Wednesday, November 29, 2006

Want to be a pathologist?

One of the aims of MMC is to push doctors into career decisions earlier and earlier and better careers advice is supposed to be available to ‘help’ doctors decide that they either accept a job in a speciality they don’t like or they’re out of work. All specialties require different characteristics in their practitioners, so if you think you might be suited to histopathology – or want to prove that you’re not – I’ve compiled a list of useful qualities for histopathology:

Two hands. There is no such thing as a one-handed pathologist. After giving your most likely diagnosis, practise saying, “on the other hand…”

Obsessiveness. Do you check you’ve locked the door. Twice? Obsessive checking of slide details and block numbering is vital.

Interest in pictures. If you only read books with lots of pictures and preferably very little text then pathology is for you.

Pattern recognition. Can you pick out the exact wallpaper from hundreds of similar designs? If you can then you’re an ideal candidate for pathology.

Strong stomach. You will need to be able to eat your lunch with hands that smell of formalin or worse, with a photo of that anal carcinoma you dissected 3 days ago in front of you on the desk.

Eccentricity. You won’t get ahead in pathology without it.

Black humour. Essential for anybody who has to open other people’s bowels.

Will of iron. For standing up to the surgeons.

Strong arms. Pathology books are very big and heavy

So if you’re an odd wallpaper obsessive with two hands and lots of picture books, this is the job for you.

Sunday, November 26, 2006

Blogging Famous

Yes I know that most people viewing this page will have stumbled here via Dr Crippen's BritMeds but if you haven't please do go and check it out. I'm off over there to discover more....

Tuesday, November 21, 2006

A1 Pathologists

With the news that hospitals will soon be advertising their services, I decided I'd put in my contribution to the pathology department's ad campaign. Never mind the huge piles of slides sitting on our desks in the department, we've got to come up with a glossy brochure. You might think that we'd do better by reporting our slides and that the money for this advertising might be better spent on other things (maybe a new automatic slide stainer, a nurse or two, a neonatal intensive care unit perhaps?) and so would I. But, for what it's worth, here's my ad....
Ill? Dead? Do YOU need a histopathologist?

A1 histopathologists are here for all your diagnostic histopathology needs.
Yes, we will fix, examine, dissect, block and report YOUR biopsy ASAP. First, second and third opinions available. Special rates for multiple biopsies from the same patient. Send any large resection and get the lymph nodes reported FREE! Full autopsy service, hospital or coroner, toxicology, microbiology and other tests available. Cervical screening and non-cervical cytology. Full immunohistochemistry service and access to flow cytometry and cytogenetics. Ring us TODAY to discuss your case.

*turnaround times may vary

That should do it….

Thursday, November 16, 2006

Back into the mortuary

Well the NCEPOD report into coronial autopsies seemed to create little more than a ripple before vanishing from public view. Autopsies are only interesting if people think they are something out of a horror film and produce headlines like ‘Doctors stole my relative’s insides’. When we want to talk about what autopsies are really for and how they can be improved apparently hardly anybody is interested.

In the report the very important question was raised: ‘what is the purpose of the coronial autopsy?’ and a few possible answers were suggested. The most contentious aspect of the autopsy is the retention of tissue or organs, something that a lot of people believe is unnecessary. In many coroner’s jurisdictions the directions given to pathologists are restrictive. Some are told that no tissue, organs or fluid samples (for tests such as toxicology) can be retained in cases of natural death, or they can be retained only if no acceptable cause of death can be determined otherwise. This is not necessarily an accurate cause of death, just a reasonably plausible one.

Interestingly, very little research has been done into the use of histology as a postmortem investigation. This is probably because in the past it has been an integral part of the autopsy itself. If we received a surgical specimen, for example a mastectomy specimen containing a breast carcinoma, there would be uproar (and a pathologist before the GMC, probably) if we had a look at it, dissected it, and then got rid of it without making and examining a set of slides under the microscope. Without the microscopic examination of the specimen we have not done our job properly, the diagnosis is inaccurate and incomplete, the tumour cannot be typed and graded and the patient cannot get an accurate assessment of their likely prognosis and best treatment options.

But at autopsy, suddenly the tables have been turned and we are now frequently forced to rely on a naked eye examination only. For many relatively common autopsy diagnoses this is not such a big problem – the ruptured aortic aneurysm and massive subarachnoid haemorrhage are easy enough to spot. For others our ability to diagnose them without histology is in doubt; the common cause of death that is pneumonia is a case in point.

So what is the point of the coronial autopsy? Are we expected to make an accurate assessment of the cause of death, because if so our hands are already tied by restrictions on our practice. Or are we only expected to exclude foul play (without a toxicological analysis?) and produce our best guess as to the cause of death.

What it seems to boil down to is the question: is the coronial autopsy a medical or a legal procedure?

Imaginary autopsy #1

I’ve made this case up to illustrate a point; any similarity to any real case is purely because I’ve chosen medical problems that are common.

A 58 year old man with a history of hypertension (high blood pressure) and a previous heart attack (myocardial infarction) was found dead at home. He had been completely well 3 hours earlier when he was last seen.

The autopsy shows widespread atheroma, an enlarged heart with left ventricular hypertrophy (thickened left ventricular wall) and myocardial fibrosis (scarring within the heart muscle), and triple vessel coronary artery atheroma. There was no visible coronary thrombosis (blood clot within the coronary artery) or obvious recent myocardial infarction.

Do you examine the brain?

Opening the skull to examine the brain is usually the last part of the autopsy to be done. Some coroners do not like you to open the skull if a cause of death has been found elsewhere, a problem discussd in the NCEPOD report into coronial autopsies. In this case the patient had severe heart disease, certainly enough to be a cause of sudden death. But it is not necessarily the cause of death.

The skull is opened and inside there is a massive subarachnoid haemorrhage from a berry aneurysm. This is the cause of death. These aneurysms are occasionally related to inherited diseases so finding this cause of death might have implications for this man’s relatives.

In cases like these where there is pressure not to examine an organ (but not a specific limitation on the extent of the autopsy) it can be difficult to decide what to do when a plausible, but not necessarily definite, cause of death is found such as severe heart disease. So is this autopsy a medical examination to determine the cause of death or a legal examination to determine that the death was natural, without as much thought to finding an accurate cause of death?

Saturday, November 11, 2006

MMC - shake your head

There’s a lot of talk amongst doctors about the new training scheme (MMC) being introduced at the moment. It’s a source of despair, debate and fear for many and you can read about more of the issues including those facing house officers and more, explained by Dr Crippen.

Histopathology is one of the first specialties to start run-through training (or ‘rush-through training’ as it is affectionately known). The new scheme seems broadly similar to the Calman training that specialist registrars of my generation are doing at the moment. The time to complete training is not much shorter, unlike in some other specialties. So do we need to protest about MMC in histopathology? While other specialties are having training times cut and a subconsultant grade brought in by stealth, will things be so bad in histopathology? Or is it that they already are?

When Calman training was brought in between 1995 and 1997 the period of time junior pathologists spent in training before becoming consultants was longer. The new Calman training shortened this period. Many consultants I know who trained in the Calman scheme think their training was too short to provide the breadth of experience they need to practice independently and safely. Before Calman, there were problems with senior registrars waiting for long periods before a consultant job came along, or having to go abroad due to lack of consultant jobs in the UK. The situation is now the opposite; training has shortened and registrars are being pushed through training into vacant consultant jobs. MMC will make this process even faster and increasingly less experienced doctors will be called consultant at an earlier stage in their training. They will not be equivalent to the consultants of the past.

Even though I am ahead of MMC and will finish my training under the Calman system, I still worry that my training will not be as broad or deep as I would like before I am deemed to be a ‘consultant’.

A second problem, affecting junior doctors in all specialties, is the lack of exposure to different specialties they will have before being expected to start a run-through training scheme. Some people say that because junior doctors under MMC will rotate through more specialties during their first two years that they will get more experience. Unfortunately they will be spending a short period in each specialty, long enough to know where their ward is but not to develop many useful basic specialist skills. Many will be on rotations where the majority of the specialties they rotate through will be of little interest to them. They then need to compete for a run-through training post in their chosen specialty, which they may never have worked in before.

This system is supposed to reduce the bottleneck between the senior house officer and registrar grades by amalgamating them into a single run-through training grade. It may do this. It may simply create a bottleneck elsewhere. It also prevents the undecided senior house officer from working in a series of jobs in different specialties to gain some experience, some maturity and some idea of what they wanted to do with the rest of their career. These periods of time were not wasted. The senior house officer grade allowed doctors to change specialties fairly easily and develop a set of skills in a variety of different areas.

Of the histopathologists I know, several began training in other specialties before starting pathology, they did surgery, general medicine and GP training. Some people left pathology training for other branches of medicine. These are not people wasting their time by being indecisive. They have acquired many useful skills in understanding diseases, seeing how patients with different problems present, how they are managed and how the histological diagnosis affects them.

The new MMC style training will drastically reduce the opportunity for doctors to experience a range of specialties they are interested in and consequently gain a unique range of skills. It will produce less experienced consultants with a narrower range of experience. It has already started (in addition to other problems) to produce unemployment amongst junior doctors, with predictions that this will worsen. The situation is not good for doctors or patients.

The system of training prior to MMC had its flaws but it looks to me as if MMC has many more.

Friday, November 03, 2006

How glamorous is your job?

Just as some internal organs are more ‘glamorous’ than others, some diseases and some medical specialties are more ‘glamorous’ than others. Hearts and brains are glamorous organs. Breast cancer is a glamorous disease: emotive, well-publicised and attracting a lot of funding. Cardiothoracic surgery and neurosurgery are glamorous specialties, as is transplant surgery. Breast surgery is much less so, and despite the brain being an organ with so much mystique, psychiatry is a distinctly unglamorous area. It is appallingly underfunded and has few high profile people fighting its corner. The realities of NHS psychiatric services are well described at Trick-Cycling for Beginners.

Pathology has a dual personality. Forensic pathology, a relatively small field of pathology practice, is very glamorous, gritty but glam. For many years charismatic and often enigmatic forensic pathologists have appeared on our TV screens, characters such as Quincy and Sam Ryan for example. Most detective dramas have their own pathologist lurking in (usually) an impractically dark mortuary. Many of these portrayals are hopelessly unrealistic.

No wonder 30% of the British public think pathologists run criminal investigations and only 9% know we diagnose cancer, according to a survey done for the Royal College of Pathologists.

More recently the series Death Detective on BBC3 gave a more realistic insight into the work of forensic pathologist by following the work of pathologist Dr Dick Shepherd. This showed a less glamorous side to the job with real internal organs and real blood, but few high profile murder cases. The real work shown included more cases of the sad and unfortunate who die alone, on the street, in questionable but not always suspicious circumstances.

The mostly glamorous image of the forensic pathologist contrasts with that of the histopathologist. We seemed to be pretty much under the radar until the organ retention crisis occurred and turned us into heartless body snatchers. Hate campaigns against paediatric pathologists, even including the bullying of their children, led some to leave their jobs. The specialty of histopathology has been in crisis with the number of consultant vacancies in England and Wales in 2004 standing at over 200. The organ retention issue is not the sole cause of this but it hardly helps.

Despite considerably outnumbering forensic pathologists, histopathologists are rarely seen on TV. I can only recall two: Professor John Lee who appeared with Gunther von Hagens (who is an anatomist, not a pathologist) on Autopsy: life and death, Anatomy for Beginners and The Autopsy, and the very brief appearance of a neuropathologist on a documentary about a neurosurgeon.

Perhaps forensic pathology gets is glamour from its association with crime – dangerous and fascinating. In comparison, diseased organs and microscopes may not seem so exciting. The vast majority of patients never meet or even know about the existence of the histopathologist who makes the diagnosis on their tissue sample. They may only have two images of pathology, the glamorous crime-stopping forensic pathologist and the organ-snatching histopathologist. Neither of these is accurate.