Sunday, October 29, 2006

Angry writes from Planet Research

I have the privilege/onerous task of being involved, albeit in a small way, with some research. It’s not an easy thing to cram into an already packed pathology training programme and much of it ends up being done in my own time. I managed to wangle some time in the research lab using a bit of study leave and I go there occasionally for meetings.

My two main impressions from what I’ve seen are:

It’s like being on another planet
Some of the scientists hate medics

It’s a lab Jim, but not as we know it

The research lab is nothing like the pathology lab. It’s full of weird machines and endless shelves with lines of bottles. In some of the labs they culture cells which some of the scientists assume we also do in pathology. I grew some bacteria once as a med student, that’s the closest I’ve got to it. This is hardcore stuff, though. They’ve got all kinds of human and mammalian cells which look totally different to the fixed and stained cells I see on histological slides under the microscope. These cells sit in little plastic bottles making little ghostly shapes. It’s bizarre to think that they’re alive.

Didn’t they teach you anything at university?

Some of today’s medical students might need to answer in the negative to that question, being as with PBL they pretty much need to teach themselves. I’m a bit more ‘old school’ so I did actually get taught things as a student.

Unfortunately I heard the above comment bandied about when medics in the lab didn’t know some something about science. Interestingly medical school is so called because you learn medicine rather than detailed science. That’s why your doctor can help you if you’re having a heart attack or suffering from Crohn’s disease. Your doctor, however, has not learnt the in depth details of how to sequence DNA, or how a mass spectrometer works. That’s because these are generally not very helpful when faced with a patient with acute asthma, or a resected stomach from a patient with stomach cancer.

My blood began to boil even more when I was told by somebody who knew **** all about pathology that skin pathology was really easy because the only thing you needed to identify was melanoma - which was simple because of its black colour. Sadly I didn’t have a copy of ‘Skin Pathology’ by David Weedon handy. This book is approximately 5 inches thick and contains every diagnosis a pathologist could hope to make on a skin biopsy. It would be a useful aid to the education of such people. Alternatively I could have just hit them with it.

I’m glad to say this attitude did not seem too widespread. While I was there I got talking to a couple of other medics who were there working towards higher degrees. They told me that there was a real ‘anti-medic’ feeling in some labs, one of them was working in a lab that was particularly bad and seemed quite unhappy. It’s made me think twice about getting more involved in research, which is a shame. Some of the scientists I’ve met or worked with were keen to encourage more medics into the research labs and genuinely valued the fact that we have some expertise in a different area to them. I learnt lots of fascinating things, new ways of looking at medicine and disease and generally had my horizons broadened. Spending some time in the lab was definitely worth doing, but the whether it’s worth doing more of and taking the obvious crap that comes with all the good stuff I don’t know.

Friday, October 27, 2006

Have a heart

The other day I was doing the ‘cut-up’ – the process of examining and dissecting the surgical specimens that come to us from the hospital’s operating theatres, outpatient clinics, and the local GPs. Apparently in the US it’s sometimes called ‘grossing’ but most of the specimens aren’t as yukky as that might imply! The last specimen wasn’t adequately fixed in formalin yet so I put it back in its pot after having a quick look.

It was a heart

All the specimens come with a request card giving the patient’s details, the consultant looking after them, the specimen that’s been sent, and some ‘clinical details’. The rather nebulous sounding clinical details section should be filled with useful information including one or more of: what disease/problem or suspected disease/problem the patient has, relevant medical history and medication, what the person sending the tissue would like to know about it etc. It all useful information in helping us make the diagnosis, stage the tumour, or whatever we need to do with the specimen.

The ‘clinical details’ with the specimen simply said ‘heart’

No sh*t! I’d never have known, although the heart does have quite a characteristic appearance for those in the know. I presume the heart had been removed for some reason but why? And why keep it such a secret? Knowing a bit about the specimen helps us decide the best way to dissect it, which parts are particularly important to look at under the microscope, which stains we need to use to look at the slides and if we need to take samples for other more specialised tests.

The result is me wasting my time trying to get in touch with surgeons who are in theatre/in clinic/not in because they’re on nights. Just to get hold of information that should have been sent with the specimen. And then they ring me wanting the histology report ASAP. I sometimes feel like sending them a report ASAP saying ‘No clinical details were provided with this specimen.’ Or even (in the spirit of the request card) ‘Histology report.’ But I just ask them for the details. Maybe I’ll be more militant when I’m a consultant…..

Wednesday, October 25, 2006

25% of autopsies substandard

The big news in histopathology at the moment is the release of the latest report from NCEPOD (National Confidential Enquiry into Patient Outcome and Death). This year the report is ‘The Coroner's Autopsy: Do we deserve better?’ My printer churned it out at the weekend and it makes for interesting reading. Of course many pathologists will rightly say ‘I told you so’ about much of it, but at least we now have evidence for our grumblings. One of the things that struck me, apart from the annoying lack of contents and page numbers in the pdf I downloaded, was the discussion of the purpose of the coronial autopsy (found in section 4 of the report). The authors suggested a range of possible answers to this:

1. To consider and exclude homicide

2. To consider and exclude unnatural death

3. To provide an acceptable – though not necessarily correct – medical cause of death for registration purposes

4. To provide the correct medical cause of death and accurate data for national statistics

5. To provide an account of sufficient, accurate detail to address any concerns from the next of kin and to be useful to them

6. To provide detailed information for medical audit and explanation of events following medical interventions

7. To provide the basis for a publishable case report

The authors thought that the current coronial autopsy fulfils the first 3 at least. I think (hope?) in most cases it should also fulfil the fourth. In an ideal world I’d like to think it would fulfil 1-6, as well as serve other purposes such as training and research, with appropriate consent.

Overall the authors found that 25% of coronial autopsy reports were ‘poor’ or ‘unacceptable’ according to their criteria. Note that they were reviewing the autopsy report and additional information available to the pathologist, not standing and watching the autopsy being done – an impossible task when reviewing over 1500 autopsies done across England, Wales and beyond in the space of one week! However a poor report doesn’t necessarily mean the autopsy itself was badly done, and a badly done autopsy might be disguised to some extent by a well written report.

One point made in the report is that if 25% of surgical operations were substandard there would be an outcry and it is because of the lack of knowledge on this issue amongst the public that there is no protest about the state of coronial autopsies. Despite this, since the publication of the report there has still been little outcry. Why not?

Well I don’t know but I’m going to have a think about it, and I’m going to say more about the report later. In the meantime, you can read it yourself here.

Monday, October 23, 2006


Welcome to Pathologists Anonymous.

Dr K stands up and raises her hand

"I'm Dr K and I'm a pathologist"

Because sometimes this is what is feels like in pathology when few people understand what you do and some think 'pathologist' translates as 'psychopathic body snatcher'.

"I'm Dr K and I'm a pathologist. I don't steal human organs and keep them in a cellar. I don't hack dead bodies into pieces. I do think that patients should get the most accurate diagnosis from their tissue samples. I do think investigating why people die is important and I know that every day pathologists do things that help patients even though they usually never meet them."