I used to detect CNV in 36 naevi and 35 melanoma samples. Most of my time was spent in designing and optimising these two methods, which I have come to understand is a major step in almost all research projects: 80% of the time is spent tackling various related aspects of the project, whilst the remaining 20% is then dedicated to finally collecting the data needed to prove or refute the hypothesis. A PRT works on the premise that there are paralogous sequences in the genome: pairs of homologous sequences which occupy two different loci. A unique pair of paralogous sequences was found between chromosomal areas of amplification and deletion. Previous array Comparative Genomic Hybridisation (arrayCGH) data on melanoma samples was used to choose which targets to study. To make a PRT, only one set of Forward and Reverse primers were designed to amplify both targets, whilst assigning two differently labelled fluorescent probes for each target. For those who prefer visual aids, figure 1 demonstrates how a PRT works. Since one primer set amplifies both paralogous targets, it was assumed that
CNV detection by this method would not be confounded by differences in primer efficiency at amplifying each locus. Figure 2 shows the display on the q-PCR machine as amplification of the targets takes place. In the example shown in both figures, a PRT between chromosomes X and 13 was designed and assayed on male and female tonsil samples. A difference in the amplification plots is seen in the male sample, due to the lack of a diploid status for the X chromosome. In this way for the targets studied, it was found that in the normal (diploid samples) the ratio between the two targets was approximately one, i.e. both targets are present in equal numbers. For melanoma samples, the ratio was found to deviate from this due to differences in copy numbers at the loci studied (remember that a locus commonly amplified in melanoma was paired with a locus commonly deleted). A DRT is a slight modification of the PRT. In a DRT, each target is amplified with its own specific primer set, in a multiplexed q-PCR reaction. Specific multiplexed PCR primers generating software was used and these were electronically verified to check for a pair of primer sets with the same efficiency. My study served as a proof of concept. It was concluded that PRT and DRT are promising novel techniques in the detection of CNVs based on which melanocytic lesions can be classified into benign or malignant. The difficulty in designing PRT and translating the PRT to an effective q-PCR reaction meant that another novel q-PCR based technique was developed: DRTs. This year was an invaluable experience. At times, stressful and heart-breaking (especially when the experiments would not work in spite of my rigid planning), whilst at other times, enjoyable and worthwhile (I met a few good friends, and presented my work at a few conferences!). Despite having been away from the clinical setting, I can confidently say I have gained some generic key skills, which will undoubtedly be of use in the future. I have a good basic understanding of medical statistics, can finally use online literature search engines (without pulling my hair!); and most importantly, by taking leadership of my project this year, I have developed my managerial skills on both a personal and professional front. My thanks go to my supervisors and staff at the Department of Cell Signalling and Cancer Studies for their patience and support. Finally, thank you to ACP for your generous grants. Without the support from organisations such as the ACP, I (along with many other students) would not have been able to extend my academic pursuits.
ACP news - Winter 2010
ASSOCIATION OF CLINICAL PATHOLOGISTS Pathology Record # 2713 Name: Dr Eric Watts Current appointment/s: Consultant Haematologist I became interested in medicine whilst being treated for a neuroblastoma many years ago. I studied at Glasgow & was immediately attracted to haematology as the most scientific of all the clinical subjects. I worked as Prof Goldberg's HP there but was put off academic haematology by the obsession with irrelevant small print that typified the department and I went straight into General Practice. Realising that much of GPs work is with children I did a paediatric job then worked in rural Canada - where you can easily be a GP with your own hospital & laboratory – which demonstrated the value of Path Labs in making diagnoses & monitoring treatment. Returning to Blighty I've followed a path of specialisation peaking with two years at the Hammersmith in the early days of bone marrow transplantation – the appliance of science as it should be done! I am proud to have made many of our HPs & SHOs interested in haematology – the perfect blend of science with the art & humanity of medicine. For some years now I've been CD for clinical sciences (includes X-Ray & pharmacy) & the clinical lead for the Essex Pathology Network – testing times !! I've always preached manage or be managed; I try to teach managers about common sense & the real world but it can be challenging; however, medical management is not for those who want the easy life – to quote the Chinese curse, we do live in interesting times. Outside of work my big passion is music – after years of struggling to make a decent sound on the guitar I now play saxophones, particularly the baritone, the biggest of the breed as it looks more natural when you're 6' 3". I have greatly enjoyed my time so far on the ACP Council – a genuine meeting of all the best talents dealing with an eclectic mix of highly principled to every day issues & I look forward to being of service in the future. Pathology Record # 2608 Name: Dr John Murphy Current appointment/s: Consultant Pathologist, Clinical Director Diagnostics (pathology) Clinical Interests: Uropathology, colorectal pathology, dermatopathology PERSONAL DETAILS: Newspaper/s: Times (Mon - Sat) Sunday rest-day (cannot bear broadsheet format and rehash of week’s news in Sunday times). Car: Peugeot 807 (reliable, excellent transporter of people, children, luggage and pet dog. Hobbies: Travel, walking, fitness, reading, music, gardening and learning languages FAVOURITE Authors: Sebastian Faulks, William Trevor, Ian McEwan, PD James. Films: ET (sheer simplicity), I am Legend (stark futuristic theme), Blood Diamond (gripping topical theme) and many others. Football team: Gaelic Games, Cork in Football, and Hurling. TV programme: Spooks, the Apprentice. Music: Eclectic taste with current favourite Tracey Thorn. Anything Celtic including Christy Moore, Mary Black and songs of Jimmy MacCarthy, especially like old reliables, including Carol King, Sarah McLachlan, Paul Simon, Coldplay and Queen. Likes: Company of family and friends with good food and wine; winter evenings in with family and friends in front of blazing fire; exploring new holiday destinations. Dislikes: Lack of enthusiasm and motivation in a person; any social networking with no face to face contact; routine (which is unfortunately part of our life). The person I most admire: The achievers in life, especially those from underprivileged backgrounds. Idiosyncrasies: Constantly looking for new challenges in life.
ACP news - Winter 2010
Pathology Record # 4117 Name: Dr Gavin Spickett Current appointment/s: Consultant & Senior Lecturer in Clinical immunology and allergy Clinical Interests: Severe allergic diseases/immunodeficiency/chronic fatigue PERSONAL DETAILS: Newspaper/s: Times/Telegraph. Car: BMW. Hobbies: see idiosyncrasies. FAVOURITE Authors: Eddings/Canavan. Films: Lord of the Rings. Football team: F.C. Barcelona. TV programme: Time Team. Music: Eclectic! Likes: Efficiency, punctuality. Dislikes: Inefficiency, people who don't reply to texts/e-mails. The person I most admire: Caesar Augustus. Idiosyncrasies: (as described by secretaries!) Fitness fanatic; very competitive; grumpy old git (GOG); likes his own way; strong willed; generous; very supportive; hoarder. Pathology Record #357 Name: Professor Tim Stephenson Current appointment/s: Clinical Director of Laboratory Medicine, Sheffield Teaching Hospitals, Honorary Professor, Faculty of Health and Wellbeing, Sheffield Hallam University Clinical Interests: Histopathology of endocrine system, breast and GI tract PERSONAL DETAILS: Newspaper/s: Times, Sheffield Telegraph and Star. Car: Jaguar. Hobbies: Music, theatre, garden, photography. FAVOURITE Authors: John Wyndham, so scary that I read books from end to beginning so that there wouldn’t be nasty surprises. Films: First few 007 films. Football team: Yuck! TV programme: The Gadget Show, especially when the gadgets don’t quite work. Music: Early classical music. Likes: Anything that’s parsnip-free.Dislikes: Parsnips and anything similar. The person I most admire: My favourites are the inventors who invented useful things in a flash of inspiration and under difficult circumstances, like AB Strowger the New York undertaker who invented the telephone exchange. Idiosyncrasies: None. Pathology Record # 4366 Name: Dr Fiona Roberts Current appointment/s: Consultant Pathologist, Western Infirmary, Glasgow Clinical Interests: Eye and Lung pathology PERSONAL DETAILS: Newspaper/s: Sunday Times. Car: Toyota Prius. Hobbies: Skating (figure and inline), running, swimming. FAVOURITE Authors: Lionel Shriver (We Need to Talk About Kevin – a bit of eye pathology); David Nicholls (Starter for 10 – reminiscent of student days). Films: Shrek (Princess Fiona!). Football team: Scotland (it’s a minimal time investment). TV programme: Dancing on Ice (to see if I can pick up any new moves!).Music: Bob Marley, UB40. Likes: Decent coffee, rice cakes, peanut butter, organisation. Dislikes: Instant coffee, hospital food, crumbs, constant interruption, disorder and chaos. The person I most admire: Sir Ernest Shackleton for determination, self-belief and leadership. Idiosyncrasies: Always try to swim at least my age in lengths (it’s becoming increasingly difficult); according to the trainees, the use of articles (definite or indefinite) in my reports.
ACP news - Winter 2010
Using digital pathology to assess the superficial anatomy of the colon – Peter Brown Peter Brown is a 4th year Student Doctor at the University of Leeds. He reports here on the work that he performed which was funded by a £1,000 ACP Student Research Award Email: Um06pjb@leeds.ac.uk
be direct interaction with NHS clinicians. The department has been instrumental in the introduction of virtual pathology, which has allowed me to pursue my project into the realms of new three dimensional reconstruction techniques. Using novel immunohistochemical antibodies and techniques I have been able to reliably and accurately identify blood and lymphatic vessels within superficial layers of the colon. The development of relatively new computer software allows the detailed digital analysis of large volumes of data. Traditionally it has been possible to analyse histological sections but the reliability of the measurements has required more data collection and it has been very time consuming. By comparison the digital analysis of slides is both more accurate and less time consuming. Digital analysis allows data collection of new information previously unobtainable, such as the circumference and area of arterioles and capillaries (figure 1). However, I still spent the largest proportion of my time annotating vessels and collecting data. Once all the vessels had been annotated, using novel computer software, the annotations from each of the sections were recombined in
Having just completed an intercalated degree year, I decided to complete a laboratory project during my “last proper summer holiday” instead of going travelling around the world like many of my colleagues. I elected to spend some additional time in a laboratory in Leeds following up the pathology project I started during my intercalated degree. Having spent around half of my time during the last year on a research project, my interest in colorectal cancer has developed and consequently I wanted to be able to spend more time in the laboratory in the hope of obtaining additional results. I decided to do this because from only eight months of part-time research I realised that I had only just dipped my toes into the research pond. With the possibility of a career in academic medicine, the option of having additional time within the research setting was also a great opportunity. With the support of my tutors I decided to alter the main focus of the project and branch away from my intercalated project. In addition to learning new laboratory techniques this also pushed me to the boundaries of digital pathology which was interesting and insightful. Leeds Institute of Molecular Medicine is one of the leading centres for cancer research within the UK. Additionally, it is full of researchers who Figure 1: Image showing the annotations in Aperio ImageScope on are willing and able to share their knowledge of a digital copy of the slide. Annotations are hand-drawn around laboratory medicine to inspire potential students regions of interest. Each colour corresponding to one layer/one set to pursue a similar career. The section of of information. Firstly, the digital image was studied and the region Pathology and Tumour Biology, where I have of interest identified. Here the green box was applied to define the been based, was awarded Gold pinnacle status for region within which each of the characteristics would be studied. the quality of their research by the University of Red lines were then drawn around each of the blood vessels and yellow around the lymphatic vessels. Pink denotes the muscularis Leeds. Therefore, it is arguably a great place to mucosae, blue denotes the muscularis propria and purple denotes gain experience of scientific research. a lymphoid follicle. The programme calculates the area of vessels Additionally, being located on the same site as St from the length of the line, the circumference of the vessel, and James’s University Hospital in Leeds there can using the co-ordinates used to plot the circumference.
ACP news - Winter 2010
Bursary Reports the hope of generating a three-dimensional model of the vessels. Over the last four years, in association with the University of Leeds School of Computing, software has been developed to allow the reconstruction of structures previously only visible in two-dimension. This software allows the recombination of selected components, the vessels, from a stack of serial sections generating a threedimensional volume which can be manipulated to view the interaction of the components in different planes (figure 2).
Although this technology is still in the relatively early stages of development the potential is evident. Using virtual pathology software, such as these programmes, shows that the future of histopathology is becoming increasingly digitalised. Virtual pathology has already been shown to be of equal value to traditional microscopy in generating high quality images; however, it will also potentially change the modus operandi of diagnosis by histopathologists. The possibility of creating three-dimensional models also increases the options for research, allowing the interaction of different items to be studied in detail for the first time. Being involved in research towards the limit of current knowledge is both rewarding and exciting, especially as an undergraduate. Despite travelling around the world I have managed to have an enjoyable and rewarding summer. Participating in scientific research has also allowed me to improve my limited understanding of academic medicine. If any other students were in a similar position and given the two choices I would wholeheartedly recommend the option I took, in spite of it being the less attractive option in the beginning. Furthermore, the opportunity has allowed me to see the work of academic junior doctors, helping me appreciate the role and gain a greater understanding before applying for foundation jobs. I would not have been able to complete the project without the support and insight of Professor Phil Quirke, and the continual guidance of Dr Darren Treanor, a pioneer of virtual pathology. Both have both provided me with academic support throughout the project which has been invaluable and is greatly appreciated. The project would also not have been possible without the financial support of the ACP, who provided funding for laboratory reagents. I am grateful to all for allowing me to conduct my research on a topic I find interesting and also at the forefront of current knowledge.
Figure 2a: Image of the 3D model, looking from the bowel lumen outwards. The lymphoid follicles (purple) can be seen on the muscularis mucosae (pink). Blood (red) and lymphatic (yellow) vessels can be seen above the muscularis muscosae in the region surrounding villi. 2b: Image of the 3D model, looking from the serosal side inwards towards the bowel lumen. The muscularis propria (blue) can be seen with blood (red) and lymphatic (yellow) vessels penetrating the muscle travelling towards the submucosa. 2c: Image showing the close relationship of the blood (red) and lymphatic (yellow) vessels with lymphoid follicles (purple) and muscularis mucosae (pink) present to act as a reference but the muscularis propria removed.
ACP news - Winter 2010
Tradecraft and Meetings
NHS – RIP? The 24th ACP Management Course 22 - 24 September 2010 – Chris Carey and Mike Galloway and expertly delivered insight into modern NHS pathology management. It is highly contemporary, with a strong emphasis on the 2010 white paper and its proposed impact on laboratory services. The speakers provided varied and authoritative précis on a number of topics. Initially we were provided with an overview of health policy from the local SHA head and the national clinical director for pathology. The recent political history of the NHS was carefully contextualised, summarising changes Chris Carey is an ST7 in from the Darzi report (2008) up to the prospective Mike Galloway is a Co-organiser of the ACP Haematology in the implementation of the 2010 White Paper. The coterie of Northern Deanery Management Course trainees (and some consultants) was diverse in experience and they enlivened the lectures appropriately with challenging questions and debate. This is the ninth year that we have held the Management Soon into the first day we were asked to plan the Course at Hardwick Hall Hotel in Sedgefield. Durham restructuring of a struggling Trust pathology department County Council has over the last 10 years completed the in small group sessions. The scenario was precisely and work to re-establish the grounds around the hotel as they realistically devised and the exercise focused attention on were in the mid-18th century. The hotel at that time was a the dilemmas and competing interests of practical country house owned by John Burdon, a Newcastle management. Each group was tasked with prioritising businessman. This year all the follies that surround the changes in one of several directorates, balancing the books main lake have now been completed and they give an and maintaining laboratory accreditation; to write an added interest as part of the walk round the lake. effective business case meant implementing This year the course was fully booked in principles of ‘QIPP’ that were June and due to the amount of learned in the interest we negotiated introductory lectures, with the hotel to “The ACP management course is a in the confines of include some carefully structured and expertly the inevitably tight additional delivered insight into modern NHS budget. participants, As a prelude to a taking the total pathology management.” later group activity number of attendees to Mike Galloway clearly set 47. The vast majority of out the current model of NHS structure participants were from England but and drew attention to the regional differences since we did have representation from Wales, Scotland, devolution in management approach. Each country’s Northern Ireland and Kuwait. system was summarised in diagrams, useful for future reference and a preface to future government policy; A participants view CQUINs, and the overarching principle of ‘judgement It is often said that the change in responsibilities between frameworks’ were exemplified by the looming ST posts and consultancy is the greatest of all in the career of a hospital doctor. As that day approaches it seems that requirement for standardised management of venous even those cautionary words are euphemistic, one of the thromboembolism. Bookending the lectures, the most daunting aspects being the complexity of NHS Galloways later walked us through the practicalities of management structure; this is even more so in the revalidation, toolkits and all. tumultuous times of political regime change and After the short straws were drawn nominated speakers unavoidable efficiency savings. presented the conclusions from each group with varying degrees of technological polish, and prizes awaited the The ACP management course is a carefully structured
ACP news - Winter 2010
Tradecraft and Meetings
Figure 1: Business planning winning group
winners (figure 1). Role-playing worked extremely well and tangibly demonstrated much of the course’s core content as well as mixing together delegates from disparate areas of the UK and beyond. On the second day two speakers, including Professor Peter Furness, comprehensively explained what quality means in pathology and dissected the influence of every step of the structure, from personnel through to premises and the analytical processes. Paul Stennett spoke with equal authority as the chief executive of the UK Accreditation Service (UKAS). As well as describing the history of accreditation in the UK he outlined mandatory accreditation and the support and expertise that is available from such services. Where he succeeded most was in engendering enthusiasm in what is almost invariably considered a dry logistical process. We were all encouraged to consider becoming peer assessors in the future, to ensure and maintain standards of pathology. As payment by results is supplanted by payment by activity, budget management was brought into clear focus. Lectures on realistic budget setting and reviewing followed before more light-hearted but no less useful descriptions of ‘The First Two Years as a Pathology Consultant’ and ‘Managing Staff’. In a particularly wellreceived talk, Professor David Hunter provocatively suggested that the NHS as we know it is ‘dead’, amidst a more philosophical assessment of modern healthcare politics. Practically, the course is skilfully rehearsed and enjoys excellent facilities. The lectures took place in a designated annex and the regular meals and snacks are served with
well-planned frequency in the adjoining area. The course folder is an authoritative reference tool and, if the wealth of lecture plans and course exercises do not suffice, then there is an exhaustive suggested reading list (with some available for reference). An unexpected bonus is free single year ACP subscription and it would be a hard heart that is not tickled by the second night’s entertainment. The hotel itself provides superior accommodation for such a course and is very accessible by road, set just a few miles from the A1 Stockton turnoff. The rooms are modern and well appointed with many providing a view of the carefully landscaped lake and surrounds; I would recommend at least one walk around the water and up to the twin facades. In summary, this course is highly recommended. NHS management had hitherto seemed a byzantine and inaccessible process to me, far removed from the inherent competencies and curriculum of specialist training. In a practical sense this separation will continue until the first day as a consultant, but these lectures demystify the politics somewhat and most importantly encourage the delegates to take an active role in the future, to recognise the influence that individual pathologists and clinicians can assume in shaping patient care. The details of NHS structure will change seemingly with every incumbent secretary of state, but engagement with the process is the ultimate aim of this course. An organiser’s view Each year I reflect on the course to identify what was the theme of the year. Last year the theme was “Prepare for Financial Winter”. Events have certainly unfolded as was predicted on last year’s course. This year’s theme “NHSRIP?” is taken from Prof David Hunter’s (Professor of Heath Policy and Management, University of Durham) last slide from his presentation. However, he didn’t put a question mark on his slide! The consensus appears to be that the days of a publicly funded and publicly provided NHS in England are over. Despite a change in government in England health policy has not changed. The current jargon is “any willing provider”. This means that any type of organisation, either NHS, private or third sector, can provide services to NHS patients providing that they are registered with the Care Quality Commission and deliver services with the prices set by the national tariff. This is a continuation of the previous Labour government’s policy. Apparently the new labour leader is unlikely to oppose these changes so this appears to be a permanent change in
ACP news - Winter 2010
Tradecraft and Meetings
Management course delegates
policy for the English NHS. This is also true within pathology, with a number of private companies now running NHS pathology laboratories in England. So is quality off the agenda? No, not yet. Prof Peter Furness led an interactive session with participants on what they understood when asked the question “what outcomes could be used to assess the quality of a pathology service?” This was followed by a discussion on how the outcomes of a CPA(UK) Ltd assessment could be developed to inform the requirements of a number of bodies such as commissioners, Human Tissue Authority, MHRA etc. Perhaps with the current cull of QUANGOs this might happen. Richard Barker (lead for commissioning at the North East SHA) covered the role GPs might have in commissioning services. He explained how the emphasis of commissioning will switch from that based on an assessment of activity to an assessment of clinical outcomes. Paul Stennett gave an update on the major changes that have occurred in the organisation of CPA(UK) Ltd. Following receipt of a letter from Eric Watts (now promoted to Vice President of the Association), last year the course participants were offered the opportunity of attending a CPA(UK) Ltd assessment visit as an observer. Six participants took up the offer so hopefully they will become part of the new generation of CPA assessors. The offer was made again to this year’s participants. There was much discussion over the latest round of structural changes to the NHS that are about to happen in England. No one could identify any reason as to why they might be necessary. Certainly they weren’t included in any of the political parties’ manifestos. At a time of major
financial pressure these structural changes that include the abolition of Strategic Health Authorities and Primary Care Trusts are to be implemented rapidly (by April 2013) and this appears to me to be a highly risky strategy. particularly as these organisations are to be replaced by relatively small GP commissioning groups that will have no track record in either commissioning or financial management. The contents of the course evolves over time and this is largely driven by our precourse questionnaire in which we ask participants to rank a number of topics in terms of how important they perceive them. This year we had all of the top 10 topics covered in the course. The business planning and financial management exercises have been an ever present topic on the course. We know from feedback that we have received that some participants find them quite challenging. However, the presentations at the end of the first day are always of a high standard and at least there is the compensation of the prizes for the winners. This year’s feedback on the course was excellent. However, on reflection having 47 participants meant that some of the facilities were a bit tight in terms of space. So next year we will go back to having a strict limit of 40 participants, recognising that the course will probably be significantly oversubscribed. The participants appear to appreciate the resources that we provide as part of the course. This now includes a pre-course pack, course handbook, the third edition of the book “Applying for a consultant post in pathology and surviving the first two years”, and a copy of the NHS Institute’s Leadership Competence Framework. We also provide participants with a brief review of the structure of the current NHS in the UK (this can be downloaded free from the ACP website). Two suggestions that we will look at for next year are to provide copies of the presentations in read only format on a memory stick and to get a speaker from the private pathology sector to cover what they can offer in the provision of NHS pathology services. So the feeling from this year’s course was that the NHS in England is being subjected to yet another major structural change that has no evidence to suggest that it will lead to any improvement. At some point in time the experiment of comparing a market approach to delivering healthcare that has been developed in England since 1991, to the more co-operative approach of the other three countries in the UK, will reach a conclusion as to who got it right.
ACP news - Winter 2010
Tradecraft and Meetings
Report of the ACP Alumni Meeting in Sheffield May 2010 â€“ David Winfield
Compared to other medical bodies, one of the great attractions of the ACP has for many years been the friendly and sociable nature of the organisation and a guarantee that any meeting of the members will result in an enjoyable time being had by all. The annual meeting of the Alumni is an opportunity to rekindle the good fellowship for those who are retired or soon to be retired members. So if you are reading this report for the first time and wondered who the Alumni are, there is a possibility that you could become an alumnus and are very welcome at future meetings. We are always grateful to Alison Martin at ACP Head Office for sending out the initial circular and so please let her know of your possible interest and if the date and venue suit you then there will be a warm welcome for you in 2011. At first glance Sheffield may not appear to have the attractions of other parts of the UK or Eire but it is now a lively and modern city and welcomed the Alumni on 11 and 12 May. A dinner was held on the first night with a visit the following day to Chatsworth. For those who have never visited before, the first view of the great house lying in a fold of the Derbyshire hills is an impressive
introduction and for those who have been before, there have been huge improvements to the house with a ÂŁ14 million programme over the past winter. There are many new exhibits, such as a life of the Dowager Duchess, including her childhood as one of the Mitford girls and also details of the Devonshiresâ€™ close links with the Kennedys, especially JFK. Lunch in a private dining room was followed by an opportunity to visit the extensive gardens with their impressive features of cascades and fountains. A dinner on the second evening was followed by a cabaret and at an age when many men are struggling to remember the basics of life, ACP Alumni continue to impress with word prefect renditions of classics such as Albert and the Lion, and Piddling Pete. If you have any recitations or thoughts on life which you would like to share with others, 2011 could be your opportunity. Dr David Winfield is a retired haematologist, formally working at the Royal Hallamshire Hospital, Sheffield Email: email@example.com
Little old ladies Little old ladies are always asking me to help get things from the top shelf for them. I really must go to a different newsagents.
ACP news - Winter 2010
Association of Clinical Pathologists Leadership & Management Courses
2011 run by Pathologists for Pathologists
The ACP offers three levels of Leadership & Management Courses. All courses aim to deliver training and updates in the key competencies outlined in the Medical Leadership Competency Framework which has been developed by the Academy of Royal Colleges and the NHS Institute for Innovation and Improvement. The courses are delivered at a level that is appropriate for the participants’ stage of training, in the five key leadership domains of personal qualities, working with others, managing services, improving services and setting direction. *** Challenges to Pathology: An update 24 February 2011 Institute of Physics, London This one-day annual update is aimed at established consultants and provides updates on a variety of professional and management issues. Topics include Update on the development of Networks; Update on the new department of Public Health; Pathology commissioning in the brave new world; Recent Developments in CPA Accreditation (with a look forward to possible developments with CQC and government arm's length bodies); Update on College Workforce Planning; Update on Revalidation and Recertification; Update on the Royal College of Pathologist and International Links *** Basic Level Leadership & Management 2 March 2011 Copthorne Hotel, Newcastle upon Tyne This one-day course is aimed at Pathology trainees in ST1-ST4 years of training and covers: • NHS structure • Laboratory management structure and how to manage a pathology department • Laboratory documentation • Accountability and external monitoring – CPA/EQA/Audit • Personal development including publications/time management/CV development/passing exams • Research • How to be a good registrar *** Advanced Level Leadership & Management 28-30 September 2011 Hardwick Hall Hotel, Sedgefield This is a wide ranging, residential, three day course introducing management issues relevant to the running of a modern pathology service. It is intended for specialist registrars and trainees in Pathology in their final year of training, clinical scientists and those who have held their first consultant post for less than two years and covers: • The NHS reforms • Funding & structure of the NHS • Clinical governance • Role of PCTs, SHAs • Financial management • Business planning • Demand management • Managing staff • Appraisal and job planning • Self management • Future organisation of pathology services *** Details from: Jacqui Rush, Tel: (01273) 775700
ACP news - Winter 2010
Tradecraft and Meetings
British Association for Ophthalmic Pathology (BAOP) 29th Annual Meeting, Exeter 8 - 9 April 2010 – Margaret Jeffrey Dr Margaret Jeffrey is a Consultant Histopathologist at the Queen Alexandra Hospital in Portsmouth and Secretary of the BAOP. Email: Margaret.Jeffrey@ porthosp.nhs.uk
The Peninsula Medical School, Exeter
The 29th Annual Meeting of the British Association for Ophthalmic Pathology was held on 8-9 April 2010 in Exeter, hosted by Dr Lyndsae Wheen and Dr Paul Newman. Exeter’s one-way system provided a challenge to those of us arriving by car without the benefit of a satellite navigation system. The meeting was held in the Peninsula Medical School, a gleaming glass and steel construction, a complete contrast to the Victorian Medical Centre in Liverpool we visited in 2008. Our hosts provided us with excellent buffet lunches, as well as regular tea and coffee, ensuring that we were well fed and watered. The refreshment breaks offered an excellent opportunity to catch up with colleagues from other centres. The meeting followed our usual format with a mix of case presentations, research and audit presentations, guest lectures and EQA review.
The first morning comprised case presentations and an audit: • Primary apocrine adenocarcinoma of the eyelid – Susan Kennedy • Metastatic cutaneous melanoma in the choroid, choroidal naevus and choroidal haemangioma – Caroline Thuang • BMS reporting of corneal histology: how does it compare to a Consultant – Adam Meeney • A corneal curiosity – Margaret Jeffrey • Periocular oddities – a trio of unusual skin tumours – Paul Newman • Ice cream, pizzas, the daughter and the cat – John McCarthy’s imaginative title for a case of toxoplasmosis. • Sclerosing polycystic adenosis and giant cell angiofibroma – Richard Dinner at the Abode Hotel, Exeter. Left to right: Dr Keith Robson, Dr Katy Bonshek • Primary acquired melanosis – Salman Keohane, Dr John McCarthy, Professor Susan Kennedy and Professor Waqar Jean Campbell
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Tradecraft and Meetings The second day began with Professor Roddy Simpson’s guest lecture on Lacrimal Gland Tumours which clarified the classification of these tumours. This was followed by more case presentations: • Idiopathic orbital inflammation – Patrick Gallagher • Necrotising fasciitis of the orbit – Katy Keohane • Orbital cysts – Lyndsae Wheen Two more guest lectures followed, the first by Dr Terry Riordan – An Overview of Ophthalmic Microbiology provided a fascinating overview of ophthalmic infections and infestations; and the second by Miss Fiona Irvine – The Surgical Management of Periocular Tumours was beautifully illustrated by photographs of oculoplastic preocedures. The morning concluded with another case presentation: • Primary acquired melanosis – Chin Ong
Refreshed by lunch we returned for the afternoon session: • Role of the National Cancer Research Institute task force on Pathology and Research – Brian Clark • Congenital myopathy with tubular aggregates involving the extraocular muscles – Dominic O’Donovan • Mantle cell lymphoma in a temporal artery biopsy and conjunctival dysplasia – Hardeep Mudhar • Conjunctival melanoma spreading into the nasolacrimal duct – Luciane Irion. The afternoon concluded with a discussion of the last two rounds of the ophthalmic pathology EQA. The scheme organiser Dr Keith Robson reminded members of the need for more cases to be submitted for the EQA. For the more adventurous there was a tour of the underground passages of Exeter. These date from the 14th century and were built to supply fresh water, which was carried in lead pipes laid in the passages. The passages were extended over the years and have played a role in the Civil War and later in the Second World War. The tour of the passages was made more interesting as we had come straight from the meeting. I quickly realised that high heels and a suit were perhaps not the ideal clothes for walking along narrow, low passages, and I am not convinced that the compulsory hard hat produced an overall image of sartorial elegance. However, this was a small price to pay for such an interesting and unique tour. The tour was followed by the Meeting Dinner in the Exeter Abode Hotel overlooking the Cathedral. The view of the Cathedral from our dining room was enhanced by the spring sunshine and the excellent dinner.
After lunch members returned for the business meeting chaired by the President, Professor Jean Campbell. Professor Campbell completed her term of office as President at this meeting, and the Secretary of the BAOP thanked Professor Campbell on behalf of the members for all her hard work for the Association. Professor Campbell is succeeded as President by Dr Peter Smith. The organisers of the meeting were thanked for hosting a very successful meeting, which provided an excellent mix of educational and social activities. Next year’s meeting will be held in Manchester on 7-8 April 2011. Anyone interested in joining the BAOP should contact the Secretary Dr Margaret Jeffrey by email at Margaret.Jeffrey@porthosp.nhs.uk.
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Houses opposite Exeter Cathedral
How to fail the FRCPath Part II examination in Histopathology: a guide for trainees â€“ Ed Carling Dr Ed Carling is a Locum Consultant Histopathologist and Assistant Editor of ACP news Email: edcarling@ doctors.org.uk
Hopefully without appearing arrogant I can claim significant expertise in the skill of failing postgraduate medical examinations, having amassed a running total of eleven failures at various parts of the MRCS and FRCPath examinations, including three in the FRCPath Part II. This article aims to pass on the myriad of techniques I have used, pouring several thousand pounds into the accounts of various royal colleges, to help you achieve a monumental fail in your FRCPath Part II examination in Histopathology. By reading this article you can acquire the skills, attitude and personal demeanour necessary to reach this goal. I will first address general aspects of training in histopathology, and then turn to the examination itself. A prepared mind is the enemy of your attempts to fail, and as such the first two years of your training are an essential time in which to become lazy and to dull your mind. A slack attitude to work is vital. You must develop the skill of spending your time at work, without obtaining knowledge or experience. This has become more difficult in recent times, with the advent of workplace based assessment methods. Your greatest ally in this fight is of course your workplace computer, as many an unproductive hour may be spent browsing the internet. If this is not possible, simply staring at an unfinished report, drooling, with your mind full only of thoughts of cute fluffy kittens, is an ideal alternative. Colleagues, especially those prone to vacuous gossip, are another welcome aid in the fight against exam success. Medical research, especially of an esoteric or molecular nature, is also an ideal environment to dull your diagnostic skills. Your employers and colleagues will, of course, place obstacles in your path. Training days and teaching sessions on rare and difficult diagnostic entities will be arranged. These must be avoided, as must such things as EQA materials, black box meetings, multidisciplinary meetings and especially multiheader microscope sessions.
If you follow this advice, it is doubtful you will ever need to achieve an examination fail. However, many trainees nevertheless find themselves in the situation where they are required to sit the FRCPath Part II examination. Proper preexam preparation is therefore an essential component of your journey to failure. An attitude of total denial is the ideal, but as this is unlikely, complete disorganisation is almost as effective. Rigorous timetabling of the months prior to the examination is to be avoided. Instead, it is better to concentrate your studying on one small facet of the examination, preferably a rare subset of diseases of a single organ. I found the areas of hereditary inflammatory skin disease and NK-cell lymphomas particularly productive areas on which to spend large amounts of time. This has the added bonus of enabling you to completely ignore large areas of study (especially gynaecological pathology) through lack of available time. I need barely mention to avoid, at all costs, the mere concept of specific examination-related courses and mock examinations. Feedback as to your deficiencies is not the way to fail. I will now make special mention of the supremely effective method of achieving the failure you desire. Become a parent, ideally for the first time, in the months prior to the examination. The trials and tribulations of caring for a newborn are sufficient to empty the fullest mind, and to dull the sharpest. Sleepless nights and an unbroken routine of nappy changes and infant feeding will
Figure 1: Sleep is your enemy
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Trainees’ Zone Figure 2: Stain your way to failure
scrotum death 1 Adenomatoid
Tumour2 Notes on immunohistochemistry panel failure: 1 Include a disease that obviously does not exist 2 List the most likely diagnosis last 3 Include at least one stain that no one has ever heard of, even better if you have written a paper about it 4 Never complete the table 5 Equivocal staining illustrates your lack of knowledge 6 Non specific immunohistochemistry leads to specific failure. turn the brightest and most prepared candidate into a surefail zombie (see figure 1). Concerning the examination itself, my fail philosophy can be summed up as follows: Look Fail, Think Fail, Write Fail, Act Fail. Look Fail reminds us that this is a professional examination, so a poorly groomed, unkempt appearance is required. Poor personal hygiene and foul body odours are the pinnacle of this approach. Think Fail encapsulates the knowledge that only the proper mental state can lead to true failure. Feelings of selfdoubt, personal worthlessness, cowardice and other aspects of low self esteem are your aids to the necessary mental collapse. If you find this difficult, just compare yourself unfavourably with your fellow trainees. Panic whilst sitting the examination is a most useful tool, helping you to question your own judgement, misinterpret visual information, lack confidence and generally underperform. Caffeine rich drinks such as strong coffee or energy drinks are helpful in achieving a state of supreme panic. Write Fail is obvious in its intent; however, there are two ways to achieve a definitive written fail. The most useful is the short, overconfident and wrong answer. However, the long, rambling, obviously ignorant answer that ends in a list of vague differential diagnoses is equally effective. As an illustration, consider the following example of a surgical histology case. The lesion is described as a lump in the
scrotum of a 25-year-old man. When looking at the slide, it is obvious the lesion is a benign adenomatoid tumour. A written answer to achieve a pass would be as follows: “Sections show a lesion composed of epithelioid cells and fibrous stroma. The epithelioid cells are arranged in a network of tubules and small cysts. This is a benign adenomatoid tumour. Should there be clinical doubt, this may be confirmed by demonstrating Calretinin positivity in the epithelioid cells.” • Diagnosis: Adenomatoid tumour, Benign
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Figure 3: Avoid this at all costs
Trainees’ Zone To achieve a fail, a different report is required: • “Sections show fibrofatty connective tissue, within which is a small, ovoid lesion composed of slightly spindled, vaguely epithelial-like cells. Some cells have round nuclei, some more ovoid. The odd one looks a bit square. The chromatin varies slightly in character, from clumpy to vesicular. There are spaces within. The mitotic count is 3/168 hpf. No tumour lymphocytes are seen. The differentials diagnosis and immuno panel required are wide, but as a start I would do (See figure 2). • This is a difficult lesion with a wide differential. I would also show this case to a more able colleague, and then send it to Dr Otto von Mergenlaëützer and his dear wife Helga at the Sorbonne, as I know they have an interest in such things. Diagnosis: ? Await further work As you can see, such all pervasive lack of clarity, decision making skills and basic knowledge is guaranteed to produce the failure you seek. The concept of Write Fail encapsulates so many possibilities as to make listing them all impossible. I will, however, make mention of the time-honoured traditions of
Figure 4: A perfect fail
requesting further levels on each and every case, and of requesting and immunohistochemistry on any slide showing more than three plasma cells. Write Fail within the cytology sections of the examination requires special attention. The key is to inform those reading your answer that you consider cytology a pointless, unreliable tool. Breast lesion aspirates should always be coded as C3 or C4, and should contain a request for a core biopsy, as should bronchial cytology specimens. Bile duct brushings and neck aspirates should always be reported as equivocal, remembering the time-honoured rule that the examination has never in its entire history contained a negative cytology specimen. In regard to gynaecological cytology, whilst the various borderline categories are a useful aid to failure, this part of the examination is best used as an opportunity for a quiet sleep. Act Fail refers to those sections of the examination that involve face to face interaction with other human beings. It is best to act as if you find such interaction deeply painful in order to reach your fail goal. Remember, you are being judged as a potential future consultant, and as such a lack of eye contact and a low, mumbling voices will help you towards a fail. Dangerous, obnoxious and generally bigoted attitudes may be effectively communicated at this point. Try to communicate an appearance of deep mental disturbance. The macroscopic photograph section of the examination provides an ideal opportunity for this, both through bizarre drawing (figures 3 and 4), and making large scything motions with your hands whilst describing tissue sampling. In summary, the FRCPath Part II examination in Histopathology provides many, many opportunities for failure, should you so desire. I would be most grateful to hear of techniques others have found effective, and remember: Look Fail, Think Fail, Write Fail, Act Fail.
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Association of Clinical Pathologists NO INCREASE in subscription Rates for 2011! The ACP is pleased to advise members that there will be no increase in subscription rates for 2011. Direct debits will be taken during the first week in January and individual invoices/advices of direct debit will be sent out to members in December. The rates for 2011 will be: Ordinary & Extraordinary Members (UK & Eire) Reduced rate for online Journal of Clinical Pathology only
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Book Reviews 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.
The Poisoner’s Handbook: Murder and the Birth of Forensic Medicine in Jazz Age New York D Blum Penguin Press, 2010 ISBN 9781594202438 336pp £25 (hardcover) Set in “Jazz Age” Prohibitionist New York, this is a non-fiction book devoid of music but riddled with poisonous cocktails aplenty. Each chapter covers a different drug or poison from arsenic and mercury to radium and chloroform and these stand-alone chapters are skillfully weaved and structured to form a single, flowing story. Central to the stories are the protagonists – New York City medical examiner Dr Charles Norris and his sidekick Dr Alexander Gettler, New York’s pioneering toxicologist. The book chronicles their efforts in scientific crime solving and the birth of forensic medicine brought on by immense frustration with initial test limitations. This book is akin to reading CSI Crimefiles (albeit set in the 1920s) and it is amazing to think that the current sophisticated investigative techniques are less than a century old. Also, how people survived this particular era given that most ingredients in common household items were poison (e.g. thallium was used in hair removal cream and tonics with radium mixed in were sold) is indeed baffling. Despite it being an education in forensics, this is a compelling book that reads like a novel. The downside is that the author never develops the personalities of Norris and Gettler, apart from them being of a most doggedly determined mindset. Definitely a must-read “book noir” (although I was a bit disappointed in that I had misunderstood the cover: voodoo it still is for my non-favourite people then. Rats.) Su Enn Low
Readers wishing to become book reviewers for ACP news should contact: Dr Ian Chandler, ACP news Book Reviews, Department of Pathology, Royal Devon and Exeter Hospital, Exeter EX2 5DW. Email: email@example.com. 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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Password Protected! – C*4l G7&y Dr Carl Gray is a Consultant Histopathologist in Harrogate and a former editor of ACP news. Email: Carl.Gray@ hdft.nhs.uk
Autumn mists lately swirling, I returned from three weeks’ annual leave, kissed my colleagues hello and did some work. Having at long last written some reports, I keenly rushed to authorise them. I opened the laboratory information system, put in my name and “Hey Blanko..!” I could not recall my password. I remember changing it just before I left, to the next one in my usual sequence. But no, this was not it. Eighteen different variations on the names of favourite Italian lakes did not fit. Obviously, I had not written it down: that would not be secure. The computer was implacable: I was not its genuine friend; I could not be me. A froideur was perceptible, like the bit in “2001: a Space Odyssey”, when Hal the ship’s computer decides that humans are less important than The Mission. (Of course, in “2001,” after some deep space vicissitudes the chap remembers the password scrawled on the sleeve of his space suit and eventually beats the computer by taking its memory out.) Machine: one, man: nil. I shamefully rang up the IT department, was given withering sigh No 51B and some Password Advice. For 10 brief electron-swirling minutes I was lent the infamous nursery password for passwordforgetting wimps and had my image placed in the virtual stocks for the punishment period. Back to my desktop, a new easy-to-remember password – not an Italian lake this time – in place and I was away. The PC did its wholepages-of-Greek-language glitch later to pay me back for my infidelity until we both calmed down and basal cell and other carcinomas could be coded in peace. T’was brillig, and noughts and ones and slithy toves gambolled in the Wabe. In case you are wondering, I do have the mild forgetfulness of early middle age – particularly for names and faces – superimposed upon basic absentmindedness. But I can remember the name of the prime minister, Mr Blair, my wife’s birthday if not her name, she’s not Mrs
Blair, I know that one, and the given name and colour of our last cat but three and the colour of my first car. I do forget to do minor household tasks even if they are on a written list but this is normal in educated Yorkshiremen. One forgets the list. Even if it is technically “in view”. All these passwords are becoming very silly. We each have one or two PINs to make plastic cards bring forth money and goods. But I have accumulated over 46 different passwords, not including the super-difficult online banking ones. Every time you buy an Amazon from Amazon, a Begonia from Begonias-R-Us, a light bulb from Lightbulbs Direct or a vuvuzela from Zulu Trumpets.com you must put in your password. For tickets for the play or the train or the plane, batteries from BatteryForce, to consult your College or club or to download an e-book, you must register your online account with your email address and a new password. This earns you your cheery, “Hello [fill in name]?” next time you try to get in or perhaps an hour of frustration if the password does not fit. Even filing one’s tax return or sending money to HM Customs and Revenue takes some tense cryptological minutes as one labours to send money to the Chancellor of the Exchequer, Nigel Lawson. How modern life can be lived if one impetuously changes one’s email address, I do not know. It must take a year. We know it really ought be a different password each time because Sergei Hakov from cyberrobbers@space parknearvladivostock.com is watching our every keystroke and writing them all down. He already knows your mother’s maiden name and is awaiting your next email to the vet’s to catch the colour and given name of your current cat. After a run-in with a bank who were reluctant to let me have my money abroad, I consulted specialists in password security. I was directed to the many password protection advice sites on the web. Just Google “password security” and there they are, from Bill Gates downwards to Mr Hakov himself. There are password checker tools – not tool checkers: they’re different – just pop in your password and get it’s security score from ‘weak’ to ‘strong.’ Nice try, Gospodin Hakov, I did not put the real ones in! But the algebra seems persuasive: those Bletchley Park cryptanalysts were onto something. There is a science of digital encryption based upon multiplying prime numbers together – although three times seven does seem easy enough. Password security based upon a ‘strong’ password has up to 14 digits, they say, including letters upper case and lower case and numbers. Ideally, the
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Columnists guidelines state, you should include some top-shelf symbols such as “$” or “!’” or the fiendish “&” but these are not always acceptable. Any whole word or name such as ‘CARL’ or ‘JULIAN’ is meat and drink to cybercriminals everywhere; hackers have search programs that can predict the completion of any slightly meaningful string that you offer, including the lexicons of all known languages, all proper names worldwide and the totality of literature, including your favourite songs from the sixties, seventies and eighties. The dogs in the street know your date of birth and all your other Significant Numbers. Your next cat will have to have an otherworldly given name such as “iixt23&QR45”. (Has “iixt23&QR45” drunk his milk, Darling? No, I think our other cat “qrgTVX£123*7” must have taken it all already.) Moreover, cyber-nanny scolds, passwords should be changed often, monthly at the very least. Frankly, my original practice of having just one memorable password a bit similar to my own eight-digit name for everything was an open door. But now I am Fort Knox. My jewels, accounts, portals and blogs are secure. My passwords are so “strong”, various and regularlychanged that a 1,000 trained monkeys tapping away at keyboards at GCHQ or the Pentagon or wherever it is have less than a one in ten to the seventeen millionth probability of cracking by chance my WH Smith e-book account. WH Smiths itself has this very day notified me of its changed web-site address: you just cannot be too careful in online book sales these days. So there you are. You must maintain your 50 or more diverse non-memorable “strong” passwords, change them monthly and not keep the resulting look-up file in your computer memory. That’s the first place hackers will look: in your computer, obviously. But they will not know to look under the sack of compost in the greenhouse. The readers of ACP news do know to look there having read this article. Stepping back from the world wide web world to the real wild wide world, folding money must be taken from
holes in the wall and obscure specialist batteries must be purchased for rare electronic devices. The summer has been a moderate digital success in 21st century terms. Our holiday suitcases have mechanical padlocks whose numbers I remembered, after a short thinking process. Plastic PINs had an immediate reward and the Pavlovian incentive worked in Europe for Euros to gush forth although they are not much worth having. There are three doors with different numerical pads between the car park and my office. And I got back in; I breezed through like the autumn mists ... But ask me the 13th digit of my third secret word – the colour of the cat that my mother ran over in her first car, gingery brown I think, maybe, reddish towards the end – when my cash card chooses not to work in Japan and I will not remember. As the nice bank security person assured me on the international telephone from her secure office in a shed in Mumbai or Vladivostok or Livingstone New Town, it’s alright. Your money is completely secure. No one can touch it, not even you. It’s password CXT34£$%xti47ing protected and those are the 14 digits that we bank security people understand to “take you through security”. Thank you for calling, can we be of further assistance short of telling you your password? If you are seized by the idea of stealing my identity – and I can think of better ones to try – and you form a data fraudulent conspiracy to enter my office and covertly authorise my reports, then forget it. The password is no longer an Italian lake, it is ..., oh ..., ah ..., it’s on the tip of my temporal lobe, it’s past presidents randomised, no it’s Austrian towns – I know I have this somewhere. Has anyone got an electronic crow-bar? No actual cats or passwords were harmed in the writing of this article.
Your next cat will have to have an otherworldly given name such as “iixt23&QR45”
C%5L G&3y is a bank customer and digital-age secure cyber person working in H14+&^QXe. He can be contacted at firstname.lastname@example.org. The password is “JULIAN”.
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SLOW SLOW QIPP QIPP SLOW – Dame Dorothy does the Coalition Foxtrot So here I am, possums. Faced with breaking in yet another Newbie Editor and I’ve only just got used to lastminute.com.knowles. OK, so it’s not as if Julian Burton is a complete stranger to any of us (I’m sure we all remember his voice-over on the track to War of the Worlds) and I happen to know he’s been tapped on the shoulder more than once for the prime job but played hard to get the first few times. Well Jules me old crockapoo. You’re in the limelight now and no mistake. I was sitting on a coral reef the other day, somewhere along the equatorial line that divides us up here from the good old folk down under, pondering. Well, let’s face it, there’s not a lot else to do on an atoll where the highest mountain only comes up to your knee and you’re wondering what you’re going to do as a flightless bird come the next tsunami. Which I still think sounds like a bunch of characters from a Disney animation. Anyways. I got to thinking about my first column under the New Regime. Would Big J want me to continue? Would I still be allowed to extract the editorial bladder contents or should I take a more serious approach to the very serious times you Poms find yourselves in? And there must be a score of rants I could get stuck into after a bit of a gap filled by the Profits re-run, mustn’t there? Well that’s as may be but here I am now, faced with a page that gets blanker by the minute. I suppose it’s a bit like writing letters home to the folk at Bandicoots Crossing – loads to talk about if you write weekly and absolutely sweet Fanny Adams to say if you only scratch your ballpoints once in a blue moon. No point in talking about that fabulous creature you picked up at a College Dinner just after the last massive missive if it turns out that the individual concerned was actually a cross dressing refugee from the Turf Club booze-up at Number 5 who promised to phone but never did. Could be, of course, that it’s also something to do with the seemingly permanent phoney financial war we are currently disengaged in, living in this Sceptic Isle. Masses of talk about the money problems facing the country, the health service and pathology. In that order. But few manifestations of real pain. As yet. And a Coalition that keeps on criticising the public sector that they now own: don’t the ruddy drongoes understand that they’re not in ruddy opposition anymore? We are, of course, all focusing on Lord Carter of Coals and his Second Review and not a bare ankle in sight let alone a stand-up comic unless it’s one of the Millipede brothers. Meanwhile, everyone else is concentrating on the most dramatic re-disorganisation of the NHS since the last one. And didn’t that announcement come as a big surprise?
It’s a bit difficult to read the Newbies just at the moment: we aren’t going to distract people with yet another reorganisation; ooooh yes we are; we’re going to stop school milk; or perhaps not. NHS Direct is definitely going to go; well, the phone number is going to be different; maybe. And so it goes. Or maybe it doesn’t. Anyway, it would seem that SHAs and PCTs are Out and GP Commissioning is In. So where does that leave us poor pathological sods in what is increasingly perceived as just another Back Office service? And doesn’t that term irritate the daylights out of you? Not just because pathology is NOT a back office function but more because the term has been specifically designed to demean and dismiss – sometimes literally – a whole bunch of perfectly nice people doing their best to do the job that they were lead to believe was a worthwhile one and are now being told is a criminal waste of taxpayers money. That is not to say that I think for a minute that everyone down the road at the PCT is actively engaged in life saving activities and there is a distinct probability that some bludgers are still engaged in arse saving activities but toujours la meme histoire as my gyno says. So perhaps, for some, the back office can be found somewhere up the back passage; but for the majority of folk down my neck of the woods, it’s just a bit rude, especially coming from a bunch of MPs who have been milking the taxpayer to fund their own back offices. But I digest. The only real act in town – or so I’m told by the Noble Hubby who, as you know, is a Westminster Bird – is QIPP. Which stands for Quantities of Income Please Produce. Or Quit Immediately Poor Performance. Theoretically it’s about quality and innovation and stuff but the only time I’ve ever heard anyone talk about it is when it’s been coupled to one of two figures: 20 billion squid (NHS) or half a billion squid (pathology) and both with minus signs attached. So we’d better get on with saving some moolah because, for this lot, quality and innovation equals cash release. And listen, my proud pathological potteroos: if you really don’t know what QIPP stands for then good for you. Keep your heads down out there in the back orifice and remember to prime your satnav with the postcode of the lab down the road over the weekend. You may be working there on Monday. Hooroo. Dame Dorothy Dixon is an Emu. Email:
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Facebook and I – Mike Harris Dr Mike Harris is a consultant histopathologist and a former editor of ACP news Email: mdharris@ doctors.org.uk
OK, come on now, it’s confession time. Do you use Facebook, probably the largest social networking site on the internet? If you don’t, then I rather suspect you are in the minority and that is why no one sends you Christmas cards anymore. I have had a Facebook account for the last few years, but I have not really used it much until now. Like most parents, I mainly looked on there to find out what my kids were up to. Until recently, my profile rather grumpily said, “I really don’t have time to fill this in, you know.” But then that all changed. It started when I became “friends” with my kids. I don’t mean in some touchy-feely, New Age fathery sort of way. No siree! I mean in a kind of cool, hip-hoppy sort of way as “Facebook friends”. But what happens when you befriend someone on Facebook is that you appear on their profile as a friend and all of their mates start sending you friend requests too. So I am now Facebook friends with a whole load of 20 somethings who were in the same classes as my kids at school. As a significant number of these are young, female university students, who mainly seem to post pictures of themselves and each other at parties, in various stages of inebriation and undress, I feel like some sort of pervy voyeur every time I go on the site. Who needs to pay out for Nuts, Loaded or FHM magazines when you’ve got Facebook? In my experience, Facebook users fall into two main categories. There are the young people who use it to organise their social lives, meet their friends and lovers online and just generally while away the hours. There is no point in telling them to get off the computer and get a life; these networking sites are their lives. Then there are
the old farts. Now, this group is particularly interesting for their more subtle use of the internet for that age-old passtime of boasting about what you have got, showing off about your kids and generally making your friends and neighbours feel inadequate. “Mummy is so proud that Drusilla has just sailed through her grade eight ballet exams.” “Ooh look, here is a picture of me with my perfect wife on our new boat.” “I have such a headache from the noise the builders are making working on our new kitchen extension.” As blatant one-upmanship goes, it is just as bad as those irritating “round robin” newsletters people send tucked inside their Christmas cards, except it is online and available to torture those less fortunate than you all year round, 24/7. Well, I can see the appeal in that, I suppose. At least showing off to the neighbours is slightly more interesting and less perplexing than those who feel the need to share with the world the intimate details of their food intake, the state of their hangovers, or the timing of their recent bowel movements. “I’ve got indigestion.” “I can’t sleep!” “I have just made a cup of coffee.” (In that instance, it was actually with a picture of the cup of coffee attached! Thanks for that – I have never seen one of those before.) The scary thing is that, although I have slightly altered the above in order to protect the guilty, I did not make them up. Some people really do seem to think that everyone else cares what they are having for supper. I suppose you can’t blame Facebook for that, any more than you can blame a paintbrush for bad art; but it does reflect a strange, self-centred mindset in modern society. Or maybe I am just turning into a grumpy old man and everyone else is fascinated by such details and wants to be informed whenever their friends are feeling a bit peckish and have made themselves a cheese sandwich. Worse still are the funny little games on Facebook, where you can play at being a farmer, a Mafia boss, or (rather bizarrely) running various coffee shops and food outlets. Now, aside from the obvious question as to why grown adults would want to spend their time in this way, there is an even bigger question mark over why they should feel the
“Who needs to pay out for Nuts, Loaded or FHM magazines when you’ve got Facebook?”
ACP news - Winter 2010
Columnists need to tell all and sundry about it. As an example: “I just mastered the ‘Become Level 55 (Prince)’ Quest in Kingdoms of Camelot! King Arthur has rewarded me for completing the Quest and I wanted to share their success!” Now, leaving aside the rather dubious grammar and over-use of the exclamation mark, is that something even the geekiest of teenagers would wish to inflict on their friends? It becomes even more sad if I tell you that the above is not only word-for-word genuine, but that it actually comes from a grown woman who really should have better things to do with her time. OK, I accept that these “success” notifications are probably automated, but they are a complete pain and, although you can switch them off on your computer, you don’t appear to be able to block them from your iPhone. This means that, in order to get to something that might be of interest, I have to wade through virtual piles of this self-congratulatory crap. If someone else tells me that they have made a pile of virtual pancakes and want to offer me one, I might just tell them to stick it where the virtual sun don’t shine. Lately, however, I have become aware of another new phenomenon, or possibly a phenomenon as old as the internet itself, but never before given a name, the practice known as Facebook rape. Now, Facebook rape, or “frape”
as it is sometimes known, is what can happen to you if you use someone else’s computer to log in and it remembers your details, or someone sees you type your password, or one of your mates manages to log onto your account from your PC which has your password saved. They then have free reign over your account and can post all sorts of stuff in your name. A prominent figure at the College was recently “tagged” with a picture of a large warty penis because their nephew was “fraped” by a couple of his school friends. Said image was then sent to all of their own Facebook friends, including the Great and the Good of the RCPath, amongst them a few former presidents. As career moves go, it is perhaps not the best, one feels … Anyway, so far my use of Facebook has been pretty much confined to “lurking”, surfacing only rarely to post a response to something if the temptation to correct someone over some trivial point or other becomes too much to resist. But maybe l should use Facebook more and widen my circle of friends. Perhaps I’ll look up a few old school buddies, or some of my old teachers, if they are still alive. I could post a picture of my perfect wife on my new yacht. Moored next to my Ferrari. In the Caribbean. To where I have recently retired. Very rich. Having just had a bowel movement.
Travel is supposed to broaden the mind; but it’s getting to be so much hassle – the unmasked Pathologist I am currently sitting in a deserted departure lounge at Birmingham airport, on my way to an investigator’s meeting in Prague. According to the notices all over the walls, they are working hard to improve the customer experience. I am not convinced: the reason the departure lounge is empty is because everyone is in the queue to get through security. As usual, I arrived two hours before departure and I have only now got into the lounge one and a quarter hours after entering the building. Fortunately I did not stop to have breakfast before joining the queue as I would probably have missed my plane. This makes Birmingham the least efficient airport I have ever had the misfortune to travel through. It even makes Gatwick look good. The other problem is that I am tired because I had to get up in the middle of the night to get here. There are no direct flights to Prague available at the moment. Not because this was a last minute flight and all seats were
The Unmasked Pathologist is Professor Tim Reynolds, Consultant Chemical Pathologist in Burton-on-Trent. Email: tim.reynolds@ burtonh-tr.wmids.nhs.uk
full; no, it’s because Ruinair and Sleazyjet have cut their Prague services from Birmingham so I had the choice of a long drive to London or time in departure lounges to catch up with typing my ACP news column. The meeting I am going to is only for six hours on Friday but I have to go the day before because although a direct flight takes only two hours, the four hour wait in the middle in
ACP news - Winter 2010
Columnists Frankfurt because there are no direct flights adds a long delay. On top of the long intermissions, it was a very difficult job to find a route that allowed me to get home on the day the meeting finished. Again, the only option includes a long stopover in Frankfurt, but it could have been worse. The route I avoided included a 15-hour sleep on the seats of a Zurich departure lounge. This means that it would now be almost impossible for the ACP to stage the National Scientific Meeting out of the UK. Hopefully Gordon’s recession will start to ease in the next few years once we have paid back some of the crippling debt his irresponsible over-spending has lumbered the country with. At least my previous flight, from East Midlands, was not so bad. East Mids airport was previously the holder of the most useless airport award but they have got their act together and it is now only a 45-minute exercise to get into departures. The way back however was completely different. All I can say is that whilst Birmingham has the prize for the worst security queue, Mahon airport has the prize for the least effective check-in desks. Despite arriving two and a half hours early (package tourists are always dumped at the airport early), checking in took two hours and we had to run to get to the gate before final call. Airports do seem to be getting progressively worse – it’s no wonder cruise lines are beginning to run cruises direct from Southampton. Maybe in a good few years time (i.e. when I am old enough/beginning to crumble), I might risk trying one. One of the funniest events during our trip to Menorca was the one where we were able to give a long health education talk to our 12-year old daughter over dinner one evening. The woman at the table next door to us lit up immediately she finished the last mouthful of every course and only stubbed out when food was delivered. At the fifth cigarette between the main course and receiving the menu to order dessert, we had reached the ‘loud theatrical coughing’ stage whilst also commenting audibly that it was a shame the Spanish had not yet joined the civilised world by banning smoking where people were trying to breathe. This immediately caused our neighbour to launch into a diatribe that she was clearly allowed to smoke because there was an ashtray. We suggested that the ashtray was an option that could be ignored and it certainly did not give one the right to attempt to kill off everyone around you by polluting them to death and that it may be more appropriate if she had a factory chimney
grafted onto her head (so the smoke could be released at a much higher level in the atmosphere). For many years my daughter has been paranoid about smoke. You may remember the advert about eight years ago where they showed smoke billowing out of the mouths of children when their parents lit up. One day when she was about four years old, she was walking down the high street and a man with a cigarette walked past. She immediately rushed to a shop window to watch her breath to see if it was full of smoke – it’s amazing how powerful adverts can be. So with our neighbour blowing smoke she started making childishly indiscrete comments about nasty people who try to poison children. We could not resist adding to the health education message. We told her the fact that 50% of smokers will die early because of their bad habit and then went on to describe the gory details – children always like a bit of gore. The more blood and pus the better. She particularly liked the explanation of smoke damage to the lungs because we told her that the lungs are like a sponge and that smoke can make the holes bigger so they don’t work properly (my wife once worked in a hospice and was able to describe how patients with emphysema were the most distressing of all – emphysema makes a much more unpleasant death than a simple cancer. We then told her how if you get a tumour it can block the pipework and the area behind fills up with mucus and pus. Children like pus. However, our neighbour did not … She really liked the story of the lung cancer that eroded the aorta and how the plumber had to strip down the sink because the blood clot had completely clogged the U-bend. Our neighbour didn’t. Next we got onto discussing the coronary arteries and the research projects we were involved with (one of which is the reason I am now in Prague). This was more than the smoker could bear and she demanded the bill instead of pudding. Somehow, I got the feeling that this was not the first time this had happened because the smoker’s husband who had not smoked at all during meal had the resigned look of someone who was used to his wife causing arguments in restaurants because of her between course chain-smoking. At least we got to enjoy our pudding in fresh air. What about Prague. I am in the Hilton. I could be anywhere. There is a standard Hilton corporate-style bedroom, overlooking the internal atrium of the hotel. If it were not for the walk I took this afternoon as I arrived
“Children like pus. However, our neighbour did not …”
ACP news - Winter 2010
Columnists before the meeting began, I would have not seen anything of the city. I wanted to look at the new “shopping city” that has been opened in the old meat market. The internet gave the impression it was a really good shopping experience. Not that I like shopping; far from it, but it is my wife’s birthday in a few days time so I thought I might find a nice present. If you go to Prague, don’t fall into the trap of believing that River City is a pleasant experience. It isn’t. It is a dodgy flea market, with lots of stale sweat and probably real fleas. The only shop bigger than 10m2 was the sex shop, and that was right next door to the Amsterdam-style window brothel. So, I will be buying my presents in the duty free shop in the airport, which means more garnet earrings for my wife and another Russian doll for my daughter. The same as I bought last time I came to Prague, although that was a day trip so I did not have any chance to have a walk or look at the shops. This raises one of the other challenges of travel. Money. Given that the hotel and all transport is supplied by the drug company, there is little point in getting any Czech
crowns because there is virtually no opportunity to spend them, which means that in the brief wait in the departure lounge (not enough time to eat in Prague on the way to Frankfurt), you do not have any change to use a vending machine so have to suffer the ire of the shop girl when you try to buy a 35 CzK bottle of coke (@ £1 = 28 CzK) with a credit card. Thus, you end up buying some chocolate just to bring up the total. At least when in Frankfurt the remaining Euros from the summer come in helpful. The Euro is a really excellent currency idea (for the neighbours to buy into – but seeing the success of Greek Euro membership it was very good that the grinning fool and the boy blunder decided we would reject it so declined to give the British population the option). Which brings me round to the really big problem with travel. Why is it that every time I get back from my summer holidays, there is a request from the editor for 1,600 words (or thereabouts)? [The departure lists for all international flights are automatically sent to ACP news editors – Ed.]
Motivation: everybody’s doing it – Simon Knowles Dr Simon Knowles is a Consultant Histopathologist in the West Country and a former editor of ACP news Email: Simon.Knowles@nhs.net
It’s a rubbish time of year isn’t it? As I write, I mean: blustery showers, gloomy mornings and all the hallmarks of the hour about to go whichever way the hour goes this time of the year to make us all even more depressed. I do not get seasonal affective disorder. I do get depressed in the Autumn. Come about the third week in January I perk up a modicum because it’s becoming clear that the days really are going to get longer again, hooray. Anyway, in the meanwhile I am finding it, as usual, increasingly difficult to motivate myself to do anything more than that which I am required to do. No question
of initiative – I just grind out the reports as the slides hit my desk. If there wasn’t an element of “push” then I’d probably just sit there staring vacantly into the middle distance that is the West Country. The idea of getting off my bum and going and finding some slides to report is fantastical. My lean training tells me I’m letting down the side. My buttocks agree but my heart is on the side of my legs. And they seem to have decided to take a sabbatical. So perhaps I’d feel a bit different if someone offered me a bit of an incentive: say a fee per case reported or the genuine chances of a brownie point in this year’s CEA competition. But perhaps I wouldn’t. And, actually, do we have any real evidence that a bit of extra dosh genuinely increases productivity? Well, there’s a daft question. We don’t work for free do we? So obviously money incentivises. Give me more money and I’ll do more work. It’s the very essence of how we all do business. But in this day and age, where Wikipedia can drive Encarta out of business, does it still hold true? Not according to a large body of research that shows that incentives often do the very opposite with regard to productivity in the long term. Counterintuitive or what?
acp News - Winter 2010
Columnists Where to stick your carrot A whole range of studies, performed on everyone from kindergarten kids through the people in the street to subsets of industrial workers and professionals, seem to refute the idea that “if-then” (if you empty the dishwasher then I’ll give you a quid) reward systems provide long term value for money. In the dishwasher example, as most parents know to their literal cost, there are two inevitable consequences. Firstly, the dishwasher will never be emptied for free again. Ever. And secondly, after a while there will be an implicit or explicit demand for a pay rise. Likewise for if-thens for doing homework, exam results and so forth. The effect wears off. And the lasting message is that the task is a chore: if it wasn’t then you wouldn’t have to bribe people to do, it would you? And the same message comes out of studies on adults. There is, however, an interesting twist to all of this. For intrinsically boring, repetitive (generally motor) tasks, standard if-then rewards do work. Sometimes. It’s when you move into the realm of creativity that the carrot morphs into a banana skin. All the evidence points to the need for a different way to motivate people who work in creative environments. For example, artists such as sculptors generate better quality work independently than when working to commission. Independent work is creative. Commissioned work is, well, work. OK, so what? Like it or not, the truth is that path labs bear more resemblance to factories than they do to artists’ studios. Well no, they don’t actually, or at least not yet. Although there is a genuine worry that the warehouse laboratory of the future will indeed feel a bit like a sweatshop.
cheapy Kindle download or buy the paper version), Pink claims that, in the modern world, we should stop depending on the old fashioned carrots and sticks and capitalise on our innate hunger for three things: Autonomy, Mastery and Purpose. I think he’s right. Purpose is not really a problem for most people working in health, although we tend to take it as a given. But genuinely handing over a bit of Autonomy and allowing people to work towards Mastery? I’m all for it. The trick is going to be how to do it, for ourselves as well as our staff. Perhaps we need to take some lessons from a motivational speaker. I’ve just been to a rather good meeting in one of those rustic conference centres that are found conveniently just off a motorway but restfully surrounded by greenery. A sort of mix between Victorian High Gothic and Motel Bland with enough space outside to justify pulling on the trainers and going for an ostentatious jog before breakfast just to make a point. Brilliant sessions, with a lot of discussion about how we are going to weather the upcoming financial storm. Then it was pointed out that the two talks from very senior finance people were both followed by “motivational speakers”, reflecting, perhaps, a somewhat downbeat message from the money men. Nonetheless, two whole motivational speakers seems a bit dramatic for a one and a half day meeting and I’ve been pondering on the art form ever since (Can you have half of a motivational speaker? – Ed]. Our two speakers both sizzled with self-confidence and talked convincingly about how You Can Do So Much Better If You Just Follow My Golden Rules. One of them had done loads of team sport and some dancing on the TV. The other one had gone from a standing start to flat-racing jockey in 12 months. Both were extremely professional, well rehearsed and entertaining. But the funny thing is that I can’t really remember much about the take home messages from either except that there was something about not going to the loo when you are chatting someone up and something else about sucking beer through a team mate’s underpants. Or was it the other way round. I think I may stick with Autonomy, Mastery and Purpose. Anyway, I must stop now. I need to go and empty the dishwasher and I’m really looking forward to it.
“The truth is that path labs bear more resemblance to factories than they do to artists’ studios”
Autonomy, mastery and purpose: what’s not to like? The truth is that most of our staff, from pathologists office to specimen reception, get the bulk of their motivation from internal sources. They work better when treated as – to move into trendy jargon – Type I individuals. That’s I for internal as opposed to X for external, according to a very readable chap called Daniel H Pink. Mr Pink is an interesting character who was speech writer for Al Gore and is the author of several rather good books, including a Manga-style business textbook. But don’t let either of those attributes put you off. In his new book “Drive: The Surprising Truth About What Motivates Us” (you can get it from Amazon as a
ACP news - Winter 2010
Sunday evening paranoia – Su Enn Low Dr Su Enn Low is a I think I have an aversion to Sunday evenings. Sunday Consultant mornings are lovely – all about lie ins, breakfast muffins, Histopathologist at the newspapers and dreaming about a leisurely Sunday lunch. Pennine Acute Trust I think it all began when I took up column writing some and Assistant Editor years ago, the stupid fool I was. Now every three months, of ACP news I dread the coming of a particular Sunday evening like I Email: dread my bank statements arriving. It’s when I know I preciousdumpling@ cannae put off writing this column. I become all anxious doctors.org.uk and moody and mentally unhinged, rather like King George. Are there any other fellow procrastinators out there so parted and my reception committee of heavy rain was we can form a support group? Procrastination’s not all bad enthusiastic in welcoming me home. though. In fact to put off writing this column, I have today But I think I’m being unfair to Manchester. It doesn’t watched a DVD I wanted to watch some 3 months ago but rain all the time. Sometimes there’s hail. And sometimes never got around to (Casino Royale – does Daniel Craig there’s snow. have his lips set to permanent pout? Is it Botox?), baked So suddenly the cold snap is upon us and I have the some cake, cooked some stew, washed and blow-dried the heating on and the urge to light a fire and to gorge on cat and tidied up. So actually I have the ACP to thank for cream cakes. Rorycat is also settling well into his winter my sparkling house and (slightly annoyed) cat – so function as a tea cosy; the teapot being my head as I beneficial is column procrastination that all my household snooze in bed. I know I go on and on about my cat, but chores get done. he’s actually a good investment. My house is a fly and This wasn’t what I had planned though. I had initially spider free zone although what I cannot fathom is why my planned a weekend of relaxing nothingness curled on the dinners keep going missing. sofa, drinking myself to oblivion. Unfortunately My summer clothes have only just been my brain has a mind of its own tucked away under the bed and and when it knew I had Halloween and Bonfire “I’m being unfair to Manchester. planned to enjoy Night are still ages myself away. Today I It doesn’t rain all the time. immediately venture out to Sometimes there’s hail. switched itself onto Tesco and find And sometimes there’s snow” constant nag mode. It’s they have their like I have a wife for a brain Christmas decorations up. sometimes; louder than a vuvuzela and And TV adverts are already in full doesn’t shut up even if you offer it your credit card. So swing telling us how if we buy now, we’ll have, hurrah, my weekend went to hell and I did chores. new sofas delivered for Christmas and better yet, we don’t Anyway, have you noticed that it’s only September but need to pay for it till next year. I’m cold so I tell Rory to it already feels nippy like winter? Summer has been a total come warm my lap but he feigns ignorance. I pick him up disappointment this year. Rain rain rain. I don’t know and he gives me a few swipes with his claws for my whether it is a total country thing or whether it has just efforts. Honestly, the amount of scratches I have on my been limited to Manchester. In Manchester it seems to be hands, I’m afraid people might think I self harm. Rory perpetually raining: does Manchester have its very own looks at me pityingly, sighs and disappears off in search of rain cloud? The good thing is that all of my plants are tuna. flourishing and I don’t think I’ve watered them even once Eight paragraphs already! I may be cold but inside I feel this year. I remember recently journeying down south for all warm and glowing now that the deed is done and Jules a barbeque and the weather was lush and sunny. I even can stop telling me about how he can telepath death rays managed to use my sunglasses for more than (shock should I dare to go over copy date. Finally I can celebrate! horror!) a half hour. Driving back home was similarly dry Unfortunately my eyes fall on the mantelpiece clock. Drat. although not sunny, given that I was driving at night but as It’s midnight. Time for bed. [Column received at 22:39 – soon as I reached the Knutsford junction, the heavens you need a new clock – Ed.]
ACP news - Winter 2010
Dornoch tourist attractions – Mike Biggs
Newtworking – Su Enn Low
Tumour of doom – Robert Hadden
Humour tumour – Mike Biggs
ACP news - Winter 2010
Editor – Dr Simon Knowles 2008 – 2010 The Association of Clinical Pathologists
The Association of Clinical Pathologists
The Association of Clinical Pathologists
Storm Warning? Results: Can you trust GPs?
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The Association of Clinical Pathologists
Join the debate: What is the point of Foundation Trusts?
The Association of Clinical Pathologists
preliminary opinions on the final Carter Report short codes for skins old animal bones Las Vegas
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Play the regeneration game
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The Association of Clinical Pathologists
The Association of Clinical Pathologists
Hiroshima Lean thinking Live long and prosper The trainees section zone returns
The Association of Clinical Pathologists
Will necroradiology replace the forensic autopsy? Is Pathology screwed? Ian Barnes doesn’t think so Training for academic pathology Fostering research & development
Jim Easton on innovation Stem cell therapies Medicine in art
Thorns or low hanging fruit? The new landscape for pathology Dr Cyril Molethrottler, police surgeon Learning leadership