Pathologists Anonymous

Wasting time

2007-06-15T16:29:00.000Z

There has been a discussion in the pathology forum on DoctorsNet recently about rapid tissue processors and how useful they are. It reminded me of an occasion when I walked into the histopathology department at one of the hospitals in our region and found the corridor filled with empty wooden crates. It was a similar sort of time-saving machine. The senior biomedical scientist told me it had been bought to speed things up in the lab. This seemed a bit strange since the things that slowed down the turnaround time in this department were the volume of work compared to pathologists, the antiquated computer system and the long process of report typing, correction, retyping and authorising. Making the slides come out of the lab faster wouldn’t really help. The senior BMS thought so too. I don’t know who decided this machine would be a good idea but I bet it was expensive, and even if it was cheaper than a new lab software package, an extra consultant, an extra secretary or a good think about how to improve efficiency, it won’t improve turnaround times as much as any of these options.

Who thinks of these ideas?

Shocking email

2007-06-03T08:16:00.000Z

I got an email from the BMA this week. Periodically I have been getting emails from them in the last few months telling me what they’re doing for junior doctors. Before that I got the occasional email trying to sell me their financial services.

But this week, for the first time, I got an email from the BMA asking me to fill in a survey about what I thought of MMC.

Wow.

A survey, something the BMA has never, to my knowledge, bothered to do before in the whole MMC/MTAS fiasco. All this time they’ve been ‘representing’ junior doctors and sending me emails telling me what they were doing and now, finally and too late, they’re actually asking what the people they allegedly represent think. Not there’s any guarantee they’ll listen anyway.

Why the hell haven’t they done this earlier?

Day of judgement

2007-05-25T13:37:00.000Z

Like most junior doctors I’ve been busy following the judicial review into the MTAS fiasco over the past week and waiting eagerly for the result. It may be a loss but the judge’s comments are very interesting; although he didn’t rule that the MTAS review group’s actions were unlawful, he did suggest that many junior doctors would have good cases to take before an employment tribunal. Many recent posts from Dr Grumble and Dr Rant tell the story in more detail.

What is maybe more important than the result is the fact that the judicial review happened at all, and that it was initiated by a small group of doctors and allies who decided they couldn’t just do nothing.

This week I am proud to be a doctor and proud to know that the Remedy UK team and all the junior and senior doctors involved in standing up to MTAS/MMC are my colleagues. The sad downside is that I’m ashamed to be associated with the BMA and horrified by what the policies of Blair et al are doing to medical training and patient care. The fight cannot stop here.

Go be a pathologist then!

2007-05-06T07:55:00.000Z

Yesterday I was surfing around the latest Britmeds and discovered an interesting but typical example of ‘pathological ignorance’ (there’s also a link to a good article just below here!). When I say ‘pathological ignorance’ I mean the failure to understand what pathologists actually do, which tends to lead to statements like this one (on the subject of doctors refusing to do abortions):

If those doctors don’t want to do so, they should consider going to work in pathology, where most of the human beings they come across will already be past giving a damn about a doctor’s precious prejudices or their religious hang-ups.

Contrary to what Ben Fenton, the author of this article thinks, we do have religious issues with abortions in pathology. Some pathologists do not report specimens of ‘products of conception’ derived from abortions; the issue does not go away outside the gynaecology department.

The author of this piece also makes the mistake of assuming that in pathology the vast majority of our patients are dead. Not true. In most departments I’ve worked in there are around 10 times the number of living patients (their specimens, at any rate) than dead ones examined by us pathologists. He also assumes that the dead will not care about our prejudices or religious hang-ups; maybe the dead don’t but their relatives certainly might. In pathology it is more often the religion of the family that impacts on us as certain faiths need to bury the body as soon as possible after death so an autopsy needs to be done more quickly.

A second issue with autopsies is that in some cases the relatives, via the coroner, will allow only a limited autopsy which may not answer the questions posed by the death. As pathologists we want to do a high quality autopsy that is thorough, answers the questions and doesn’t miss anything. In cases where the pathologist thinks the autopsy will be too limited to be of use, he or she can refuse to do the autopsy (RCPath Guiodelines on Autopsy Practice 2002 section 4.6.2). Does this count as ‘prejudice’ or professionalism in Ben Fenton's book?

Bad medicine

2007-04-29T11:07:00.000Z

One of my moments of fun at the end of the week is getting my ‘Friday dose of woo’ over at Respectful Insolence. It never ceases to amaze me that people can invent and promote the kind of stuff reported there, and that some people seem to believe it. The most recent entry contains something that is implausible whatever your branch of science and reading about it is an almost psychedelic experience. It’s called the SCIO.

Another place to sample some of the dubious medicine to be had via the net is over at The Little Black Duck’s blog. He discusses the subject of hair mineral analysis, something that sounds rather conventional and much more believable than the SCIO.

Shinga has been talking about food allergy and intolerance tests, another very plausible and conventional sounding set of tests.

While it might be easy to spot the rather dodgy nature of the SCIO, allergy testing and hair analysis sound much more plausible; and all these things have ‘scientific evidence’ presented to add weight to their claims. Shinga and the Little Black Duck show that it’s necessary to go back to the scientific and medical research literature and have a careful look at it to really evaluate whether these tests are actually of benefit to real individual patients. Allergy tests can be very useful – providing you’re doing the right test in conjunction with a good history of the patient’s symptoms.

I’ve talked before about what the RCPath have to say about diagnostic tests. Neither the allergy tests nor the hair mineral analysis would fulfil their criteria. They may sound more plausible than the SCIO but in the end they are no better.

Anonymity

2007-04-22T08:22:00.000Z

Dr Michelle Tempest has written an interesting post on bloggers and anonymity, or lack of. When I set up my blog I didn’t even consider the possibility of not being anonymous, maybe because one of the great attractions of the internet is the ability to hide who you are.

So why am I anonymous on here? I don’t need to hide because I express controversial opinions as I don’t think I do and the things I say on here are the same things I say in the real world. A good reason for anonymity is to preserve the anonymity of my colleagues and hospitals. Sometimes I talk about them and they might not want to be exposed on the internet; maybe worse, they might think I’m talking about them when I’m actually talking about somebody different. Anonymity for me and my colleagues is a solution to this. Either that or naming all names so there can be no misunderstanding but that’s hardly acceptable.

Another reason for being anonymous is that it’s a bit of fun. Sometimes I wonder if anybody I know in real life reads this blog (actually they probably don’t!) and has realised who I am, or if somewhere, somebody is erroneously suspecting one of their colleagues of being me. It ‘s also a play on the slight stigma attached to being a pathologist. Sometimes it’s easier not to be specific about what you do because of the comments you might get. It reminded me of the stereotype of the Alcoholics Anonymous meeting where new members stand up and say: ‘I’m K and I’m an alcoholic’ – being honest about what they were. That’s where the name of the blog came from, and it kind of follows on from the name to be anonymous as well.

RCPath talk tough

2007-04-14T14:13:00.000Z

I have obviously happened on this issue rather late, but I noticed this document on the RCPath website the other day. It’s a response to another document I hadn’t heard of before, a discussion paper called ‘The future of the medical workforce’, published by NHS Employers.

I read the RCPath’s response first and it’s quite a strong-worded response considering pathologists often hedge their bets with phrases like ‘suspicious but not diagnostic of’ in histology reports. I wondered what had provoked this and read the offending document. This is a piece of writing supposedly about the recent ‘reconfigurations’ in the NHS, the European working time directive (EWTD) etc and the effects these things have had, and will have, on how doctors work, how they are trained and how many are needed. To me it looks like a load of vague waffle written by somebody who uses the buzzwords but doesn’t really understand the issues. It talks about ‘mergers and closures of some smaller units’, the reduced training time for doctors due to MMC and EWTD without any hint that the authors have considered the effect of these things on patients and doctors and whether these are a good thing or not. The document is full of ‘key questions’ and I’m glad to see the RCPath have answered many of these in their response. Here are a couple of examples:

‘Is there a need for a new specialist grade below consultant?’ ask NHS Employers.
RCPath response: ‘No’

‘What will the doctor of the future look like?’
RCPath response: ‘Here is a likely distinction between expectation and reality. The doctor of the future should be fully competent in the clinical management of patients through a deep understanding of the scientific and pathological basis of disease. The reality is that he/she will be a politically-correct apparatchik who responds to clinical situations in a protocol-driven and codified manner. If such an event occurs, it will be highly detrimental for the medical profession and patients alike as well as being severely damaging for society as a whole.’

The RCPath’s conclusion says: ‘Overall, this is a naive document that exposes many errors and misconceptions currently held by employers and managers within the NHS. There continues an inherent advocacy of a ‘top-down’ directive approach without an acceptance that medically trained doctors are probably best suited to develop the environment necessary for good clinical care within society. Obvious lack of appreciation of fundamental constraints such as time and money do not engender confidence in the proposed discussion or consultation process as advocated at the beginning of this document.’

Neither of these documents is very long and they make interesting reading, particularly if you’re careful to read between the lines. I think the RCPath is pretty spot on in the majority of what is said, I just wish they’d shout about it more.

Is it rewarding?

2007-04-07T15:31:00.000Z

Before I started to specialise in pathology nobody ever asked me this question. Now even other doctors ask me if pathology is rewarding. Is this because people, including other doctors, think that being a doctor (translation: seeing patients) must be rewarding and that being a pathologist (translation: not seeing patients) might not be?

What surprises me is that anybody thinks I’d be doing the job if I didn’t find it rewarding. If I preferred seeing live patients I wouldn’t have switched from the specialty I originally started training in after my house jobs; and if I decided I didn’t like it I had given up by now and be doing something else like the author of this article in the BMJ.

Some people (maybe the ones who thought up MMC?) think that my years of training in something other than pathology are a waste of time. They think junior doctors can make do with a quick run round three different specialties, probably not of their own choosing, and then be propelled straight into rush-through training in a specialty they may never have done since a 2 week placement in med school.

So has my previous training made me a better pathologist? Well it didn’t really help with things like how to do an autopsy, use a microscope or look at histological sections. What it did do was show me how difficult it can be to make a clinical diagnosis, the wide range of presentations there can be for a single illness, how to pick up clues from the history and external examination, when and how different pathology specimens are taken and what clinicians want to know from them. Being a good pathologist isn’t just about looking down the microscope, it’s about looking at the whole clinical picture in conjunction with the histology – this is why we often complain about a lack of clinical information on pathology requests.

My previous experience has, I think, made me a better pathologist than I would have been if I’d come into pathology straight from house jobs. It also showed me, as the author of the BMJ article found, that sometimes you have to try something for more than just a couple of months to be sure it is or isn’t for you.

So having tried something else I can say that pathology is definitely rewarding. You get the same diagnostic challenge but without having to be up all night. You can drink your coffee while working (maybe not in the mortuary!), do something practical like cut-up and autopsies to get out of the office for a bit and there’s always the MDT if you want to argue with/talk to other clinicians. The main advantage is that every specimen is a sort of ‘virtual patient’ meaning you can do something to help patients all over the hospital every day by providing a verdict on their specimen; which is what medicine is all about.

Secondhand consultation

2007-04-01T15:19:00.000Z

One of the disadvantages of being a doctor is that non-medical friends and colleagues like to ask you about their relatives’ medical problems, somehow thinking you are a better source of advice about their aunt’s odd rash that you’ve never seen than the consultant dermatologist their aunt saw last week.

Sometimes they casually mention that their granddad has been ill for the last month and their mother wants to persuade him to see a doctor. They think their mother is worrying unnecessarily and want you to advise. They describe granddad’s symptoms: a bit of back pain, weight loss and indigestion. This has happened to me a few times and I’m faced with trying to persuade them that granddad really should see the doctor sooner rather than later but without sounding too alarmist. It could be something bad like cancer of the stomach or pancreas but it might not be and I can’t make a diagnosis based on secondhand symptoms. I don’t say what I think it might be and I don’t know if anybody else in the same situation would but I do encourage them to make sure their relative sees the doctor. Dr Shroom also sees similar patients in A+E where I imagine the pressure to come up with a likely diagnosis is greater. It’s difficult knowing when to talk about something that is only a suspicion and when to avoid worrying somebody unnecessarily. Whichever end of the experience you’re on it isn’t nice.

Gone but not forgotten

2007-03-24T17:30:00.000Z

Apologies to my regular reader(s) for my recent lack of posting. I've been suffering from bloggers' block. If I was more organised I'd have a small stash of pre-written and uploaded drafts so all I had to do was log in and hit the 'publish' button and nobody would know the difference.

What are the causes of bloggers' block? Well in my case it's partly down to a bout of illness compounded by some bad news.

During the week I heard that an old colleague who I used to work with and chatted to sporadically since, is no longer with us. I wish I'd spoken to him more often.

It's made me think about two things. One is the the effect that the sudden death of a colleague has, creating shockwaves through the hospital. It's something I've observed after the sudden death of senior doctor in my hospital a few years ago and the suicide of a fellow house officer a few years before that. The second thing is that we have to carry on. Death and disease carry on in the hospital and the world and we must carry on too. We have a quick cry into a coffee in the hospital canteen and then get on with the ward round. We all look normal and the patients, and sometimes our other colleagues, can't tell the difference but inside we're weeping.

Light relief

2007-03-11T14:07:00.000Z

If it's all getting you down and you want a laugh, the little black duck has found something to amuse. It made me laugh.

The nightmare continues

2007-03-11T13:52:00.000Z

So MTAS is unravelling. For the uninitiated what is going on is that in August all junior doctors of SHO or equivalent grade are having their contracts terminated and they are having to re-apply for what were their own jobs. These are doctors who qualified around two to eight or more years ago and since then they’ve been training, gaining clinical experience, passing tough exams, getting advanced life support certificates, doing PhDs and many other things that will help them provide better care for sick patients. They are applying for training jobs that will train them to consultant level.

MTAS is the system through which they have to re-apply for their jobs. Over the past few weeks flaws in the system have been coming to light at an appalling rate. They include:

Unvalidated selection criteria being used

The majority of marks are awarded for creative writing exercises rather than experience and qualifications

Some applications have been marked by unqualified shortlisters

Some applications have been ‘lost’ in the system

Candidates who are ineligible for jobs have been shortlisted

Candidates have been offered interviews for jobs they did not apply for

Shortlisting consultants have been offered interviews for junior doctor jobs they didn’t apply for

Some shortlisting consultants have been able to see the names of candidates because applications were not always anonymised

Some shortlisting consultants have been able to see and potentially alter marks given to applications by other shortlisters

Some applicants were made aware of shortlisting criteria before applying

There are only two rounds of this system to allocate jobs for the NHS for a whole year – so doctors left jobless will be in trouble as junior doctors can only train in the NHS in this country, they cannot set up in private practice

In some areas consultants have refused to conduct interviews as they felt the selection process was grossly unfair. It is obvious to anybody that the system is a shambles. It is obvious it is incapable of selecting the best junior doctors for the jobs. This system is supposed to help produce well qualified, well trained consultants for the NHS. It will not do that. Yet the Association of Medical Royal Colleges (AoMRC) recommend continuing with round one interviews (the RCPath has the documents here). This is ridiculous. I can’t express how angry, disgusted and despondent I feel about this.

The AoRMC (and that includes you RCPath, show a bit more gumption!), the BMA and anybody who thinks they might need treatment from the NHS in future (and that’s pretty much all of us, me included) should make a strong stand against this disaster. Please visit the excellent mmc360 site to learn more, write to your MP (and ask them to sign these early day motions - 737 and 1059), march in London or Glasgow with RemedyUK, sign the petition and email your royal college. Please help.

Writing therapy

2007-03-03T16:20:00.000Z

Imagine the person closest to you has bowel cancer. Horrible isn’t it. Obviously you want them to have good treatment. Who do you want them to go and see?

An expert on bowel cancer. Definitely.
Somebody who really knows what they’re doing. Oh yes.
Somebody with plenty of experience of treating the disease. Absolutely.
Somebody who is well trained in their field. Spot on.
Somebody who can care for them properly if they have complications. Nothing less.

Somebody who is good at creative writing. No? Are you sure?

Well you could go and see Miss K Scalpel. Even when she applied for higher surgical training she’d already done 5 years of basic surgical training and 1 year of training in anaesthetics and intensive care medicine. She’d got a PhD from a prestigious university for studying bowel cancer. She was an instructor on Basic Surgical Skills and Advanced Trauma Life Support courses.

She sounds ideal.

Or maybe you’d rather your loved one went to J K Rowling for treatment?

Don’t laugh, tomorrows consultants are now being selected mostly on the basis of their creative writing ability rather than their qualifications and experience.

Welcome to MTAS.

Liam Halligan I love you

2007-03-01T17:39:00.000Z

If you watched Dispatches this week you’ll know why. Liam Halligan brilliantly explained how so much money has been poured into the NHS and where it has been wasted/siphoned off into the private sector. If you didn’t see it find somebody who taped it and if you can’t do that then read the pages on the Channel 4 site.

If you’re feeling up to it, read his interview with Patricia Hewitt in the Sunday Telegraph. The interview was shown in the programme and for the very first time I experienced an urge to eviscerate somebody who wasn’t dead. I had to bite my fingers to stop myself bludgeoning the telly with a frying pan. Here’s a quote from the Telegraph interview which was shown in the programme:

I put it to the Secretary of State that she is desperately trying to rein in the deficit, in an unrealistic time-frame, to save her own political skin. For the first time, she loses her cool, and the interview comes alive. "That is an absolute insult to thousands of NHS staff across the country," she retorts, her eyes wide with anger. "That is an insult to NHS staff across the country who have worked their socks off this year to make difficult decisions."

HOW DARE YOU PRESUME TO SPEAK FOR ME YOU ODIOUS BAG. YOU, PATRICIA HEWITT, ARE AN INSULT TO NHS STAFF.

I’d love to see Liam doing a programme on the UK chainsaw massacre that is MMC and MTAS (this is the second of 5 posts so far, have a look at the others too) soon.

How to learn medicine

2007-02-25T11:02:00.000Z

It can be difficult being a medical student. I remember having at least twice as many timetabled teaching sessions as my non-medic friends and there was a huge amount of stuff to learn. Sometimes I felt like I was using my brain purely to stuff textbooks into instead of to think with. The practicals were better although some of the physiology ones seemed to be mild forms of initiation ritual. We did a lot of carefully measured breathing and urinating in them.

I did a traditional style course, something the Angry Medic is battling through at the moment and wondering if one of the shiny new style integrated PBL based fashionable courses would have been a better choice. I can’t really say because I haven’t done one, but before the traditional style course gets chucked out like those Dallas style shoulderpads at the end of the 80s, I’d like to remember the good aspects of the course.

Most of the time there was only one textbook to consult. When I was learning anatomy I looked in the anatomy book. Simple. None of this trying to learn the anatomy, physiology, pharmacology, pathology and treatment of a heart attack all at once. It also meant we had anatomists teaching us anatomy, pharmacologists teaching us pharmacology etc unlike having a pathologist trying to teach you about all the medical aspects of a hernia. By the time we were let loose on patients we already knew where their organs were and how they worked and a bit about how their drugs worked, it might not seem much but it helps.

But the best bit was when it suddenly all made sense; sometime in third year the reason for learning everything I’d learnt before became clear. Maybe it was a long time to wait but so what. We were in a teaching session with one of the cardiologists, who took us to see a patient who had been admitted with chest pain a few days before. The cardiologist asked us what conditions could cause chest pain. Er…heart attack….er…..angina. We didn’t do too well until she told us to think of all the structures in the chest that the pain might have come from and now we were back to basic anatomy. It was suddenly much easier. It could be pain from the heart (MI, angina), oesophagus (oesophagitis, reflux), pericardium, pleura (pleuritis, pneumonia), ribs, chest wall muscles, nerves (shingles), costochondral junctions etc. Basic physiology told us why the patient might have gone into heart failure after a heart attack, and a bit of pathology and pharmacology explained the use of aspirin and nitrates. The knowledge was there in our heads and now it was time to do something with it.

The basic sciences are vital. I don’t know if they are covered as well in new integrated courses or sidelined in favour of communication skills. Surely part of being able to communicate with patients is having something useful and accurate to tell them about their illness, why it has happened, why it causes the problems they are having, what you are going to do about it and what is going to happen to them. Or maybe even why you don’t yet know what the problem is, what it might be and how you’re going to find out.

The best way of teaching medicine is still causing controversy and there are various discussions on doctorsnet (if you have access) about different courses and different medical schools. But if you walk down the street in the UK you’ll see some 80s fashions are coming back again. maybe medical courses just follow fashion too.

Have you had the test?

2007-02-24T13:35:00.000Z

When we hear about celebrities being ill or admitted to hospital we hear phrases like ‘undergoing tests’ and ‘tests showed that…’. ‘Tests’ are obviously very important and a lot hangs on the results. ‘Tests’ are safe and always right. Aren’t they?

We’ve all seen patients where the test gets it wrong; the normal x-ray in the patient with bone metastases or the dangerously high potassium level due to a dodgy blood sample in a normal patient. In these circumstances we know the limitations and problems with the test and can repeat the test, do a different test, or even ignore the result.

I’m sure that all medical students and junior doctors have had some rules about diagnostic tests drummed into them by their seniors:

If you don’t know why you’re doing a test you shouldn’t be doing it

If you don’t know what you’re going to do about the test result when you get it you shouldn’t be doing it

If the result of the test isn’t going to change or aid in the patient’s management you shouldn’t be doing it

Treat the patient not the result (all tests can produce false positive or false negative results)

This avoids patients having unnecessary tests and unnecessary or wrong treatment based on incorrect results. Obviously unnecessary treatment could be risky with surgical complications or drug side effects but some tests carry their own risks, for example radiation exposure (x-rays, CT scans etc), bleeding (liver biopsy) or other injury (colonoscopy, diagnostic procedures under anaesthetic).

We try to take these problems with diagnostic tests into account but sometimes doctors as well as patients can become over reliant on them for diagnosis or reassurance (or medico-legal reasons). Many of the diagnostic tests we do have had their reliability studied in depth before they are recommended for everyday use because it’s important to understand how often and in what circumstances a test is likely to give a false result. Newer tests are still being studied and developed and we’re often cautious about them. The histopathologists out there will know about the latest immunohistochemical stains which show early promise at differentiating benign from malignant or being highly specific for a certain type of tumour. When more research is done they are often not quite as good as we initially thought, although they may still be useful.

In 2003 the RCPath produced some draft guidelines: Who can request a test? This document then seemed to vanish but over three years later it is finally being revised into a more definitive form. The draft version states:

‘the test must not only be ordered appropriately, but also… the result must go back to someone who can take appropriate action.’ (sounds just like what your consultant told you when you were a house officer).

On a related note they’ve also released this report: Evaluating and introducing new diagnostic tests: the need for a national strategy. This document talks about some of the things I’ve mentioned above about the reliability of tests and summarises the issues that must be looked at when introducing new tests, the first of which is:

‘Is the scientific evidence for the validity of the new test sufficiently robust?'

The report also goes on to state:

‘There is increasing pressure to introduce new tests precipitously, without rigorous evaluation of their true utility, when related to emotive topics (such as cancer) or when there are possible medicolegal threats.’

‘It is difficult for staff to evaluate recently introduced tests objectively and consistently across the NHS; published evidence demonstrates that papers on the diagnostic accuracy of new tests are often of poor quality and to make a good decision is difficult.’

The RCPath might be a bit late with these documents as increasing numbers of ‘diagnostic’ or ‘screening’ tests are being offered to anybody with the money to pay, as well as the time and stress resilience to cope with subsequent investigation of their incidentalomas.

Shinga has written about some of the allergy tests available and finds, via some dedicated literature searching, that they aren’t as reliable as some suggest. Despite the amount of work that should go into studying tests, Shinga has found that tests can be let loose on the public without being properly validated, and worrying they can be requested by anybody – regardless of the risks.

Organs and autopsies

2007-02-17T15:34:00.000Z

A while ago I talked about the latest Royal College of Pathologists Bulletin, and mentioned two things in that were particularly interesting. One was training and the second was coronial autopsies (page 13 if you can get hold of a copy). This article by Dr Peter Cowling, discusses the latest NCEPOD report (and its launch at the RCPath) which I’ve also talked about before.

One of the main points made both in the report and in the article is that the function of the coronial autopsy is not well defined. I think part of the problem is that as medics we see the autopsy as a medical procedure, whilst the majority of coroners are not medically qualified and to them is it the legal aspects that are important. At its most basic the legal function of a coronial autopsy is to exclude an unnatural cause of death and this (in combination with the new Human Tissue Act and coroners’ rules) leads to the situation where, as soon as a plausible cause of death is identified, the autopsy is stopped and no histology, toxicology or microbiology etc is usually done. This occurs in the jurisdiction of some (the minority I think), but luckily not all, coroners. No toxicology? Remember Harold Shipman? As a medical procedure this practice is unacceptable. The RCPath position as stated in the article is:

‘post-mortem examinations should be performed to the highest standards possible, to answer the needs of relatives and to serve the public health through improved national mortality statistics’

After reading a paper referenced by this article (Discrepancies between clinical and postmortem diagnoses in critically ill patients: an observational study. Full text available free) I would add ‘providing feedback to the clinicians treating the patient’ to these functions. Historically this was one of the main functions of the autopsy – in the past the autopsy room would have been full of doctors seeking to learn and improve their practice. Now it is almost deserted and this function has been sidelined. The rate of consented (non-coronial) autopsies has declined dramatically recently.

The paper above looks at patients dying in an intensive care unit. They reviewed 38 cases which is not a huge number but considering the low and declining number of autopsies is not surprising. 39% of the cases had a major diagnosis missed before death, although the missed diagnosis may not have had an impact on the patient’s survival.

I’m sure all of us trainee pathologists have heard consultants say that a third of death certificates are wrong, something also mentioned in the NCEPOD report, hardly a good thing for mortality statistics. If finding a plausible cause of death and then stopping the autopsy is also occurring then this is likely to reduce the accuracy of the cause of death in some autopsied cases. So falling autopsy rates and the poor standard of some autopsies is likely to have a negative impact on mortality statistics.

As for answering the needs of relatives, as the RCPath article says, we don’t know what the relatives or the public want from autopsies. Maybe they don’t care at all about autopsies, is this the reason for the results of the NCEPOD study sinking without trace in the media? I don’t think is entirely true; autopsies were never out of the news during the organ retention scandal. So what do the public think of autopsies now? Do they know why autopsies are important, what the uses of the autopsy are and the potential consequences of badly done autopsies? Do they understand how the Human Tissue Act and coroners’ attitudes to autopsy histology (partly in reaction to the organ retention scandal) make medical investigation of deaths difficult and the implications of this? I doubt it. A browse through the RCPath guidelines on autopsy practice shows why histology is so important as a component of the autopsy, including in relation to cardiac deaths, where the heart may need to be retained for specialist examination to assess any genetic problems that might affect other family members.

During the NCEPOD report launch, Professor Peter Furness talked about some of these problems and wondered if the next ‘organ retention scandal’ would be failure to retain important organs for further examination. In the past we had headlines like ‘Doctors stole my son’s heart’. Will we have ‘Doctors threw away my son’s heart’ in the future?

Where are your kidneys?

2007-02-10T14:01:00.000Z

This is first year anatomy stuff (for anybody who still does anatomy these days). What is the normal position of the kidneys in humans?

a) in the upper abdomen
b) in the lower abdomen below the waist
c) in the pelvis
d) in the sports department (that’s for any Two Ronnies fans out there)*

Many people think the answer is B, including it would seem, Dr Gillian McKeith (read about her PhD here). I saw this bit of news on the web saying that her book You Are What You Eat now tops the non-fiction chart of most borrowed books from UK libraries. Coincidentally a friend showed me this book the other day after a relative tried to convince her of the benefits of kidney massage. It’s on page 198 and encourages you to ‘treat yourself to a kidney rub…..find your kidneys by placing your hands on your back below the waist but above your bum’. If you’ve correctly answered the question above you’ll know this is utter drivel.

Now you’d expect me to know my anatomy. I’d be doing a ******* appalling autopsy if I didn’t know where to find the organs. You’d expect a surgeon to know their anatomy, in fact all doctors need to know their basic anatomy – even psychiatrists have patients with physical illnesses and need to know where organs are and how to examine them.

Yet anatomy teaching is being eroded in UK medical schools. There is a huge amount to learn as a medical student and anatomy cannot be taught in the kind of depth needed to be a surgeon, for example, more advanced anatomy can be learned during surgical training. But medicine is primarily about the structure and function of the human body and mind in health and disease. As doctors we need to understand that structure. We particularly need to understand it when so many other people are reading the kind of book that tells lies about our innards. Leonardo da Vinci knew where the kidneys were by 1508; how can such easily available facts be ignored?

*The answer, of course, is A. If your kidney was previously owned by somebody else it will be in position C. If your kidney is in position B it is abnormal and if it's in position D you're really in trouble.

Don’t die young

2007-02-02T19:18:00.000Z

Some of my colleagues hate watching any medical programmes. The dramas are unrealistic and make them cross because of the number of inaccuracies and the documentaries are oversimplified and just stuff they already know. I enjoy some of the documentaries; they can be a bit like watching somebody else do some of the less taxing parts of my job while I relax with a cup of tea.

Last week’s episode of Don’t Die Young was just such a programme, presented by somebody who is actually medically qualified and with the experiments, though simplified and jazzed up for TV, illustrating real physiological principles. Dr Alice Roberts continues that great medical tradition of experimenting on yourself and even gets into the operating theatre to show ‘scenes of surgery which some viewers may find disturbing’ before 9pm.

What really interested me was the reaction of the smoker shown the lung cancer. Handling specimens like the one shown in the programme is a regular occurrence for me and it’s easy for us medics, nurses etc to forget that although we see cancer every day, the average member of the public encounters it relatively rarely.

Lung cancer (the yellow bit)

Lung cancer is still a fairly rare disease to the man or woman in the street; especially compared to the number of people they might know who smoke. For those of us in histopathology, cardiothoracic surgery, oncology and respiratory medicine it is far too common. For the lady in the programme, facing a real, grey and white lumpy tumour seemed to be a very powerful experience in her quest to stop smoking. I hope it had the same effect for others watching.

The lung picture is from the Pathology Education Instructional Resource.

Sack Patricia Hewitt

2007-01-28T12:31:00.000Z

Nobody likes being walked all over. Nobody likes being treated like a doormat. Nobody likes to have their informed opinions and ideas ignored by people with more power than sense.

If you don't like being walked over, if you want decent healthcare, if you want to do something to try to save the health service, please sign this petition.

If you need any extra incentive to make a stand then Dr Rant explains just a bit about the state of the NHS and what the labour party have done to it.

Choose your own adventure

2007-01-27T20:35:00.000Z

Does anybody remember those ‘Choose your own adventure’ children’s books that were popular about 20 years ago? You read part of a story and then had to make a decision about what the character did next. Depending on your decision the story was continued in line with your choice on a different page. I always seemed to choose the option that led to death but let’s forget about that now.

Here’s the new NHS version

Mrs Smith is a 63 year old widow who started feeling dizzy and a bit ‘funny’ one morning. She sat down for a bit and had a cup of tea but it didn’t go away. She told herself to ‘pull yourself together’ but it still didn’t go away. Being a stoic type she didn’t want to bother her doctor and she didn’t want to miss her friend who was coming over later. When Mrs Smith’s friend arrived she thought Mrs Smith looked a bit peaky and persuaded her to:

1. Go to A+E
2. See her GP
3. Phone NHS Direct

Choose carefully, and then read the corresponding paragraph…..

1. Mrs Smith felt embarrassed about being in A+E when she didn’t really think it was anything. When the triage nurse saw her she explained that she just had a bit of a dizzy feeling and it was nothing really. She didn’t have any pain or feel short of breath. The nurse did some observations and noticed that Mrs Smith’s heart rate was only 30 per minute. The nurse took Mrs Smith through to another room and called a doctor over, while connecting Mrs Smith up to a heart monitor and giving her some oxygen. The doctor saw Mrs Smith straight away and she was admitted to hospital with a complete (third degree) heart block. The next morning she had a pacemaker put in.

2. ‘I’m sorry to bother you,’ Mrs Smith said to her GP, and explained about the dizzy feeling. The GP asked if she had any other problems and she said she’d had some heartburn the other night, which was odd because she hadn’t eaten tomatoes which usually brought it on. The GP took her pulse and blood pressure and then told Mrs Smith that her heart rate was dangerously low and that she would have to go to hospital in an ambulance which was rather a shock to her! The next morning she had a pacemaker put in.

3. Mrs Smith had heard that NHS Direct was now available online and decided her broadband connection would probably be quicker than the phone: ‘They might put me on hold with some dreadful music’ she said. On the NHS Direct website she found ‘dizziness in adults’ in the A-Z of symptoms. She didn’t have any pain anywhere, feel feverish (she didn’t have a thermometer), feel breathless, she didn’t think she was going to faint, have any ringing in her ears or any of the other things they asked. NHS Direct told her she should stay at home. She made another cup of tea.

Would it have turned out better for Mrs Smith if she’d phoned NHS Direct and spoken to a real person? Not if they were simply following the website protocol. These people found the phone line even more unhelpful.

What I’m trying to illustrate is not that NHS Direct is useless (although personally I think it is an unnecessary waste of money) but that if you are seen as an emergency in hospital you are being seen by somebody (hopefully a doctor!) who is experienced in seeing emergency patients and has access to a second opinion from doctors who are more senior and/or in different specialties, and has rapid access to blood tests, x-rays and other investigations to help them decide what is wrong and how best to treat you.

If you go to your GP as an emergency you are being seen by an experienced doctor who can examine you, perform some basic tests and decide what to do next. The GPs job in this situation is more difficult as he or she doesn’t have immediate access to specialists and many other tests like the A+E doctor does.

If you phone a helpline you are talking to somebody who, whatever their level of clinical skill, is unable to even see you, let alone examine you and has to rely solely on what you say and the protocol in front of them. They cannot see your lips turn blue as you stoically claim to be ‘not too bad’ or see you sitting comfortably while claiming to be ‘doubled up in agony’. This is why telephone consultations/telephone triage should be done (if at all) by the most experienced, knowledgeable and qualified people available.

The black pit of despair

2007-01-22T21:25:00.000Z

The black pit of despair has opened up and swallowed several of my colleagues, meanwhile releasing from its depths a miasma of misery and hopelessness. Or to put it another way the MTAS site has opened for applications to specialist training posts - of which there are ridiculously few - from junior doctors - of which there are a lot.

The sense of helplessness is all too obvious around the hospital and in the forums at DoctorsNetUK.

To everybody stuck in this MMC nightmare, good luck, I don't really know what else I can say.

We don’t need no education (says MMC)

2007-01-20T13:30:00.000Z

The Bulletin of the Royal College of Pathologists arrived this week with a slick new design and picture of a heart attack on the front cover (a prediction for the NHS in 2007?).

There were a couple of articles about training in it which got me thinking. There was another article that I’m going to blog about soon – but first I need to get down the hospital library and look a few things up (I thought this blogging lark was supposed to be relaxing, not work inducing!).

One of the articles (page 11 if you can get hold of a copy, it's not available online for non-members of the RCPath website) says that histopathology training is typically moving from 48 hours a week to 40 hours, with a slight shortening of the duration and say that this could lead to a 25% reduction in training time. As I’ve already pointed out, histopathology training has shortened before under the Calman scheme, a change that many of my colleagues thought was verging on the unsafe in terms of producing consultants fit for independent practice. The article goes on to discuss ways of trying to train to a reasonable standard in the shortening time available, concentrating on e-learning (for those of us who have broadband at home, since we won’t have time to do it work by the looks of things).

As I flicked through I saw a second article on training (page 22) and spotted in bold type ‘CBT is a process not a product’. My first thought was that trainees now needed cognitive-behavioural therapy to deal with MMC but it appears that it also stands for competency-based training. The RCPath have produced a curriculum for histopathology training, which is nice as now we know what we’re supposed to know and be able to do. The author points out that the curriculum doesn’t really help in terms of things like assessing competency and the potential for independent reporting by trainees. At this point it’s worth saying that currently independent reporting by trainees is a rather mixed up area. In some hospitals trainees are not allowed to report specimens independently (without the consultant checking the slides as well) until after they have passed part two of the MRCPath exam (the part 1 is written only and doesn’t test practical skills) which is only taken as a more senior trainee. In some hospitals there are structured schemes to enable more junior trainees to report certain types of specimen if the consultant thinks they are able to do so. In some hospitals there are similar, but more informal arrangements.

In this article it says that independent reporting would have to be based on objective and clear assessments of a trainee’s ability and that such a scheme could improve training but if it is inappropriately applied could result in demotivation and concentrating on the minimum acceptable standard. I’d like to think that competency based training would motivate us trainees and help us to learn as much as possible in the short time available but with MMC, reduced working hours and understaffed departments where consultants have little time for teaching I’m worried that demotivation and dumbing down may be coming.

The knock-on effect

2007-01-14T16:13:00.000Z

I watched the recent BBC series Can Gerry Robinson fix the NHS? and a few things struck me about it. A few things nearly struck the telly during the first episode but the other two weren’t as anger inducing – luckily for my telly.

The first thing that bothered me was the length of time it seemed to take Gerry to realise that the reason that surgeons have fixed theatre lists is that they have other things to do. Surgeons are not like the people on the car production line fitting the parts as the patients are wheeled past. They have patients on the ward to look after, they have patients in the clinic who need seeing, they have admin to do, they have to go to A+E for emergencies occasionally. Just because they’re not in theatre it doesn’t mean they’re not working.

The second point was about the knock-on effects. If the surgeons were operating on more patients, where were they going to put them? Patients generally need a bed to lie on; even a day case patient having a local anaesthetic procedure probably needs to lie down for a bit. So if you operate on more patients you probably need more beds. And nurses to look after the extra patients. And if they’re orthopaedic patients you might need another physiotherapist. If you put an extra theatre list on you need an extra theatre, complete with equipment, anaesthetist, theatre nurses and operating department assistants. If your increased patient throughput leads to an increased number of biopsies (endoscopy for example) then you might need extra lab staff and pathologists. Extra patients being seen in clinic might generate extra requests for xrays/scans, blood tests and other investigations. Of course if the target is purely to see/scope/operate on patients more quickly then maybe it doesn’t matter if the wait is shifted from waiting to be seen to waiting for test results or scans. If you’re the patient it probably does matter.

I didn’t see these two points very well explained or addressed in the programmes. Maybe it was due to the editing, but I think they are important points and should have been looked at more closely. Just as in the body, a change in function in one area of the hospital has effects on other areas which need to be considered.

The last point came at the end of the third episode when Gerry finally got to the bottom of the NHS mystery/disaster – the Department of Health. Now while Gerry suggested rather subtly that this was at the root of many of the problems, he apparently failed to really put his mouth where his money is (as I hear he is a supporter of, and financial contributor to, the Labour party) and give Patricia Hewitt the serious grilling she could really do with.

Overall – he didn’t save the NHS (bit overambitious). Some of his ideas were good and maybe he made an improvement in some areas in one hospital but who can tell when the programmes will have been edited to show what somebody (who?) wanted us to see. An honest and unbiased view from Rotherham would be a welcome addition. Things like this that I see on the telly I usually regard as entertainment only and factually suspicious. That’s what I think about this programme, shame really.

For more views on this series check out Dr Grumble and Dr Crippen, who has 3 posts on it.

I want to complain

2007-01-14T14:41:00.000Z

I don’t normally talk too much about money or politics, other people do it so much better. But this week I’m feeling like a bit of a whinge (even more than normal!).

This week the BMJ tells me that according to the BMA the number of medical students has increased by nearly 10,000 in the last five years which seems rather inadvisable considering the current increasing unemployment amongst doctors in this country.

They also say that the number of medical academics, who are supposed to be teaching these students, has decreased by 25% - not so good for the students. On the other hand, since the total spend on medical research has been cut by pooling the amount spent by the MRC and the NHS and reducing the total a bit, at least the academics (oh yes, they need to produce high quality medical research as well as teaching students) might not see their own cut of the funding fall too much. However, hospitals aren’t always keen to employ medical academics (yes, they need to look after patients in the NHS as well as teaching the students and producing high quality research) because (unsurprisingly) they can’t spend as much of their time on direct patient care.

The BMJ also tells me that the average debt for a graduating medical student these days is £21,755 and if universities raise tuition fees this is likely to increase, so maybe we will come full circle when few people can afford to go to medical school, numbers fall and the remaining medical academics (if there are any) have less teaching to do.

This doesn’t strike me as a very good solution. We are spending a lot of money training doctors who may well end up unemployed (waste of money, not to mention the time and hopes of the individuals involved). We are allowing the numbers of medical academics to decrease (short-sighted cost cutting – medical academics contribute directly to patient care by looking after patients, training future generations of doctors and producing world class medical research which leads to improved patient care). We are reducing spending on medical research even though it is one of the things we can still do well in this country.

Meanwhile millions of pounds are being wasted on the NHS IT system, NHS Direct, and Choose and Book. I know where I’d rather my taxes went.

Outbreak

2007-01-05T20:29:00.000Z

In 2002 there was an outbreak of infection in the UK. Nearly 200 people were affected and there were seven deaths. This outbreak of disease was well publicised and there were calls for punishment for those felt to be to blame for it. Every year in the UK there are around 100-400 cases and up to around 40 deaths due to this infection. Most cases of this disease are preventable and effective drug treatment is available. After the 2002 outbreak the people considered responsible for providing the conditions which allowed the infective agent to multiply and infect members of the public were fined for breaching health and safety legislation. Manslaughter charges against them were dropped.

In the first five months of 2006, in the UK, there were 449 cases of another infection, and one death from it, over five times the number of cases in the same period one year previously. Worldwide this disease affects around 30 million people per year and kills around 1200 people per day. Most cases of this disease are preventable, lucky as there is no specific treatment for it and only supportive care can be given. Nobody was charged or prosecuted in relation to this disease in the UK and there was less publicity and little public outcry about it.

Have you guessed what they are yet?

The first condition is Legionnaires’ disease. Read a news report about the outbreak here and see the UK case statistics here.

The second is measles. It is a worldwide problem as described by the WHO and is on the rise in the UK. The Health Protection Agency has some statistics on cases in the UK here and here.

I wouldn’t fancy catching either of these diseases. There is no vaccine available for Legionella pneumophila, the cause of Legionnaires’ disease but there is an effective vaccine freely available in the UK for measles. As a healthcare worker I regularly get blood tests from occupational health departments in the hospitals I work in, to check that I am immune to common and potentially dangerous infections. A couple of years ago one showed that I wasn’t immune to measles. Luckily there is a solution to that – I went and got my MMR jab.

Dr Crippen has more thoughts and interesting links on the subject of vaccination, as well as a request for other bloggers – check it out.

Difficult cases

2006-12-30T13:48:00.000Z

Over the last year a lot of people I know, some research scientists, some friends and relatives, have suggested to me that doctors should be allowed (and in their opinion would prefer to) concentrate on the more ‘difficult’ or ‘severe’ cases, leaving patients or pieces of tissue with ‘straightforward’ diseases to be diagnosed by somebody else (they never suggest who).

There are two assumptions being made here: the first that it is immediately obvious which are the straightforward and which are the complex cases; the second that doctors only want to deal with the complex cases.

The first assumption, that the severity/complexity or straightforwardness of the case is obvious from the start is completely wrong. This distinction is only possible after the diagnosis has been made correctly. For example:

A 55 year old man wakes up in the night with anterior chest pain – heartburn or heart attack?

A 6 year old girl complains every morning that she can’t go to school because she feels sick and has a headache, by the evening she always seems better – school refusal or brain tumour?

A 60 year old woman has felt tired all the time for weeks – depression or bacterial endocarditis?

Making a diagnosis is a difficult task that requires the skills of history taking to establish what has happened to the patient, examination to assess the patient’s physical condition and a broad knowledge of the conditions that might be causing the patient’s problems. I recall as a medical student spending up to an hour struggling to get an adequate and useful history. As a junior house officer I could take a history and examine a patient in around 30 minutes. The registrar could make a better job of it in 15 to 20 minutes and the consultant could extract the relevant history and the clinical signs even faster. It takes years of training and experience to do this. And even then, based on the history and examination, some more tests relevant to the patient’s condition are often needed to establish what is wrong.

The second assumption is that doctors don’t want to see patients with straightforward problems, or that pathologists don’t want to see normal biopsies (how do you know it is normal beforehand?). A lot of straightforward cases can be rewarding to treat – healing the sick, however ‘simple’ the problem, is the whole point of being a doctor. Even for a pathologist, diagnosing normal tissue can be a joy when you know the alternative diagnosis being considered was cancer. A second point in pathology is that seeing normal tissues and common problems helps us keep a handle on what normal tissues and normal variants look like. If we can’t recognise a normal tissue what hope is there of spotting an abnormal one?

Both of these assumptions are wrong. The irony in this situation is that these assumptions and the deduction that doctors do not need to see ‘simple’ cases are made by people who have never had to make a medical diagnosis in their lives.

Christmas entertainment

2006-12-23T13:54:00.000Z

Christmas is just around the corner, I’ve finished the shopping (hooray!) and I’ve got some time off work (hooray!). So I'm relaxing at home and reading the Christmas bmj. I've been particularly enjoying an article on the portrayal of doctors in children's books, but there are plenty of other illuminating articles available until this issue becomes subscription only.

If you'd prefer a musical interlude, then you can sing along to the NHS version of band aid at Trick-cycling for beginners or check out the latest west end hit from Dr Informed.

Merry Christmas!

On Sunday

2006-12-17T20:11:00.000Z

After a week at work, Cecil read the latest BritMeds.

A week in the life....Friday

2006-12-15T17:35:00.000Z

Friday started with more reporting including a biopsy of a liver metastasis (the lesion on the right of this picture)

that needed some immunohistochemistry to determine the most likely site of the primary tumour, numerous gastrointestinal and bladder biopsies and a placenta. There was a tray full of urine cytology specimens with several slides from each patient and Cecil wished the urologists would read the RCPath document Histopathology of limited or no clinical value. There was a skin specimen marked urgent which was a possible melanoma. Cecil found it difficult to decide and went to show it to some of the other consultants, they all decided it probably was a melanoma.

The post arrived with a reply to the referral Cecil had sent to the tertiary centre for bone tumours. He had asked for an opinion on a soft tissue biopsy from the thigh. Everybody in the department had seen it and there were various theories as to what it was. They had thought of osteosarcoma, Ewing’s sarcoma, lymphoma and metastatic small cell carcinoma. The slides and blocks had come back with a letter confirming the diagnosis as a rare small cell osteosarcoma. Cecil dictated a supplementary report to go with the preliminary one they had issued saying there was a malignant tumour which had been referred for a second opinion; and rang the patient’s surgeon.

At lunchtime it was time for the registrars’ slide seminar. Cecil had given them a set of slides last week and wondered if they had correctly diagnosed the Spitz naevus – a benign lesion easily confused with a malignant melanoma.

After that Cecil had a quick look through the latest issue of Histopathology and signed some more reports before the slides from yesterday’s cut up started arriving. The stomach had a poorly differentiated adenocarcinoma (the groups of large cells in this picture)

with a few malignant cells invading through the wall to the serosa. Before he went home he dug out the autopsy report for a patient who had died due to acute alcohol poisoning after a night out and was having an inquest next week. The last thing he wanted was a last minute panic on his way to the coroner’s court.

Pathology pictures from the Pathology Education Instructional Resource.

A week in the life...Thursday

2006-12-12T18:42:00.000Z

Luckily for Cecil he could finish off the EQA slides this morning as their senior biomedical scientist put the small biopsies in for processing, after which Cecil cut up the bigger specimens. The kidney he’d opened yesterday was still quite pink on the inside so he left the blocks he cut in formalin for another day before they would be put in for processing. The gastrectomy was better fixed and had an irregular ulcerating tumour like the one in this picture.

The last specimen was a gallbladder and the biomedical scientist showed him the specimen pot which had a different patient’s name on it than the name on the accompanying card, although the address and date of birth were the same. They left that specimen undissected so one of the surgeons could sort out whether the histology form and specimen definitely belonged together and what the patient’s name was.

After lunch he made a start on some of the research slides he was supposed to be looking at, but grading the immunohistochemical expression of receptors on a stack of very similar breast carcinoma cases was pretty repetitive and always got pushed aside in favour of more urgent diagnostic work.

He spent the rest of the afternoon reporting more cases with one of the registrars. The extra slides on the bronchial biopsy showed more of the odd looking cells appearing in groups in the sections cut further into the tissue. The cells were large with big, abnormal nuclei and Cecil reported the biopsy as non-small cell carcinoma. There was a series of colonic biopsies from a patient with ulcerative colitis which showed minimal inflammation and no dysplasia, a tray full of normal duodenal biopsies, a gastric biopsy with inflammation and Helicobacter, and a breast biopsy from a patient thought to have definite carcinoma clinically, which turned out to be a benign granular cell tumour.

The interesting cases at today’s slide meeting included a thyroid gland from a patient with both Hashimoto’s thyroiditis and papillary thyroid carcinoma.

Picture from the Pathology Education Instructional Resource.

A week in the life...Wednesday

2006-12-12T18:32:00.000Z

The breast MDT started at 8am and most of the pathology was straightforward ductal carcinoma this week. There was one pleural fluid specimen which contained metastatic carcinoma in a patient with a previous mastectomy for a grade 3 carcinoma, who has now developed a pleural effusion. After the MDT there were some cervical smears to look at. Luckily the cytoscreeners report the majority of them and only pass them to the pathologists if they aren’t sure about something. The department will be changing over to liquid-based cytology soon which promises far fewer ‘inadequate’ smears but means learning what normal and abnormal smears look like all over again due to the differences in the way the cells look using the new technique.

Over lunch in the office Cecil checked and signed some histology reports, and added SNOMED codes to them. After lunch he made sure the registrars weren’t too swamped with work and offered to report the unexciting looking tray of basal cell carcinomas so that they could concentrate on a laryngectomy case instead.

Cecil picked up the slides that had arrived for him. He put the cases marked ‘urgent’ at the top of the pile. The first was a bronchial biopsy from a patient with suspected lung cancer. It was only a small piece of tissue but there were some odd looking cells in the submucosal tissue at the edge of the specimen. Cecil asked the lab staff to cut some more slices from the tissue block to see if there were more of those cells in the specimen. The next two bronchial biopsies looked inflamed but there was no cancer visible. The next specimen was a lymph node with nodular sclerosing Hodgkin’s lymphoma. A Reed-Sternberg cell (large purplish cell with two nuclei), characteristeric of Hodgkin's can be seen in the middle of this picture.

Cecil dictated a report, requested some immunohistochemistry to confirm the diagnosis, and put the slides aside to show the registrars later.
When he had finished the afternoon’s reporting, he went into to the cut up room to open any large specimens that had arrived during the day so they would fix overnight. There was a gastrectomy which Cecil opened along the greater curvature, and a kidney containing a large tumour which he cut into two pieces, leaving them connected at the hilum. The kidney tumour looked like a typical renal cell carcinoma – it was yellow and lobulated with areas of haemorrhage.

The specimens would fix much better now the formalin could get inside.

Pathology pictures are from the Pathology Education Instructional Resource.

A week in the life....Tuesday

2006-12-11T21:31:00.000Z

This week Tuesday was Cecil’s autopsy day. There were three cases – two for him and one for the registrar. All were coroner’s cases because the causes of death were unknown. His first case was a 57 year old man who was found dead at home and came with the usual scanty coroner’s office information via a police report.

“Found dead at home, collapsed in kitchen. Last seen at midday the day before by his son. House secure, no suspicious circumstances. Medical history: high blood pressure. Medication: losartan, ibuprofen.”

On external examination Cecil saw tar staining on the fingers of the patient’s right hand, a sign of smoking, and an old appendicectomy scar. Internally he found widespread atheroma throughout most of the arterial system. In the heart there was thrombosis over an atheromatous plaque in the left anterior descending coronary artery. Blood clot can be seen in the sections of coronary artery in this picture.

This would have cut off the blood supply to part of the heart and caused a heart attack. There was left ventricular hypertrophy, one of the consequences of high blood pressure. The thickened wall of the left ventricle can be seen in this picture of transverse slices of a heart (the right ventricle is the irregular slit-like space on the right of the slices).

The lungs were filled with frothy fluid, suggesting that the patient had been in heart failure at the time of death. There was an incidental simple cyst in the left kidney. Cecil gave the cause of death as:
Ia Coronary thrombosis
Ib Coronary artery atheroma
II Hypertension

The second case was a 74 year old man who had been admitted to the hospital on Friday with a two week history of back pain, lethargy and loss of appetite. When he had been seen on Friday he was noted to be thin, and have some tenderness in his upper abdomen but there was nothing else found on examination. His blood results showed a microcytic anaemia, a slightly raised urea, and slightly raised bilirubin and liver enzymes. He had been stable on the ward over the weekend while waiting for more tests, but collapsed on Sunday and could not be resuscitated. His hospital notes said that he had had an uncomplicated hernia repair 8 years previously.

During the autopsy Cecil found a large ulcerated tumour on the back wall of the stomach. It had invaded through the stomach wall and into the pancreas. There were metastases in the liver (the paler lesions in this picture) and a single metastasis in the brain.

There was a rib fracture, probably due to the resuscitation attempts, and the patient also had gallstones and diverticular disease. The local coroner did not allow the pathologists to take any histology unless they could not identify a cause of death without it, so Cecil could not sample the tumour to prove that it was an adenocarcinoma, although that was the most likely type. He gave the cause of death as:
Ia Metastatic gastric carcinoma

Then he went over the registrar’s autopsy, dictated his autopsy report and faxed the causes of death to the coroner’s office.

After lunch it was time for more reporting, including some reporting on the double headed microscope with one of the registrars. Some of the specimens he cut up yesterday had come through. The slides from the uterus and ovaries showed a benign leiomyoma in the uterus and a benign serous papillary cystadenoma in the ovary. The breast specimen contained a grade 2 ductal carcinoma. Cecil had to measure the size of the tumour and distance to the resection margins. When he’d gone through all 23 lymph nodes that came with the specimen he filled in a minimum dataset with all the information about the tumour on it.

Then it was time for the department slide meeting. All the pathologists got together round the multi-headed microscope with interesting or difficult cases to discuss. One of the other pathologists had brought some slides from a soft tissue tumour from a patient’s thigh. Everybody seemed to come up with a different idea about what it was and the registrars just looked a bit blank. They decided on a selection of immunohistochemical stains which should help.

Pathology pictures are all from the Pathology Education Instructional Resource.

A week in the life...Monday

2006-12-11T19:42:00.000Z

It’s Monday and our fictional pathologist, Dr Cecil Polyp (yes we really do get biopsies called this sometimes), started the day with some cut up. Not a euphemism for an autopsy, ‘cut up’ is specimen dissection. There were lots of small pots containing biopsies of things like stomach, colon, bladder and bronchus which went straight into cassettes whole. Cecil had to measure and describe the gallbladders and the appendix while cutting important pieces out to be processed into blocks.

He did the big specimens last. There was a time-consuming breast specimen - a wide local excision consisting of a lump of breast tissue with a tumour in the centre. The surgeon had put sutures into it to mark the top, bottom and lateral (nearest the armpit) sides so Cecil painted the lump with ink in different colours to identify which side was which before slicing it into 1cm thick slices (although some of them were a bit wonky) and looking at all the cut surfaces to find the tumour. Unfortunately in some cases it isn’t that obvious, especially when the breast tissue itself is quite fibrous. Cecil had to photograph the slices and describe his inability to find any obvious malignancy, before putting most of the specimen into cassettes for processing. There was enough to make 20 blocks. The next specimen was a right hemicolectomy for adenocarcinoma which had been diagnosed on a colonoscopic biopsy a few weeks ago. Cecil photographed and described the specimen, cutting into the tumour to measure its size and depth of invasion into the colonic wall. The tumour is the white lesion in this picture.

He dissected the whole of the mesentery which was attached to the colon to look for lymph nodes, all of which needed to be put into cassettes, even the tiny ones only a few millimetres across. The last specimen was a uterus with both tubes and ovaries, one of which contained a 10cm cyst filled with fluid. The uterus had a 6cm fibroid which was partly calcified and blunted the knife.

By this time Cecil was starving and rushed to the hospital canteen for a dose of revolting hospital food before the gastrointestinal MDT (multidisciplinary team) meeting. Most of the GI surgeons and gastroenterologists were there with the registrars and house officers clutching huge piles of notes. Dr Scanalot, the radiologist, was putting up some CT images on the lightbox, the stoma care nurse and sister from the GI surgery ward were there, and a few other people he didn’t recognise. Cecil sat down at the front with his trays of slides and switched the microscope on. They had ten patients to discuss, some of whom were more interesting from the surgical or radiological point of view. One patient had had a gastric biopsy which showed dysplasia and gastritis. It was difficult for Cecil to say if the dysplasia was a real premalignant change or if it was simply due to the stomach being inflamed. The patient was elderly and after some discussion the MDT decided to offer him treatment with proton pump inhibitors (strong antacid drugs) and repeat his biopsy afterwards.

After the MDT Cecil got down to some reporting. There was still a pile of slides from last week waiting, as well as the general EQA slides to look at. Some immunohistochemistry stains had come through on a supraclavicular lymph node from last week’s cases. The H&E had shown adenocarcinoma in the node and the patient hadn’t had any type of cancer diagnosed before. In this picture the node is filled with adenocarcinoma which is forming round glands on the left of the picture.

The immunos would help to work out where it had spread to the node from. Two likely sites would be lung and gastrointestinal tract, and the staining pattern was typical of lung cancer.

Pathology pictures are from the Pathology Education Instructional Resource where you can find loads of histopathology pictures.

I can't keep up

2006-12-10T20:21:00.000Z

but Dr Crippen can - read the latest Britmeds online now.

Death

2006-12-07T16:24:00.000Z

Death is something that people imagine pathologists are surrounded by, although for most of us autopsies are not the majority of our workload. There is an assumption that we are unaffected by death since we apparently see it so often, but the reality is that a surprising number of pathologists chose the specialty partly to escape the distress and death we were seeing on the wards.

The number of people and families whose lives were shredded by disease and death that you can see in hospitals sometimes seems relentless. Maybe the ones who recover and the tales of hope are some compensation but the continual round of death in the face of your best medical efforts can get depressing. Non-medics imagine it gets easier but it doesn’t; something I realised when I was a house officer when I saw my macho surgical SHO crying on the ward after the death of a patient.

I was on the ward when one of our post-op patients started bleeding. It was several days since the operation and he had been doing well. I’d seen him on the ward round in the morning and he’d told us a joke but the next time I saw him he was grey and sitting in a pool of blood, blood down his chest and blood on the floor. Two of the other patients, both big men, were shuffling out of the bay, white-faced and shaking. We struggled to get a cannula in while the blood kept coming. I can still see the look of terror in his eyes.

The autopsy showed that a major artery had burst and there would have been no way we could have saved him.

Watching somebody die is not something I have to see at work anymore. A dead body is very different, the soul, if you believe in such a thing, has gone and looking into the eyes give no clue as to who once lived there. Dead bodies hold no horrors, the process of death is another matter.

Review 1/52

2006-12-03T19:52:00.000Z

Incredibly it is only a week since the first ever Britmeds. How Dr Crippen manages to find and read so many blogs in one week, as well as posting up to 200 times more frequently than me and being a GP, I really don't know. But Britmeds 2 is online now with more new blogs to discover, go and have a look.

Want to be a pathologist?

2006-11-29T22:23:00.000Z

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.

Blogging Famous

2006-11-26T22:32:00.000Z

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....

A1 Pathologists

2006-11-21T17:52:00.000Z

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….

Back into the mortuary

2006-11-16T21:26:00.000Z

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

2006-11-16T21:18:00.000Z

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?

MMC - shake your head

2006-11-11T17:35:00.000Z

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.

How glamorous is your job?

2006-11-03T17:35:00.000Z

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.

Angry writes from Planet Research

2006-10-29T11:58:00.000Z

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.

Have a heart

2006-10-27T18:48:00.000Z

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…..

25% of autopsies substandard

2006-10-25T17:59:00.000Z

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.

Welcome

2006-10-23T18:58:00.000Z

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."