The Association of Clinical Pathologists Autumn 2019 ACP news · P20 CESR in histopathology: demystifying the Process – Dr Hebah Ali, Dr Vasi Sundaresan, Joanne Brinklow, Bill West

ACP newsThe Association of Clinical Pathologists Autumn 2019

Life and work of Sidney Dyke June meeting reports

Leadership & lymphomasNHS Safety Strategy

Our link with the Devil

Association of Clinical Pathologists

Officers

PresidentDr C Gray

Past PresidentDr W Simpson

Chairman of CouncilDr J L Burton

SecretaryDr K Skordilis

TreasurerProf P Twomey

EditorDr E Watts

Assistant EditorsDr M ClarkeDr G WatsonDr T Bracey

Dr S Elcombe

Education SecretaryDr K Robson

Management CourseOrganisersDr B Wilkins

Website EditorDr A Pugh

Secretariat

The Association of ClinicalPathologists

189 Dyke RoadHove, East Sussex, BN3 1TL

Tel: 01273 775700Fax: 01273 773303

email: [email protected]://www.pathologists.org.uk

Administrator Mrs R Eustace

Correspondence should be addressed to:The Editor,

Association of Clinical Pathologists, 189 Dyke Road, Hove,East Sussex, BN3 1TL

Email: [email protected]

©acpnews 2019 all rights reserved. No part of this publication may be reproduced in any way whatsoever without the permission of the Association of Clinical Pathologists.Charity registration number: 209455

Calendar of Forthcoming Meetings & CoursesDIARY DATES FOR 2019

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

Date Title Venue Contact Details

15 November ILMC Peterborough 01273 [email protected]

27 November Autopsy Update Day Royal College of Physicians,Edinburgh

01273 [email protected]

External Courses 2019 – 2020

17 – 28 February ‘20 E0E SystemicFRCPath Course

Princess Alexandra Hospital, Harlow

[email protected] 55456701279 827899

ACP news - Autumn 2019 3

ACP newsAutumn 2019

ContentsP4 Invitation to contributors P5 Editorial

ACP BUSINESSP7 ACP Journalism in Pathology Prize 2018 – Eric WattsP8 Presentation of the Marshall Medal to Dr Suzy Lishman CBE – Dr Julian Burton

MEETING REPORTSP9 National Leadership Skills Meeting, Royal Society of Chemistry – Dr Julian BurtonP11 A leadership journey in a time of revolution for genetics and genomic services in the NHS – Angela Douglas MBEP12 Histiocytic and dendritic cell neoplasms – Dr Ye Lin Hock Black P13 The evolution of Follicular Lymphoma – Dr Jessica OkosunP14 The 2016 WHO lymphoma classification and beyond – Dr Stephen SwerdlowP16 The multiplication of FISH: a practical guide to lymphoma diagnosis – Zbigniew Rudzki

ARTICLESP20 CESR in histopathology: demystifying the Process – Dr Hebah Ali, Dr Vasi Sundaresan, Joanne Brinklow, Bill WestP23 GiRFT gets into gear – Eric WattsP25 Sidney Dyke: an inspiration to us all! – W R Timperley, J Burston, E HowlP30 ACP’s link to the Devil [Alternatively: Our founder’s devilish connection] – Eric WattsP32 Being human: how much does pathology need people? – Eric WattsP35 Contracting and monitoring for quality and safety – Eric WattsP38 The pathology workforce and mental illness; it’s time to start talking – Dr Matthew ClarkeP41 From Family to Factory: the dying ethos of personal healthcare – David ZigmondP44 The death of the Tirpitz – Mike KearneyP48 The NHS Patient Safety Strategy: safer culture, safer systems, safer patients – Eric WattsP53 A ski traverse from Fugldalen to Fornes via Fugldalsskar – Mike KearneyP56 Cancer care in low income countries – Matthea RoemerP59 Art and Science? Or Somewhere in between? – Eric Watts & John Walter

BOOK REVIEWP61 Case study: Lynch syndrome – Mohamed Elshiekh

ACP news - Autumn 20194

Cover Picture

The Devil’s Dyke is a mere 5 miles from our office – coincidence or is there a connection?

Invitation to ContributorsIn addition to the constant flow of material from ACP Council, ACP committees and ACP branches, ACP news needs new material from you, the members of the ACP.

Pathology news items (1200-1500 words): Any items related to the ACP or the College, pathologists in general, or medical and management matters that may have an impact on pathologists.

Articles (1500-2000 words): These can be papers, reviews, essays, commentaries, critiques or polemics. Submitted articles are always very welcome, as well as suggestions for articles and/or details of people whom the editor may approach.

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

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

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

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

Photo-journalism: Favoured subjects include pathologists doing something interesting, or College and ACP officers doing anything at all. Interesting or artistic photographs are welcomed.

Cartoons: Suggestions are welcomed.

Curettings: Jokes and humorous titbits are always needed.

Debate: Letters to the editor are welcomed, but may be shortened for publication, or even converted into articles. Please try to refrain from writing unless you are prepared to be published. All criticisms of organisations or named individuals will entitle the parties to a right of reply. Please bear in mind

the UK libel laws!Trainees: Trainees are especially encouraged to submit material in any and all of the above categories. These will normally be placed in the trainees’ section. Appointments committees in particular value publications in ACP news.

Editorial Policy: The editor would particularly encourage overseas contributors, material from trainees, material from non-histopathologists, commentary on current affairs in pathology, occasional columnists, innovations in pathology, humorous writing on pathology-related topics, and anything downright cantankerous.

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

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

ACP news is published quarterly. Regular publication dates are:

Issue Publication month Copy dateSPRING February 5 DecemberSUMMER May 5 MarchAUTUMN August 5 JuneWINTER November 5 September

Copy is best submitted by email, in any version of Microsoft Word, although it should be possible to accommodate other formats. Submissions on paper by snail mail will also be accepted. Illustrations should be sent as JPEG digital images or hard copy prints. Please do not embed images in your text. Send them as separate files.

Please send email submissions direct to the editor at [email protected]

In keeping with GDPR, please state if you wish your contact details to be published; they will appear in the print issue and will also be available as a PDF in the members’ area of the website.


Editorial

In this issue I consider people in pathology: one person in particular but also professionals involved in providing pathology services.

The one person who we look to in some detail is naturally our founding father, Sidney Dyke, and I am very grateful to our fellow editors for allowing me to reproduce the detailed biography previously published in the Journal of Clinical Pathology.

Reading his story reminds me of the value of celebrating great lives, not only to wonder at what drove them and made them so prodigious in their output but also to view the challenges they faced, how they overcame them, and what lessons we can learn from them.

One of his earliest quotes, when he was young enough to be forgiven for the poor grammar was: “Me wants to learn” – insatiable curiosity leads to great discoveries, and acknowledging that you have a lot to learn is key to making progress.

What would he say if he were with us now? Some of his comments were of their time but some were timeless; one quote: ”the impression exists that the beginning and end of clinical pathology is the examination of the specimen without reference to the patient”, is surely timeless.

He was a great believer that the clinical pathologist’s place was with the patient and not isolated in the laboratory. His comment that the clinical pathologist’s place was at the bedside may be more of its time; certainly there is much to be gained through patient contact but cellular pathologists in particular will have to choose carefully whether they work more efficiently by spending time out of the lab rather than working through the piles of slides in the standard reporting session. For many, periods of isolation, i.e. working undisturbed with the door shut, is the best way of getting the work done.

The science that underpins pathology has progressed in leaps and bounds since then but has the way we have delivered our services kept pace?

We have seen many reorganisations, some beneficial, others not. I remember when I took up haematology the great delight of working within the laboratory that produced answers often rapidly and efficiently. What was simply regarded as the “path lab” by colleagues at the time would now be renamed an “Integrated one-stop diagnostic and treatment facility”. The main lab with staining machines was right next to the phlebotomy room, also used for taking bone marrow samples and other procedures.

This meant that should a blood film or a paraprotein spike suggest myeloma, I could be looking at the bone marrow aspirate within 10 minutes of deciding to take the sample. After explaining the diagnosis, I could send the

patient round to pharmacy for his first course of chemo straightaway.

Alas, no more. A younger colleague told me that they now send the majority of investigations away to a distant lab, resulting in a slower service, and they have much less of a hands-on experience in the laboratory, which has implications for the quality of the service. I expand on this in the article on contracting for quality and safety in pathology. Because quality in the case of a distant lab is not ensured by the consultants continued input and presence, but through a contracting process involving many intermediaries, mostly managers with no first-hand knowledge of the subject.

For pathologists working in blood sciences the danger of being “isolated in the lab” is being replaced by the dangers of being too distant from the laboratory.

One characteristic of many great men and women in science and other areas of endeavour is their acknowledgement of the efforts of others in contributing to their success. Sometimes this is a memorable phrase, such as the one by Isaac Newton that he could only see further because he stood on the shoulders of others.

Pathologists can only do their highly detailed and advanced work because of the vital preparatory work done by non-medical laboratory staff. Some aspects of this work can be automated but I believe we are seeing an over-reliance on equipment, which cannot replace all aspects of human functionality. Current trends in the workforce need to be re-evaluated. I report on problems which may be the thin end of the wedge, and it would be very useful to hear from other colleagues where there have been reconfigurations as to how well the services are being delivered.

My thanks, as always, to our contributors. You may notice one topic has been subjected to double reporting. The Study in Leadership lecture by Angela Douglas has been reported both by Jules, as part of his review of the Leadership Skills meeting, and as a separate report by myself. This is not to suggest that we needed a second opinion but reflects the fact that we were both inspired to write about it and when I completed my article I found Jules had sent his in.

Double reporting has its purposes and I would like to see this as evidence that this was such an inspiring talk

Your editor


Editorial

www.pathologists.org.uk

ISSN No. 0260-065X

There are no prizes for identifying the character in our winter puzzle picture, this time it’s entertainment only to bring you some mid-winter cheer !

that we both got straight down to reporting it without delay. Anyone eager enough to look for differences between the two will hopefully conclude the contents are similar but the style is different.

A double dose also this time from Mike Kearney, with his Norwegian adventures educating us in both geography and history. A special vote of thanks to Mike for his sterling efforts for the News.

A welcome piece, too, from another stalwart, Matt Clarke, always prepared to address serious topics deserving our attention but which are seldom given the priority they deserve. There is always something more urgent to enable us to neglect difficult topics, so many thanks to Matt for reminding us of the importance of the common problem of mental illness and the value of showing compassion.

He is not alone in speaking up for colleagues feeling the strain of work pressures. I include another piece from David Zigmond, who worked some sessions as a psychiatrist at the temple of science that was Hammersmith Hospital when I worked there in the 1980s. There is no doubt that in our early work on bone marrow transplantation we were pushing forward the frontiers of knowledge at a pace that stressed both doctors and patients. They both

benefited from a dose of the human touch that he was able to provide along the lines of a spoonful of sugar helping the massive doses of medicine to go down. He wrote his reflections on “From family to Factory” after observing changes in our health service over subsequent decades.

The ACP News has always provided a rich mixture of topics and for future issues I would like to see more pathology, and that means more contributions from you, dear readers. The formal guidance for contributors is on page 4 and there are many categories. Currently we have a section entitled “Reports”, which can include anything of interest to the readership; this could be audits, quality improvement projects, and other items worth sharing. The great advantage of the News over more formal publications is that we are not hidebound by rules and regulations on presentation. If it is interesting and informative, it goes in.

As for our links with the devil, all will be revealed in the article about Devil’s Dyke, less than five miles from our office and the connection is the number 77 bus, which goes right past Dyke House.

Eric WattsEmail: [email protected]


ACP Business

ACP Journalism in Pathology Prize 2018, awarded at the Council Dinner, summer 2019

Each year the Association of Clinical Pathologists is proud to award Journalism in Pathology Prizes to recognise the outstanding efforts of contributors to the ACP news. The First prize includes £500, attendance at the Council dinner and attendance at the National Leadership Skills Meeting. This year the standard was exceptional, presenting the judges with difficult decisions. We were unanimous in our decision to award first prize in the Trainee Member Category to Dr Michelle Moore, and first prize in the Ordinary Member category to Dr Luciane Irion.

Michelle’s article, which appeared in the summer 2018 issue, described her experiences at the six-day 2018 United States and Canadian Academy of Pathology meeting in Vancouver. She was able to attend this in part due to an ACP Travel Fund Award and presented a poster describing a rare variant of vaginal adenocarcinoma.

Luciane’s article, which appeared in the autumn 2018 issue, related her experiences attending the ocular pathology laboratory at McGill University in Montreal, supported by an ACP Career Development Award. It was evident that this allowed her to have a fascinating experience that enhanced her expertise.

Both articles were exceptionally well written and both demonstrated the clear educational value that they had gained from ACP awards. Both of you have clearly had experiences that have enhanced your careers and which will improve the delivery of pathology services in the UK. Michelle and Luciane, it gives me very great pleasure to recognise your achievements tonight and present you with your awards. We very much hope to see more from you both in future issues of the ACP news.

Dr Julian Burton addresses the Council

Dr Michelle Moore - first prize trainee category

Dr Luciane Irion receives her prize


ACP Business

Presentation of the Marshall Medal to Dr Suzy Lishman CBE: Council Dinner Speech, summer 2019 – Dr Julian Burton

Pathology has long had something of an image problem. The public, with the exception perhaps of some rather unreal portrayals on television of things done in mortuaries, has largely been unaware of pathology. To patients (and many medical students) it is invisible. To doctors on the wards, in clinics and operating theatres it may be perceived as something delivered by technicians rather than specially trained doctors – samples being something to be “sent away” (“Is it back yet?”), or dealt with solely by machines. And this matters. As the science of understanding disease, pathology is fundamental to the delivery of modern medicine – and we, like many countries around the world, have a worsening shortage of pathologists.

It is hard to think of any pathologist in recent times who has done more to try to reverse this trend and bring pathology, in a positive light, to the attention of the

general public. Described by the Health Service Journal as the “public face of pathology” in 2013, Dr Lishman has been named one of the 50 most inspirational women in healthcare. Suzy has worked with many learned organisations, including (but by no means limited to) the Royal Society, the Royal Institution, and the Science Museum. She introduced National Pathology Week in 2008 – and on a personal note I am delighted and honoured to have worked alongside her delivering virtual autopsy demonstrations to the general public in the Hunterian Museum at the Royal College of Surgeons. Dr Lishman has taken pathology out of the laboratory to parliamentarians, policy makers, and the public, and made it accessible in schools and medical schools, in hospitals, at festivals, on social media, in museums, on television, and in print. Elected President of the Royal College of Pathologists in 2014, Dr Lishman has continued to promote our profession nationally and internationally and has enhanced pathology services for patients, living and dead. She has written of her successes in the ACP news and has worked closely with the Association. These are only some of her many achievements; they are too numerous to mention in their entirety. A search for her name on Google yields more than 40,000 results. In recognition for her excellent work, Dr Lishman was appointed a Commander of the Most Excellent Order of the British Empire in the 2018 Honours List.

The Marshall Medal is one of the highest honours that the Association of Clinical Pathologists can bestow upon a member. It is awarded every three years for outstanding service to the Association of Clinical Pathologists and to clinical pathology. The Medal is named after Diki Marshall, a former Treasurer, Chairman of Council, and President of the Association, who worked hard to establish pathologists as consultants rather than S.H.M.O.s and to promote pathology as a respected clinical discipline in its own right.

There can be no doubt that Dr Lishman’s tireless work to promote pathology as a crucial discipline within medicine is very much in the spirit of Dr Marshall’s work. It is therefore with very great pleasure that I invite Dr Bill Simpson, President of the Association of Clinical Pathologists, to present Dr Lishman with the Marshall Medal.

Dr Simpson presents the Marshall Medal to Dr Lishman


Meeting Reports

National Leadership Skills Meeting, Royal Society of Chemistry, 11th June 2019 – Dr Julian Burton

Once again, the National Leadership Skills Meeting took place at the Royal Society of Chemistry in London, and was organised by Dr Bridget Wilkins. It focused on the skills essential for successful collaboration and continuous quality improvement (CQI) at work. These annual meetings form a circuit – attend each meeting for three years and you have attended the full set. This was my second meeting but was actually the third in the series of three sessions, and once again the meeting was “sold out”.

After a short introduction we got straight down to the workshops.

Workshop 1: Making the most of meetingsThis workshop allowed delegates to consider what meetings are, what they are for, and how to manage them, both as chair and as a participant. There were some excellent suggestions. We considered what makes for a good (and bad) meeting. Some meetings will aim to make decisions – and these should do so, and be rapidly followed up with actions. Meetings for information sharing alone may be unnecessary – there may be other more efficient ways to share the information – but where the information is controversial or nuanced, such meetings may be very helpful. Interpersonal face-to-face interactions may be very important. Some meetings are scheduled purely for the purpose of forming or fostering a relationship. These latter meetings, which can occur in a formal or informal setting, encourage collaboration and help foster interpersonal relationships and rapport. You might want to have a look on line for Random Coffee Trials for examples

of such relationship-building meetings.We had a lengthy and very interesting discussion on what

makes good and poor practice when chairing meetings as part of this workshop. I found this particularly useful (and am sure it will help me chair meetings in the future). We also spent some time considering a variety of scenarios detailing complex interactions and dynamics at work

Workshop 2: Giving and receiving feedbackAfter a quick coffee break we dived into the second workshop. We began by considering that what is said is not always what is heard, and that clear communication is crucial. We considered how we give feedback in environments outside work and how it might differ from feedback given at work (and how feedback given at work might differ if given in that “outside” style, and vice versa). It was notable that as a cohort we focused much more on giving feedback outside of work than receiving it. We noted that 360-degree feedback is similar to the style of feedback given outside work (both have a tendency to focus on the negative and both lack much in the way of context or redress for the receiver of the feedback). Pre-existing (professional) relationships between the giver and receiver of the feedback will influence how feedback is received and interpreted: we’re more inclined to respond positively to feedback if it comes from someone that we respect. Curiously, if feedback outside of work was given as it is in work it would be much more formal – look forward to your one-to-one meeting with your local artisanal baker.

So, what makes for a good feedback experience? We considered that it involves thoughtful effort, happens in an appropriate place, and is timely. It is honest, authentic/sincere, empowering, balanced/measured, constructive, proportionate, specific, and offers suggestions for how to improve (not just what needs to improve). Good feedback is

Burlington House – venue for our June meeting and the RSA Summer Exhibition


Meeting Reports

a collaborative dialogue. Well-delivered feedback is the gift that gives us the emotional intelligence to understand how we are perceived in the world, and how we can improve.

Keynote lectureLunch was followed by this year’s keynote lecture: A leadership journey in a time of revolution for genetics and genomic services in the NHS by Professor Angela Douglas, Deputy Chief Scientific Officer. This part of the meeting was arranged and hosted by the ACP Trainee Members’ Group. In a fascinating lecture, Professor Douglas described her career pathway to become a leader in the delivery of genomic services. Some key messages were:

• Your dreams should scare you a bit. • Work to goals – and create your own future. • Leaders create their own luck, rather than leaving

things to chance. • People might forget what you said and did, but

they will remember how you made them feel. • A leader will build their team – you are not a leader

without followers.• Find your feet first and then develop the vision –

you have to first see the wood before you can find a path through the trees.

Workshop 3: Quality Improvement – measuring what matters for CQIWe began this workshop with an overview of the methodologies that underpin continuous quality improvement. Measurements may be made to gather information for audit, research, or to improve a service.

Measuring what matters is a key principle in “Lean” working. We considered that data are not only numerical, and a wide range of sources may feed into your review of the current state of affairs before determining what actions are needed.

We tend to be focused on outcome measures, but measuring process and balancing measures (have we introduced a negative instead of a positive) are also important.

We concentrated on “fluffy data” – thoughts, feelings, pictures of things. These are data types that are often disregarded by those with a scientific background (but which are frequently considered by those with a social science background!)

Workshop 4: Coaching skills for leading, managing and appraisalsIn the final workshop of the day we considered coaching skills, beginning with a consideration of what coaching is and how it differs from mentoring, sponsoring, counselling, managing, supervising etc. Coaching is helpful for clarifying situations and encourages reflective thinking, and is one of the most successful leadership styles. It encourages you to find your own solutions for you and your own situation. The coachee retains control of the content of the conversations and is responsible for undertaking the agreed actions, while the coach controls the process. Many frameworks exist for coaching and we explored T-GROW (Topic, Goal, Reality, Will) framework with emphasis on the importance of listening and open questioning. The day ended with an opportunity to practice coaching techniques as both coacher and coachee.

Overall it was a wonderful day, and it was well supported by a variety of materials in the information pack. It was superb to see so many colleagues in attendance, and I hope to see you at the meeting in 2020.


Meeting Reports

A leadership journey in a time of revolution for genetics and genomic services in the NHS – Angela Douglas MBE, Deputy Chief Scientific Officer, NHS E.

This was an inspirational talk with the themes of having an ambition, seeing it through, and using every challenge as an opportunity to develop further.

At school her first interest was the violin then science, greatly helped by being taught by one of the few female

science teachers. Going on to university, girls were still in the minority but that did not curb her enthusiasm as she developed an interest in genetics. The slides show the theoretical ideal of progress, but the reality is not a straight line onwards and upwards but is full of all the complications life throws at you, being uprooted from one place to another, and blending two careers into family life.

Angela has set up or expanded diagnostic services, general cytogenetic or genomic in London and in the north-west, and delivered insights into how to get people on board and working together – key message: there needs to be emotional impact.

• People don’t really listen unless there is emotional impact that causes them never to forget

• As a leader you have to touch people’s hearts as well as their heads

• What you say, must have a meaningful story • What you say must resonate in the heart of the

listener – like a song does• Maya Angelou (pictured),

American poet, singer, memoirist and civil rights activist said: “I’ve learned that people will forget what you said, people will forget what you did, but people never forget how you made them feel.”

The progress with the 100,000 Genomes Project has been spectacular, and now moving on from the Project to sequence 5 million patients with Rare Disease and Cancer within five years is a great ambition, which will enable us to match genomic findings with the clinical data so that we can truly personalise treatments and interventions more precisely.

The unique nature of the NHS contribution to the 100,000 Genome Project has significantly levered learning – firmly linking routine care with academic advances, and through taking a system-wide approach.

One clear example of the benefit whole genome sequencing has provided is the classic case (courtesy of Prof Sian Ellard, Exeter and Devon) we have all used to demonstrate how a better understanding of the genome, in this case in neonatal diabetes, has led to more precise diagnosis and treatment: the example showing five babies with five different genetic subtypes, requiring five different treatments.


Meeting Reports

Histiocytic and dendritic cell neoplasms – Dr Ye Lin Hock Black, University Hospitals Birmingham NHS Foundation Trust and Black Country Pathology Services

Beginning with an amusing reflection on lymphoma classification, Dr Hock moved swiftly on to a dazzling display of fascinating tumours of considerable morphologic and immunological complexity. He commented that these are rare, which in some respects could be fortunate if that means we do not have to pay them a lot of attention, but they can be difficult to diagnose as the morphological features can overlap e.g. with anaplastic large cell lymphoma. This makes the detailed immunohistochemical testing valuable in getting a definite and accurate diagnosis.

The diagram shows the different myeloid and mesenchymal origins resulting in cells which are vastly important with wide ranging immune function but also have a chameleon-like ability to change appearances.

Clearly a difficult area for the generalist, this territory is full of unfamiliar cells undergoing morphological transformation, sometimes masquerading as reactive states, and even the nomenclature became complicated with terms like Rosai-Dorfman Destombes and Erdheim Chester disease so it was some relief when he returned to

more familiar conditions such as sarcoma.It was also a relief to know that good old-fashioned

morphology is still a major feature in the differential diagnosis. Fortunately, he gave an excellent summary of the learning points on when to suspect these tumours, which he called his personal take, modestly referring to it as a simplistic view.

Histiocytic sarcoma• Large nasty looking cells with abundant pink

cytoplasm • IHC CD 163, CD68 (PGM-1) and/or lysozyme

(muramidase)+ in malignant cells• Absence of epithelial, melanocytic, Langerhans

cell, FDC, myeloid or T and B-cell markers• Rule out myeloid sarcoma with monocytic/

monoblastic differentiation

Dendritic cell neoplasms• Spindle to ovoid cells (usually not markedly

anaplastic)• In fascicles, whorls and storiform patterns• A moderate amount of eosinophillic cytoplasm• Vesicular nuclei, finely dispersed chromatin• Nuclear pseudo-inclusions, bi and multi-nucleated

tumour cells• Light infiltrate of lymphocytes +/- plasma cells• IHC appropriate specific markers for the entity and

general haematology markers• Exclusion of spindle cell carcinoma, melanoma

and (other) sarcomas

For the final point he mentioned that help may be needed from specialist sarcoma colleagues; I think we would all agree to that!


Meeting Reports

The evolution of Follicular Lymphoma – Dr Jessica Okosun, Bart’s Cancer Institute London

Follicular lymphoma (FL) is a well described clinical and pathological entity usually characterised by fairly long survival (median > 15yrs) with frequent relapses, which tend to become more common as time goes on. Recently anti-CD20 antibodies such as Rituximab and many other Mabs have improved response time and reduced relapses.

There is considerable heterogeneity in the tumours, but one feature common to 90% is the 14:18 translocation leading to over expression of BCL 2 (a key mediator of the apoptotic response to targeted anti-cancer therapeutics). But over expression alone does not give a lymphoma; although some regard this state as a subclinical disease, another hit is needed.

Surprisingly, as the 14:18 was once thought of as a marker for the disease, it can be found in circulating lymphocytes of healthy people, with an only one in 23 chance of developing FL.

Over the last few years the genomic revolution has helped to identify various biological pathways which cooperate with the translocation. The studies have also identified targets for therapy.

One well-documented interesting feature is the remarkable spatial heterogeneity as illustrated in the slide with the lymph nodes genetic expression on the x-axis, and the bone marrow on the y-axis.

This beautifully illustrates the clonal evolution of circulating cells, but it can also lead to arguments at MDTs regarding which is the correct result.

In spite of these difficulties, the genetic information has huge potential in respect of prognosis, treatment and monitoring; all of these are exciting areas of ongoing research.

In short• Epigenetic deregulation is a key feature of FL• Additional biological pathways – mTor, JAK-

STAT, NF-kB signalling – are involved in immune modulation, demonstrating the mechanism and providing targets

• Genetic heterogeneity is found both at different sites and through passage of time

• There is a reservoir population of cells which would be the target for curative treatment

• The genetic aberrations themselves provide potential targets for biologically guided treatments

In conclusion, a fascinating lecture showing how the new technologies are helping our understanding of a well-known disease, and providing opportunities both for researchers and clinicians.


Meeting Reports

The 2016 WHO lymphoma classification and beyond– Dr Stephen Swerdlow, Pittsburgh

A brilliant lecture, packed with facts, this was a fasten your seat belts for trip down the fast lane of a rapidly evolving and growing area, with pauses for comments full of wit and wisdom. He did go outside the carefully chosen guidance on lecturing in general, i.e. faster and more information than the average student could take in; this was clearly a lecture for professionals familiar with the subject.

He started gently with a bit of personal history: that he had worked at Barts and enjoyed the fact that there was a brass plaque in the old pathology Museum celebrating the first meeting between Sherlock Holmes and Dr Watson. This has now been removed as it seemed to attract too many curious visitors more interested in a fictional duo than the contents of the museum.

He illustrated the long and winding road of lymphoma classification that predated work by WHO.

The first 2008 WHO classification came about because of the need for an authoritative body to compile and coordinate the knowledge gained by all the differing groups to arrange one standard that they could all sign up to. It was a massive effort and by the time all the participants had reached a consensus that could be published, new knowledge was already emerging, requiring a revision.

The work began in 2012 and this time the number of experts had increased so much that rather than having a committee of all involved it turned into a village. It soon became clear that with advancing knowledge the sands were shifting some of the foundations on which accepted knowledge had been built. To do justice to all the facts and the supporting evidence, the required document turned into a substantial book. Even that is, in places, an oversimplification, a snapshot in time of what could be agreed, otherwise the book would never have been

published.While they were about to close on a final agreement he

was still getting around 20 emails on a Sunday morning with new complications, and was dismayed to see one sent with High Importance “WHO Postponed” until he realised it was from Ticketmaster delaying a rock concert and not from the publisher!

This is how the publishers describe it:

“WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues is a Revised 4th Edition Volume of the WHO series on histological and genetic typing of human tumours. This authoritative, concise reference book provides an international standard for oncologists and

pathologists and will serve as an indispensable guide for use in the design of studies monitoring response to therapy and clinical outcome.

Diagnostic criteria, pathological features, and associated genetic alterations are described in a strictly disease oriented manner. Sections on all recognized neoplasms and their variants further include new ICD-O codes, epidemiology, clinical features, macroscopy, prognosis and predictive factors.

This classification, prepared by 132 authors from 23 countries, contains about 1,300 colour images and tables, and more than 4,500 references.”

Stephen then announced his commercial interest in the venture, after years of work he received one free copy! (UK price £135)

He described how it took so long to get a consensus statement. When there are so many differing approaches, achieving a consensus will always be a challenge. There was the familiar dichotomy between the lumpers and splitters, with the splitters particularly using new genomic evidence, sometimes to find later that the “distinctive” genes were not exclusively found in specific subsets.

Then there was the hazy distinction between a proliferative state and neoplasia. There was a more conservative approach in some areas, where some “lymphomas” were recognised as particularly indolent. A particular point being Chronic Lymphocytic Leukaemia (CLL). How to tell if a lymphocytosis will actually


Meeting Reports

develop into a leukaemic state is still problematic, and the panel recognised the potential psychological distress of labelling the patient with the dreaded disease.

To quote from the conclusion from his article with lead author Sarah Gibson in Haematologica (2011; 96:1144):

“Our findings suggest that biopsies containing chronic lymphocytic leukaemia-type cells, but lacking proliferation centres and with non-enlarged or only slightly enlarged lymph nodes on imaging, represent a very indolent disease that may best be considered a tissue equivalent of monoclonal B-cell lymphocytosis rather than overt small lymphocytic lymphoma. We propose that such cases be designated as tissue involvement by chronic lymphocytic leukaemia/small lymphocytic lymphoma-like cells of uncertain significance.”

Grading follicular lymphoma is a task that will never end and the panel members recognised their subjectivity in the exercise. Some interesting points were in CLL; when the proliferative centres are large it is a more aggressive disease and the GCB/ABC probes may help to distinguish subtypes where the treatment can be different. Molecular methods are providing evidence to help to distinguish kinky different subtypes (Haematological 2017 102e 404 Nat Rev Clin Oncol MEJM 2018328 1396).

With the Burkitt’s double hit NHL with MYC BCL2 markers indicate that stronger treatment than R-CHOP will be needed. Double-hit cases may benefit from a broader genetic profile. In other areas the panel could not reach a consensus; for example, in the use of FISH, so there was no Gospel according to the New Book. It was recognised that mucosal EBV+ lesions resembling lymphoma can resolve spontaneously; for example, if immunosuppressive agents are withdrawn.

Many subtypes have been grouped under umbrellas – some

of which expand, some break up; the molecular revolution is gaining ground but has not completely taken over.

ConclusionsWhile there were questions initially about whether it was worth the great effort to revise the 2008 WHO Blue Book on haemopoietic and lymphoid tumours, we ended up with many changes that reflect our enhanced understanding of the biology of lymphomas, which impact our daily practice that hopefully lead to better patient care.

He finished by explaining that the book tried to be human, and that the search for the Holy Grail had been almost as entertaining as the Monty Python film by that name.

Primary Cutaneous B-cell lymphomasThese were first classified in 2004 and he commented that the classification looked more like a table of contents of separate entities.

Interesting subtypes varied from MALTOMA, an incident form with cutaneous dissemination, not an overt lymphoma, to leg lymphomas. These can be aggressive and grow rapidly but with R-CHOP and irradiation, sometimes single-dose, 74% survival at five years can be achieved.

Throughout the talk the slides contained fascinating artwork ranging from comic cartoons to many of the great masters, including Da Vinci, Magritte and Hockney. Dali was used, somewhat enigmatically, to illustrate leg lymphomas.

His summary of this section was: Primary cutaneous B-cell lymphomas have been a contentious issue, but we do have a classification, with the only remaining differences between the general and skin WHO classification being whether the PCM ZL should be segregated from other MALT lymphomas.

Although there was a lot to take in it was reassuring to note that this difficult and wide-ranging subject has received expert and pragmatic attention, albeit with a warning that there is a lot more in the pipeline.

Dr Stephen Swerdlow with Bridget Wilkins in between lectures


Meeting Reports

The multiplication of FISH: a practical guide to lymphoma diagnosis – Zbigniew Rudzki, Consultant Histopathologist, Birmingham Heartlands Hospital

A stimulating and at times provocative piece presented with style by Dr Rudzki, who introduced himself modestly as the “Polish Plumber” but impressed us with such knowledge and judgement that he should have called himself he “Perceptive Polish Pathologist”.

This was another bravura performance, outstanding in both depth and detail. So many facts and so much comment came out of such a short title it evoked the parable of the loaves and the fishes where crowds were fed from what started off as a small helping of only two fish. This is clearly a fast growing subject from which I have selected a few examples.

The message I received is that FISHING for lymphoma subtypes is useful in selected cases but time-consuming and expensive, and should be used judiciously. It is within the reach of most laboratories and should be seen as part of the immunohistochemistry service and not as a detached and separate diagnostic procedure.

He illustrated that with a modest outlay, a histology lab could develop the service:

Equipment & costsProgrammable hybridisation apparatus* ~ £3000 = “posh hot-plate”, can be replaced by water bath + dedicated lab worker

Fluorescence microscope: motorised*, with a camera, computer and software* (for image capturing, processing and storage) > £50,000

*optional

Fluorescence microscope ‘manual’ with camera (basic) & computer ~ £10,000 – £15,000

Material cost of a single test ≈ 10x cost of a single immunohistochemical stain

For a single FISH test we charge ~ £145, extra £50 for each additional test

Workload – slide preparation, as manual immunohistochemistry

Interpretation (+photo) ~10-60min per test (even longer if you need to count) x 2 – two assessments

Their panel is -

Probes: CMYC (2 probes) CCND1BCL2 CMYC-IGHBCL6 CMYC-Kappa-LambdaIGH CMYC-BCL6

MALT1 IRF4/DUSP22ALK1 TP53 & ATM

They have identified 314 translocation cases, 22 CLL in 2018 and 318 translocation cases; 29 CLL in 2019.

In the introduction he demonstrated how the techniques gave their distinctive patterns with amazing clarity, as illustrated for detection of recurrent translocations, the dual-colour, split-signal (break-apart; segregation) approach.


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Probes flank the translocation (breakpoint) region for the gene of interest

Showing dual fusion signals “2F” with no translocations (fig 1) and single-split and single-fusion “101G1F” (fig 2)

Pros and cons of the segregation approach: • Does not confirm (directly) the translocation partner (two or more FISHes can be done to provide indirect evidence)• Detects translocations with non-standard partners• Results (usually) in easily interpretable patterns• Can be reliably interpreted even if cell boundaries are not discernible• Preferred in routine diagnostics

Gene of interest Gene of interest

Fig 1 Fig 2


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Dual-colour, fused-signal (dual-fusion; co-localisation) approachThis is another method to detect a recurrent translocation and here the probes span translocation regions in two genes/loci on two chromosomes.

This sophisticated science gives results that are not only highly informative but images that are also real works of art, as shown in fig 3.

Fig 3 CMYC-IGH dual-fusion C


Editorial Meeting Reports

Counting of cells and application of numerical cut-offs

A motorised microscope aids efficiency through compounding the images at different levels as shown:

Dr Rudzki warned of the problems and pitfalls, particularly with respect to counting numbers of positive cells and application of numerical cut-offs with split single probes in tissue sections.

The number of cells may be questionable due to overlap or indistinct boundaries:

• Admixture of non-neoplastic cells• Clonal variability as in FL and CLL• Can be done more easily on captured images(not

directly under the microscope)

In addition it takes time and is boring .Next there is the issue of which cases to FISH.

Haematologists, as represented by the British Society for Haematology guidelines, want virtually all lymphoma cases to be FISHed (along the lines of the more information the better!) Birmingham has a practical approach based on requests by their local haematologists or when the patient is fit for aggressive therapy. When the lymphoma is a double expressor, if Burkitt or high-grade BHNL NOS enters the diagnosis, or in the case of a low grade which is transforming.

After discussing the laboratory service and selection of cases to test he moved on to the clinical relevance showing differing results from different trials about the prognostic significance of MYC, BCL2 and BCL6 rearrangements. He concluded that we needed more evidence and that this could come through setting up a network.

Finally he gave thanks to Dr Jane Starczynski and Mrs Lisa James: “The true authors (and main ‘analysts’) of these FISH pictures.”


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CESR in histopathology: demystifying the Process

Author 1: Dr Hebah AliConsultant Haematopathologist, HMDSSt James’s University Hospital, Leeds

Author 2: Dr Vasi SundaresanConsultant Histopathologist Princess Alexandra Hospital, HarlowPathology Specialty Lead for SAS Doctors EoE

Author 3: Ms Joanne BrinklowDirector of LearningThe Royal College of Pathologists

Author 4: Mr Bill WestTraining CoordinatorThe Royal College of Pathologists

In March 2019, the East of England Deanery and British Division of International Academy of Pathology funded the second Certificate of Eligibility for Specialist Registration (CESR) day at Harlow for doctors who are considering making a CESR application in histopathology. Doctors applying for a CESR must demonstrate that they have obtained equivalent knowledge, skills and attitudes in the UK and/or overseas to that required for the relevant CCT curriculum. This includes demonstrating that they have completed assessments and examinations either the same as or equivalent to those required in the curriculum. It is a robust process that includes initial application to the GMC and assessment of each application by at least three College Fellows in the relevant specialty and a recommendation from the College to the GMC about whether or not the applicant is suitable for entry to the Specialist Register.

The RCPath was invited to give insights to would-be applicants, who found sessions by President Professor Jo Martin, Professor Mike Sheaff, an RCPath CESR assessor, and Jo Brinklow, Director of Learning, very useful. Dr Ian Proctor, Histopathology Training Programme Director for North, Central and East London, provided curriculum guidance in an amazing session. The day also included sessions by the GMC Specialist Applications team members Jessica Betts and Stephanie Wright, and was a great opportunity to interact with successful CESR applicants.

The course was very well-received as a valuable, stimulating and enjoyable day for the 28 delegates who attended. This piece of joined-up reflections reports on the event and provides an overview of the CESR route for prospective applicants.

Dr Vasi Sundaresan is the Pathology Specialty Lead for SAS Doctors and CESR Champion for the East of England, who has helped many SAS doctors successfully steer their way through the CESR route onto the GMC Specialist Register. Below are some of his tips to the potential applicants:

Successful CESR applications: Every year, around 60 to 70 doctors complete an approved UK training programme in histopathology, leading to the award of an ARCP Outcome 6 and a Certificate of Completion of Training (CCT). This means their names are added to the GMC Specialist Register


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in Histopathology, and they become appointable to a substantive consultant post in the NHS.

There is an alternative (non-Deanery) route by which to enter the GMC Specialist Register; the Certificate of Eligibility for Specialist Register (CESR), formerly known as Article 14. This is the process that enables doctors who are overseas-trained or haven’t finished the UK training programme, and are in staff and associate grade roles with requisite skills, experience and qualifications, to join the Specialist Register.

Evidence to be presented: A successful CESR application is dependent on many factors, not least a supportive learning environment and a supervisor/mentor who understands the process and is willing to support the applicant. The application process is very straightforward but can be a time-consuming process, so it is very important that applicants make sure they are familiar with the GMC evidence requirements.

Specialty-specific guidance, which was developed by the GMC with the Royal College of Pathologists, is available on the GMC website. It gives helpful advice on the documents to submit, and explains the requirements for histopathology competence which mirror those in the curriculum. This includes being able to evidence experiential training in specialist attachments: neuropathology, perinatal pathology (inclusive of two perinatal PMs), 40 adult autopsies, and molecular pathology. Then there are workload figures with good evidence of the development towards independent clinical practice. Evidence should also cover a range of sub-specialties of both biopsy and complex

surgical resections. A selection of these reports should be anonymised and submitted for scrutiny to the assessors.

There are other equally important aspects of training, both specialty-specific and generic: case presentations, mentoring other trainees and teaching, writing letters of referrals of cases, leadership, management and teamwork. The importance of evidencing audits cannot be emphasised enough. At least one completed audit in the last year is expected to be submitted in order to demonstrate an understanding of the importance of service development and delivery. Publications of case reports and presentations of posters at meetings can also support the application.

Selection of referees: Apart from the evidence submission, the applicant must choose four referees to provide a structured report. During the evaluation process, these reports are used to cross-reference the evidence, verify work, training and experience, and provide detail on personal attributes, skills and competencies from the last five years. Ideally, one of the referees should be the current medical, divisional or clinical director who will be the primary referee. Others need not know your clinical practice in depth and breadth, but should be able to comment on various aspects of clinical practice.

Joanne Brinklow, the Learning Director at RCPath gave a valuable session in the course highlighting more about the CESR route and developments in Histopathology training.

Once the GMC informs the College that a histopathology

Participants at the CESR in Histopathology Course


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CESR application is ready to be assessed, the College will find three histopathology assessors to evaluate the application. The College has 36 working days to submit a recommendation on the application to the GMC. When this has been submitted, the GMC will inform the applicant whether their application has been granted or rejected. The number of histopathology CESR applications has been growing over the last few years, as has the success rate. In 2016, only four out of seven applications were recommended for entry to the Specialist Register, while last year 11 out of 12 applications were successful, largely due to the support being provided to applicants by Dr Ali and Dr Sundaresan. The session also looked at the upcoming changes to the College curricula being driven by the new GMC standards for the development and design of postgraduate medical curricula, “Excellence by Design”. Once a new curriculum is approved by the GMC, it immediately becomes the new standard for CESR applicants, and so applicants were given guidance about when the new curriculum was being submitted to the GMC and what the main changes were likely to be. There was also a discussion about the Learning Environment for Pathology Trainees (LEPT) system, which will be opened up to CESR applicants from August 2019 to help them collect evidence for their CESR application.

Dr Hebah Ali is a consultant haematopathologist who succeeded in getting onto the Specialist Register via CESR route and has invaluable knowledge on applying.

She is keen to share her experience to help others achieve the same, and is currently mentoring histopathology SAS doctors around the UK. Here is her advice to applicants:

What Guidance do CESR applicants need? Where to begin? A common thought expressed by most would-be CESR applicants. If you are thinking of applying for Specialist Registration in histopathology, you can seek advice from both bodies involved in CESR assessment and evaluation: the GMC and the RCPath. A good start is the Histopathology Specialty Specific Guidance, a joint publication available at www.gmc-uk.org/doctors/registration_applications/ssg.asp. Additionally, the GMC offers advice to prospective CESR applicants over the phone and by email. It is recommended that you contact the GMC if you have any queries on 0161 923 6602 or at [email protected]

The RCPath also provides guidance. If you are planning an application, you may pop in and talk to the training co-ordinator, Mr Bill West, or you can phone on 0207 451 6748.

We are thankful for the team in the Princess Alexandra Hospital who helped us to develop this event, and volunteered their time and efforts to facilitate it. Organising the course was a huge undertaking, but we all found it to be an extremely rewarding event and are proud of its success. We look forward for the next CESR course in September 2020.

Specialist Registration Routes


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GiRFT gets into gear

GiRFT in pathology is now underway and all laboratories should have received the data collection forms and some may even have experienced a “Deep Dive” visit.

This initiative has potential to make real improvements through the established principle of generalising best practice, but all working pathologists will know that this hallowed principle is not always easy to implement. Working to the highest standards is often complicated by insufficient resources, increasing demand, and all the other challenges that real life brings.

GiRFT began in orthopaedics where the big data collection and analysis allowed, amongst other things, a rationalisation of the many different joint replacement procedures and prostheses. Pathology is different and has been through many different exercises in terms of data collection and analysis. So far these analyses have shown that there are many different ways of running the service, largely dictated by history, geography and local needs and so far there has not been a one size fits all solution.

So I began to be sceptical of what another number crunching exercise could tell us that has eluded the previous attempts.

We are fortunate that two of our stalwarts are leads for their respective subjects: Simon Knowles for cellular pathology, and Marion Wood for haematology. From discussion with Marion I am hopeful that GiRFT will enable a more intelligent analysis of data, allowing us to recognise best practice that can be generalised throughout the country.

The elements involve:

• Part 1 Collection of big data• Part 2 Analysis for identification of trends

and outliers (both high and lower performing), providing areas for discussion during a deep dive identification of the outliers.

• Part 3 Deep Dives All labs will get a deep dive, even if they are “middle of the pack” for all the data fields.

It was reassuring to learn that the main focus is on improving patient care, and for many blood science investigations timeliness is an important factor, especially the service provided to the Emergency Departments. In this respect pre-and post analytical factors are being investigated; the analytical process itself has already received much attention.

Amongst the information that will go into the data pack will be haemolysis rates, which are important both in terms of accuracy and in terms of the patient experience, as these patients may have had the samples taken badly and will need to be re-bled. Where outliers are identified, subsequent investigation (the deep dive) might reveal, for example, that departments with their own trained phlebotomy staff have lower haemolysis rates than those where samples are taken by a variety of staff members.

In general practice samples the frequency of hyperkalaemia could be an indication of delays to centrifuge samples.

At time of writing we have limited experience of the deep dive; the first visit will be in the form of a pilot study. The guiding principles are that we know that all professionals want to provide a good service and the GiRFT team will use the data pack to help in conversation with the local team about the service and to explore the areas where the local results differ significantly from the national average.

By the time they have done half the visits they should have a reasonable picture of what is going on around the country, enough to start to prepare the national report that comes out for each specialty, sharing best practice and making recommendations.


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This is going to involve a lot of work; the data pack for the first pilot is 130 pages long!

One important point is the turnaround time for the Emergency Departments samples and the needle to result time is particularly prone to pre-and post analytical issues. In respect of pre-analytical, the most important point is time taken from collecting the sample to putting it on the analyser. Many different people may be involved, including porters and reception staff at the laboratory. This is one of the areas where more detailed scrutiny may be necessary. For example, the time the sample is delivered to the laboratory may not be the time that it is recorded; in the normal working day it should be but it is not unusual to see piles of samples waiting to be checked in.

Outside normal office hours it is often the case that one BMS may be logging in the samples as well as carrying out the analyses and cannot be continuously available at reception to record the time of delivery. Only a longitudinal study, i.e. following the sample on its journey, will show where delays occur and this would be very labour-intensive.

This is the sort of area where conversations during the “deep dive” visit allow us to learn what labs do to reduce delays and manage measuring time at different stages of the specimen journey.

It’s too early in the Path GiRFT journey to have any solutions but we strongly suspect that one or more

recommendations is likely to relate to LIMS and related computer systems that are used by laboratories.

GiRFT is setting up local teams to help with getting useful information from all the laboratories.

The deep dive visits should be set up with at least six weeks’ notice to allow time for review of the data pack and enable as many of the relevant personnel as possible to attend and participate in the discussions. Attendees should include, in addition to senior laboratory staff and clinicians, members of the Executive team, who are likely to be held to account with delivery of any recommendations that are made. It is also open to local teams to decide who else to invite; for example, a local GP liaison manager, phlebotomy service manager, transfusion nurse practitioner.

GiRFT is currently being supported at a high level by NHSI/E, with significant investment. There are regional teams in place to support local staff at all stages of the process, across the many specialties that are undergoing GIRFT visits. In orthopaedics they are currently on the second or third “wave” across the country (England only, GiRFT has not yet been adopted by the Welsh or Scottish healthcare systems).

More information about GiRFT is available on the Model Hospital website.

Thanks to Marion for her help in preparing this article..

A link between two Dykes


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Sidney Dyke: an inspiration to us all!– W R Timperley, J Burston, E Howl

The founding of the Association of British Pathologists (later the Association of Clinical Pathologists (ACP)) in 1927 was testimony to Dyke’s professional standing and drive, and was the springboard for his inspired leadership. During the course of his professional life and into retirement he had a profound and wholly beneficial influence on the practice of pathology in the UK, in Europe, and in much of the world.

Sidney Campbell Dyke was born on 5 September 1886 and died on 3 March 1975, aged 88. His early life was complicated, his father having gone to Canada, leaving him to live with his father’s brother, Edward. His Aunt Kate, Edward’s wife, had lost her only son at the age of 14, one year before Sidney was born, and it seems likely that she conferred some of her affection for her son to Sidney. He certainly grew up to be a warm and loving person himself, and somebody must have encouraged his interest in books and reading. It is said that one of his earliest sayings was “me wants to learn” – a trait that lasted all his life. He went to the village school, wearing skirts, as was usual for boys up to the age of five, and remembered his fear of the geese on the common he had to cross because they pecked his legs.

During the course of his professional life and into retirement he had a profound and wholly beneficial influence on the practice of pathology.

His sister, who visited every summer, remembered life at Taplow as an eternal golden Edwardian summer. Uncle Edward had a houseboat, two punts, and a canoe. There was tennis and bathing. Sidney remembered Boulter’s Lock crammed with punts, full of smart young men in blazers and boaters, and beautiful girls with parasols. But the position of Sidney and his elder brother Gordon in their uncle’s household was somewhat equivocal. They were treated very much as poor relations, eating with the staff in the servant’s hall, where Sidney became very devoted to the coachman Talbot.

Edward ran a lucrative private school in Taplow, known as Taplow Grammar School. The school was subsequently sold and with the proceeds Edward successfully invested in land and housing, and bought a large house called Beechwood.

Sidney’s father, John, had worked his way across Canada to British Columbia, leaving his wife as “head nurse” in an Irish country house, after the final collapse of

his fortunes in an unsuccessful attempt to run a brewery in Dublin, in which Edward had set him up as manager. Thinking that British Columbia would be a good place to settle, his brother Edward and his daughter Laurie went out there to buy a 20-acre farm in the Frazer Valley, near Port Haney. His wife and children followed at intervals afterwards. This seems to have been rather a disastrous purchase, the land consisting largely of tree stumps after the woods had been felled. Sidney Dyke recalled the thrill of stuffing a tree stump with gunpowder, lighting the fuse, and then running “like hell”.

The transition to a flea-ridden log cabin in the Frazer valley in 1899, aged 12, must have come as a shock. He was sent across the Atlantic with his 14-year-old brother from Tilbury to Ottawa on “harvester’s tickets” costing £5, sleeping on a straw paliasse covered with red cotton, which stained his face pink.

Not long after his arrival in Canada, Uncle Edward, who had recognised his nephew’s potential, arranged for him to attend New Westminster High School and board locally. Sidney broke away from his family at this stage and was never close to them again.

At school he founded and co-edited the school magazine, The Pharos, and when he matriculated he won the “Governor-General’s Gold Medal”.

After leaving school he worked for a short time on the New Westminster Gazette, for which he wrote some short stories and gained a reputation as a wonderful storyteller. He was particularly proud of a story about a man who had seduced and deserted an Indian girl who took revenge by cutting his throat from ear to ear while he slept.

He spoke little about his time in Canada with the exception of his adventures while serving in the north, especially his voyage up the Skeena River in 1905. He had been fired from his paper for inaccurate reporting of a Board of Trade meeting and signed on as an axeman with a survey party going up the Skeena River to the upper reaches of the Bulkley River. He travelled up to Hazleton on the stern wheeler “The Royal City”, working as an assistant to a Chinese cook, Tom Koo. Paying passengers were put ashore for the dangerous passage up the Grand Canyon. On the return journey the steamer jammed crossways in Kitselas Canyon and broke in half, with half the steamer piling up at the canyon mouth. Five men were drowned.

According to an interview with a Vancouver Sun journalist in 1954, Sidney and a companion left the main


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party at Hazleton and returned to Port Essington in an enormous dugout manned by Indians from the missionary settlement at Meansaniskit, “the city of God”, where no smoking, drinking, or swearing were allowed. Sidney had to go half a mile up river for a quiet cigarette.

At one point he and a friend went ashore in the Kisplax country, walked for hours, alarmed by the footprints of grizzly bears, spending the night up trees and listening to bears snuffling around below.

He went on several survey expeditions, sometimes acting as cook, and followed the gold rush trail of 1896 in Alaska, noting the skeletons of the pack animals lying by the track, together with the many useless items of equipment that hopeful miners had abandoned, including a full-sized billiard table.

From 1906 to 1909 he studied general arts at Toronto University. This course covered history and English literature and he was awarded a first class honours Degree. He was an avid reader with a superb memory for poetry and the Bible, and his advice to the young was to learn as much poetry as possible by the age of 20, because

this would be what they would never forget. This quality remained with him for the rest of his life and he became famous for his ability to produce an apt quotation at medical meetings. In the early years of the Second World War, when invasion was anticipated, he set himself the task of learning the whole Bible so that if imprisoned he would have it in his head.

On his return from Toronto he worked for three months as news editor of the New Westminster Daily News and did some teaching at Vancouver High School. His love of teaching proved useful in the war when he received anonymous food parcels from a former grateful pupil.

In 1910 he went up to Exeter College, Oxford, as a Rhodes scholar to read natural science with medicine in view. He saw the last days of an Oxford that was to die in the mud of France. Each student had a room with a small bedroom and a coal fire, which was lit before rising by his scout. He described breakfast parties of lobster and champagne. Lectures were in the morning and not compulsory, the afternoon being free for sport or long walks with friends. He rowed for Exeter College, being

Sidney Dyke and his wife Janet on the occasion of their golden wedding anniversary, September 1968


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coached by the future Archbishop of Canterbury, Geoffrey Fisher. Many young men combined the pleasures of Oxford with hard study and he was one of these. He graduated, again with a first class honours degree, in 1913, and won a scholarship to St Mary’s Hospital. His love of Oxford remained with him for the rest of his life.

While working in London, like many other young colonials, he joined King Edward’s Horse as a volunteer. He started the war as a trooper in the regiment described by a visiting general as “bloody rabble on horseback”. He was anxious to qualify as rapidly as possible and managed to cram 18 months’ of clinical training into six months and qualified as Licentiate in Medicine and Surgery of Apothecaries, the lowest possible medical qualification in 1915. He proceeded to France as captain in the Royal Army Medical Corp without filling any resident hospital appointments. While in France he became interested in the subject of nephritis, and while attached for a short time to a base hospital he was able to make observations, which later resulted in several publications on “trench” nephritis.

His memories of France left him with a deep hatred of war. He remembered the jingoism of those who stayed at home and how different it was from those at the front. He once said, jokingly, that if there ever was another war he would go in the navy because at least your feet were not immersed in the mud.

In 1917 he developed pleurisy and suffered a haemoptysis, which in those days was usually a sign of tuberculosis. He was invalided home to work in the military hospital, which was housed in the examination schools in Oxford. Here began his lifelong interest in diagnostic pathology. He acted as demonstrator in pathology and bacteriology in the department of pathology of the University of Oxford, as clinical assistant to the Oxford Eye Hospital, and as temporary tutor in physiology to Exeter College, Oxford. One of his first students was a slim and beautiful woman called Janet Smith, who was rather unenthusiastically engaged to the son of a bishop. They fell in love and he asked her father’s permission to marry her (fig 1). After a short engagement they were married – a khaki wedding in September 1918. On the evening before the wedding he opened his Gideon Bible in his hotel room, which fell open at the verse “thou shalt see thy children’s children and peace in the land”.

They returned to Oxford and set up house in Longwall Street. That winter was so cold that the water carried upstairs by the maid had frozen in the jug by the time it arrived, and the urine froze in the chamber pot! At this time the influenza epidemic was raging and many doctors died. He recalls visiting a house in a poor part of

Abingdon where he had to climb over three dead bodies lying in a bed to reach the only one living. He himself picked up the infection but fortunately survived.

His continuing interest in the application of new methods in the laboratory investigation of disease and treatment led to his first appointment after the war as assistant microbiologist at the University of Durham Medical School in 1918. This post involved the teaching of bacteriology both to medical students and candidates for the diploma of public health, and the carrying out of diagnostic bacteriological work. While occupying this post he began an investigation into the prevalence of the various types of pneumococci.

While in France he became interested in the subject of nephritis, and while attached for a short time to a base hospital he was able to make observations, which later resulted in several publications on trench nephritis.

In 1920, Sir Cuthbert Wallace, director of the surgical unit, invited him to set up a laboratory for the clinical unit at St Thomas’s Hospital, London. The pathological and bacteriological laboratories were non-existent; his first duty was to establish and equip them, and to arrange for a diagnostic service to be provided. The work comprised a mixture of teaching, research, and, more importantly for Sidney, clinical diagnosis. The teaching consisted of lectures and classes in morbid anatomy and histology, in clinical pathology and bacteriology, and in practical histology; in addition, individual personal instruction was given to students, who were encouraged to work in the laboratories in their own time. His research at that time was concerned mainly with the correlation between abnormalities in renal function and the morphological changes in the kidney and other organs. Other work included the constitution, inheritance, and the general importance of the blood groups; and both alone and in collaboration with Mr BC Maybury, FRCS, he conducted experimental investigations into the routes and mode of infection of the kidneys. The results of these various projects resulted in several publications.

He was admitted to the Member of the Royal College of Physicians in 1924 and was awarded the degree of Doctor of Medicine at the University of Oxford in the same year. He always enjoyed wearing the scarlet robes and velvet cap relevant to that degree.

Also in 1924, he was appointed pathologist and bacteriologist to the Royal Staffordshire General Hospital, which became the Royal Hospital, Wolverhampton, where he worked until his retirement in 1952. His reference from SG Shattock, FRS, for that post survives


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and reads as follows:“I have known Dr SC Dyke since he was appointed

pathologist to the units at St Thomas’s Hospital in 1920. From my direct knowledge of his work I can say that he is, I think, an excellent pathologist of the broader type. His knowledge, both practical and theoretical, extends to all the chief branches of pathology.

He is an enthusiastic teacher and likewise an able investigator, as his experimental work on the fate of staphylococci in the kidney after intravenous injection, in the rabbit, proves. He is, moreover, a most obliging colleague and conscientious officer.”

Before leaving London he had been elected Secretary to the pathological section of the Royal Society of Medicine.

The 1920s were a period of rapid advances in the scientific basis of medicine. Insulin had become available for the treatment of diabetes and liver extracts for pernicious anaemia. Sidney became especially interested in these conditions and was thrilled with the opportunity that this presented for treating diseases that were previously fatal. Another contribution to local medicine was the development of blood transfusion. He gave the first blood transfusion in his area and in 1925 collaborated with the Rotary Club to organise a voluntary transfusion service. Donors were urgently summoned by a motorcyclist, even in the middle of the night, to be rushed to hospital to save a life. By 1939, this service had developed into the Emergency Transfusion Service in anticipation of the coming war. His wife headed a team of women who went around local factories to enrol donors and take blood samples.

In 1929, he was awarded the Radcliffe Prize for the Advancement of Medicine by the University of Oxford and during the 1920s he was twice offered professorships: one in pathology at Cairo University; the other in Medicine at Chulalong Horn University in Bangkok. His daughter, Dr Elizabeth Howl, recalls finding a tattered canvas cot swathed in mosquito netting in the attic, which had been bought for Siam; so he must have seriously considered going.

He was always clinically orientated and established outpatient clinics for diabetes mellitus and pernicious anaemia in his laboratory, in addition to having charge of a few beds in the hospital. He believed that the place of the clinical pathologist was at the patient’s bedside and not isolated in the laboratory. As he said “the impression exists that the beginning and end of clinical pathology is the examination of a specimen without reference to the patient”. After their blood tests patients would queue to see him. Sometimes the queue was long, extending out of the doors, whatever the weather. Dr Thorne, his

successor, remembered more than 75 patients being seen in a morning. At the end of the session Sidney would sit back, light a cigarette, and proclaim: “By God, Thorne, that was a good morning’s work.”

Additional publications included papers on the diagnosis of pernicious anaemia and locally he introduced the use of liver for its treatment, in addition to insulin for diabetes. Later, in 1936, he pioneered the use of sulfonamides in the treatment of pneumococcal pneumonia and meningitis, also usually previously fatal. This received some national publicity and tributes from grateful patients in newspapers.

He believed that the place of the clinical pathologist was at the patient’s bedside and not isolated in the laboratory.

Sidney’s greatest claim to fame was the creation of the ACP. From its inception it met twice a year, the summer meeting in the provinces and the winter meeting in London. The early scientific meetings concentrated on scientific developments followed by discussion. He reported on the various activities of council at the business meeting, often humorously and in expressive style. The warm and relaxed mood of these meetings was long remembered by his colleagues and this acted as a magnetic attraction to attend. He regarded the dinner as a particularly important part of the meetings. There were no set speeches and no invited speakers, but it was understood that after dinner anyone was free to air his/her opinions and receive the views of fellow members. These after dinner discussions proved of the greatest value in formulating the early policies of the association. This policy continues today and has evolved to include recitations of a non-medical nature.

After each meeting he produced a detailed account of the proceedings and circulated these to all members for the benefit of those who were not able to attend. He put an enormous amount of time and enthusiasm into working for the ACP, serving as honorary secretary from 1928 to 1936, president from 1937 to 1943, and chairman of council from 1943 to 1952. As the most active, forceful, and articulate member of the association, he invariably represented it (often with others) at meetings, committees, etc, where the views of hospital pathologists were of importance, such as the Royal College of Physicians’ committee considering the Beveridge Report. In 1947 he became editor of the first edition of Recent Advances in Clinical Pathology and continued this editorship through to the sixth edition in 1973.

In 1952, he gave the first triennial foundation lecture, which still bears his name, and received a gold medal


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with a very good likeness of himself on it. In that same year McMenemy wrote “his services to the association are so outstanding, indeed they must be unique, that the possibility of retirement seems to us who know and admire him, to be out of the question”. The reports evolved to the publication of “Reports and Broadsheets” and in 1947, at a meeting in Oxford, the decision was taken to publish a journal, the Journal of Clinical Pathology; AG Signy was appointed first editor.

He knew all of the regular attenders at the meetings well, where they came from, and their interests, and was still attending meetings until shortly before his death. The question of honorary membership was considered about the time of his retirement, but was not proceeded with because it would have meant that he would have lost his right to vote.

Although short-handed and working very long hours, particularly during the Second World War, he remained full of hope for a better world after the war. He firmly believed that citizens from different nations and cultures were more likely to get on together if they met and spoke to each other. It was from this belief that, in the darkest hours, in 1941, he founded the European Association of Clinical Pathologists, and he became its first president. In a letter circulated to the members of the ACP touching upon the European Association he wrote as follows: “Mr Winston Churchill has pointed out the duty laid upon each and all is to strive to become ‘good Europeans’. This demands an acquaintance and contact with our fellow Europeans closer than we as people have sought or has been sought from us in the past.” This association evolved to become the World Association of Societies of Pathology, of which he was also the first president.

After the war he was asked to go to newly liberated Czechoslovakia to advise on pathology services, travelling in a transport Dakota, sitting on the floor, propped up against a bag.

In the years leading up to his retirement he became something of an elder statesman, travelling extensively, often accompanied by his wife, who was always elegant and charming and who enjoyed meeting so many people. They were both received in audience by the Pope. She had been a magistrate and enjoyed visiting courts and penal establishments and was sometimes addressed as “Judge Dyke”.

Following the second congress of the International Society of Clinical Pathologists in Washington, USA, he and his wife paid their first visit to Vancouver since he left for Oxford in 1910.

In addition to his many medical activities he founded the Wolverhampton Civic Hall Arts Society and made a short excursion into local politics, being elected as an

Independent for Tettenhall Council. He was the last man to wear the chairman’s ornate chain of office, because Tettenhall merged with Wolverhampton in 1966. In 1952, the year of his retirement, he was appointed curator of the regional histological collection at Birmingham University, funded by the British Empire Cancer Campaign.

His attitude to retirement was one of disgruntlement, which might just be apparent in the official portrait that now hangs on the stairs of the Royal Hospital. He remained fully occupied, attending national and international meetings, and continued to look after a large number of devoted private patients, particularly those with diabetes. He and his wife continued to live in their solid 19th century residence facing the Upper Green in Tettenhall, surrounded by their grandchildren. He remained physically and mentally active until 1975 when he became short of breath and had developed widespread cancer. He accepted this calmly, having been a practising Christian for over 30 years. Shortly before his death the local vicar took a family house communion, attended by all the family, including children and grandchildren. Afterwards they drank sherry and discussed the difference between being a devout Catholic and a staunch Protestant. At one stage Sidney had considered becoming a Catholic but could not accept the doctrine of Original Sin.

His attitude to retirement was one of disgruntlement, which might just be apparent in the official portrait that now hangs on the stairs of the Royal Hospital.

His memory remained good to the end. Shortly before his death he quoted Kingsley’s “Crossing the Bar” to his daughter, Elizabeth.

In his “Personal recollections of Sidney Dyke in the early years of the ACP”, published in the Journal of Clinical Pathology in 1966, Cuthbert E Dukes described him as a very sociable person, easy to get on with – a far sighted man, but not a mere visionary – he was a man of action with the courage of his convictions. Professor E K Blackburn in an article on Sidney Dyke published in the same journal in 1991, described him as “a truly great medical man whom it was a great privilege to have known – a loyal friend. The present generation of clinical pathologists owes more to him than it may realise”.

The authors and many others looking back over Dyke’s life and the many years since his death fully endorse this discerning appraisal.

ReferencesReproduced with permission from - Journal of Clinical Pathology May 2003, 56 (5) 323-326; DOI: 10.1136/jcp.56.5.323


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ACP’s link to the Devil[Alternatively: Our founder’s devilish connection]

The puzzle in the last issue was to find the link between the picture of the dramatic curving valley, a distinctive feature of the South Downs, and our founder. The answer is in the name Dyke and the devil in the detail is that locals call it the Devil’s Dyke because of a grand old legend.

So the link between the ACP and the devil is the Dyke Road also known as the B2121 or the number 77 Brighton and Hove transport authority bus, which in the summer runs open-topped to give passengers a great view of the exhilarating scenery.*

It is a place of spectacular views and five counties can be seen to the north, east and west, and Oxford on a good day, whilst to the south the English Channel and the Isle of Wight complete the panoramic view. There are numerous pictures up of the scenery, such as this one but, on the day I visited with my camera, in spite of a good forecast it was a dull day, better for close-up and medium-range views rather than distant shots of greying clouds.

The area is fascinating geographically, as it is the deepest dry valley in England, i.e. there is no river or even a stream at the bottom. The Devil has been credited with many geographical features, sometimes because they appear so awesome that supernatural forces must have created them, and the absence of water flowing in the valley may have led some to query unnatural forces. But of all the places credited to the Devil, this one has the best story.

Although it is hard to believe that this area, next to the ultra respectable community of Hove, could be home to the Devil, there are some supporting facts. The early Christian missionaries left this area of the Weald alone as it was marshland with few inhabitants. By the 7th century the area was becoming inhabited and the marshes drained to allow agriculture.

Christianity was established in much of the country by then but the Devil felt he was safe in this area around Saddlecombe, four miles from Dyke House. Then the Christians started to move in and build churches. One morning the Devil met Father Cuthman and derided him for having the nerve to build churches on his patch. He boasted to the clergyman that the church would be gone by morning as he would dig through the hillside to the sea, flooding the valley and drowning or driving the Christians away.

Father Cuthman called a meeting of the clergy whereupon Sister Ursula devised a cunning plan. When the Devil was hard at work that night she lit a lantern and awoke the local cockerel, which crowed loudly. Hearing the Cock a Doodle Doo when the Devil was only halfway to the sea, he believed it was dawn and that he had failed in his boast. Humiliated, he fled in disgrace. The legends speak of him hurling soil around in anger, creating many of the local hills and even the Isle of Wight. Some superstitious locals still like to keep a light on at night to deter the Devil from returning.

Other locals sleep soundly believing that they finished off the Devil for good and buried both him and his Mrs in small mounds towards the northern end of the Dyke. The legend has many believers, as both the ordnance survey map and the National Trust leaflet clearly display the Devil’s grave and an accompanying mound for Mrs Devil. The National Trust’s leaflet of self-guided walks contains the advice that if you find the Devil’s graves (shown below) and run backwards around both mounds seven times whilst holding your breath, then he will reappear.

It is now a great beauty spot, having been praised by Constable as the grandest view in the world. It has attracted country lovers and adventurers of all sorts, and


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was a very popular destination in Victorian times, the site of a great funfair, and a railway line led there from Brighton.

The funfair involved swings, switchback railway and a bicycle roundabout where bicycles were fixed into a circle on the edges of the roundabout so they provided the motive power and were kept held upright so there was no danger of falling over. It seems cycling was a rare treat in those days.

There were fascinating motorised attractions with a funicular railway and a cable car. There is little evidence of these attractions now as most of the area has returned to nature but you can walk up to the site of the old railway line and find the odd piece of brickwork or lump of concrete to show where the supports of the cable car pylons would have been.

Through the wonders of modern technology, you can take a virtual drive on YouTube from our office in Dyke Road on the top of the 77 bus to view the scenery. Also on YouTube, courtesy of Richard Vobes aka the Bald Explore, you can view him pointing out all these interesting features.**

Although the weather at the time of my visit prevented me from capturing glorious views it was possible to snap some of the huge array of flowers. The delicate chalk grassland found here is very sensitive to change. This makes it rare, not just in the intensively farmed south-east but internationally, too. The grassland supports a huge array of flowers and insects, including many species of orchid, and a selection of anthills that would not be found

on more disturbed ground.

Although the funfair is long gone, the pub remains and is thriving, along with one of the newer sports – hang gliding, which is so popular now that the pub displays one on its sign. When the wind comes from the north it is an ideal place to leap into the air. I’m told that in the 1970s, when the sport was just starting, the authorities sought to prohibit it for safety reasons. Not so much that hang gliders were injuring themselves but that motorists, suddenly catching sight of a flying person, would be distracted, lose control and drive into a ditch. Hang gliders are now almost a permanent part of the scenery.

For anyone walking the South Downs Way, Devil’s Dyke is a great place to stop, and for visitors to Brighton and Hove it’s a great little outing.

Look out for some other photos of Devil’s Dyke scattered throughout this issue.

References* YouTube: 77 Bus: Brighton to Devil’s Dyke, upper front seat view [whole route] – (www.youtube.com/watch?v=OVVawEyBQyU&t=627s)pietias231, published on 1 Jun 2019** YouTube: Walks in Sussex: Exploring Victorian Amusements of Devil’s Dyke https://youtu.be/LYavW4Zw88E?t=2Picture credits – richardvobes.com, View – urban75


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Being human: how much does pathology need people?

Automation, artificial intelligence and robotics are shaping our future but have we a safe and secure system to evaluate how effectively they can replace the human element? Have the planners correctly interpreted the trends or overestimated the benefit of technology? Have they been realistic or even half right with new and emerging laboratory plans?

Many years ago, in the early 80s, I dropped into the postgraduate centre, before going home, to see the head of pathology with some dark-suited and important-looking people at the bar. He introduced me to a team from the Department of Health who told me of their plans to modernise pathology; after they explained their analysis to me, I spontaneously replied that it sounded like they wanted a factory.

They seemed to take offence – not so much that this was what they were trying to do but that I should find it objectionable. After a couple of years as a registrar in general medicine, I went into pathology, because I enjoyed the business of using science to find answers to problems and particularly making diagnoses. Not in order to work in a factory.

Like any detective work, the thought process is picking up clues and evaluating them, formulating the relevant questions and then testing them out; in other words the iterative process – a challenging mental task. That is why pathologists need to be highly-trained intelligent people. Of course, medically qualified pathologists rightly regard themselves as such, but the same is true to varying degrees for all people involved in the process.

That is why I find the factory analogy so worrying. The classic description of the factory is a place where things are made, typically on production lines requiring limited involvement by people, the human role being reduced to operating like a machine. Coming from the industrial north, I recall notices on the factory wall advertising situations vacant with a simple message “Hands Wanted”, the implication being that input from the brain was unnecessary.

I also remember how the powers that be dealt with the problem of giving people mindless repetitive work to do, and part of that was a celebrated radio programme – Workers Playtime. This began during World War II (and lasted until 1964), when it was essential to get maximum production from our factories to help the war effort. After some jolly introductory words, the programme mostly featured rhythmic music carefully chosen to aid the

timing of manual chores. An old idea; the ancient Greeks and Romans used a drummer for the same purpose, to keep their galley slaves in time.

A recent nostalgic radio programme described how the musical arrangers would take advice from factory managers about the tempo of the music and not play anything too stimulating lest the workforce get over-excited. One manager had complained that a production line worker got carried away with some up-tempo music and damaged his machine by tapping out the rhythm with his spanner.

Further thoughts on the de-personalising effect of factory working are included in this issue, in David Zigmond’s article ‘From family to factory’.

Describing pathology department as family may be overstating the case but not by much. One of the great sources of satisfaction for me has been developing the knowledge and talents of new entrants to the Department: scientific, medical, non-medical, highly-qualified, or straight from school. We now recognise that professional development requires lifelong learning and that is true for all professionals, in my view; we can learn a lot from each other in the workplace when we have time for informal discussions as well as structured training programmes.

I well recall being a newly-arrived consultant and sitting in the tea-room, used by all of the department, and finding out much more about how the lab and the rest of the hospital worked than through speaking to the managers. I also learned about how our biomedical scientists (BMSs) were being taught, in one case, rather badly. We were discussing a blood film with some blasts and I announced this was acute myelo-monocytic leukaemia. One of the BMSs, about to sit his FIMLS, commented that the patient would not have long in this world.

I then explained the recent advances in treatment, and that this patient had at least a 70% chance of achieving remission. The BMS told me that his lecturer had stated the condition was almost universally and rapidly fatal. I telephoned the college that he attended to enquire how well the lecturer updated his knowledge, to be told that “He is one of our best. He has been giving that lecture for 20 years now”. That, precisely, was the problem; an institution stuck in its ways relying on the supportive environment of the workplace to complete the education of its students.

The system is now changing: one old consultant


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colleague told me she has little contact with trainee biomedical scientists. No more “Can you look at this film please? There’s a funny cell and I don’t know what to call it”. That used to happen routinely on my many visits to the lab each day. It is no longer possible for a consultant and trainee BMS to share a microscope and look at the same cell together on an everyday basis, as most of the microscopy is done in the laboratory hub, miles from the hospital. The vital human contact, getting to know the staff and develop trust so essential for teamwork, is being lost.

Recognising the strength and limitations of man and machineOne area is at the start of the pathology process – taking blood. I don’t know of any machine being developed to replace the phlebotomist, and surgeons using robots have commented that one of the difficulties is allowing for the varying tensile strength and elasticity of the tissues or the amount of “give” they feel when they are dissecting. Venepuncture is a skill requiring great awareness of the varying degrees to which skin and veins may yield to the needle, wiggle away, shrink, or burst as we approach them and take a sample.

Humans, with their limited skill set, will be required to collect the majority of pathology samples for the foreseeable future and we need to work with our knowledge of human limitations for maximum efficiency and safety. For the best example of our need to recognise and deal with human fallibility, fast forward to a recent International Blood Transfusion Society plenary session where the speaker from California, a state celebrated for sophistication and high-tech industry, described how we need to recognise the human element in healthcare.

The phlebotomists followed the instructions perfectly: to take blood from the patient in bed 26, the identification details had already been filled out for her and having identified the bed correctly she duly took the blood as directed. Later, when investigating how the patient who had previously occupied bed 26 suffered a transfusion reaction it was realised that patients can be moved from one bed to another and that a better system is to ensure that the patient is identified and not the bed. Empowering people to use their native wit and intelligence, such as ensuring they have identified the right patient, is more effective than giving mindless instructions such as patient in bed 26. Ensuring that the phlebotomist asks the standard question, i.e. “what is your name and date of birth?” would have been far safer. Dehumanising procedures prevents intelligent people from using their intelligence effectively.

Despite advances in artificial intelligence and entertaining films such as Robocop, it is worth restating as clearly as possible that people are not machines. It is true that people can do some of the things machines can do and that some machines can do some of the things that people do. So there is overlap, but there are also major differences that need to be recognised.

Using people as machines brings with it inevitable problems and we need to recognise human limitations. One of the best authors on the subject of human error is James Reason, who has explained the enormous capacities of the human mind, its creativity and capacity for awe, wonder, love and compassion, in short – feelings.

Shakespeare went a bit further, when circumstances forced Hamlet to consider the human condition he mused: “What a piece of work is a man! How noble in reason, how infinite in faculty! In form and moving how express and admirable! In action how like an angel, in apprehension how like a god! The beauty of the world. The paragon of animals.”

Summarising the Shakespearean quote we can say that there are many things to thrill or to occupy the human mind, and at times the day job may not be one of them.

James Reason’s extensive work in this area shows that this wonderfully creative mind receives so many inputs from so many sources that it has to interpret them in order to make sense of what features on our consciousness. In short, error is the price we pay for how we process information to avoid overload.

He has explained what excites us and turns us on and what turns us off. No doubt you have guessed it: tedious repetition is a major turn-off. This is where machines, automation or AI have most to offer. Managers will delight in the fact that automated systems can be run almost continuously and do not require holidays or other forms of leave. The challenge therefore is to separate tasks into those better done by machines, and to design ways for people to work within normal human limitations, i.e. by designing in failsafe features.

Blind faith in automation can lead to embarrassing mistakes. I was describing to one senior executive that new equipment did not mean that we could lose half of our staff, making the point that even the best haematology analysers still require scrutiny of the results as they are not infallible. He looked at me in disbelief then commented that if the machines could fail then companies would not be able to sell them. It is sobering to think that such a person could be responsible for a multi-million pound contract.

In the post-Carter period of pathology we see more machines and fewer people in our labs, in particular fewer


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mid-grade, state registered BMSs, and more untrained staff who feed the machines. This was documented in the study “The State of Pathology in the UK”, carried out by Unite in 2016 with 1,200 respondents, showing that 72% of labs had vacancies and that they particularly affected band six but also five and seven, i.e. trained staff.

In its conclusion, it states that it will continue work with the National School of Healthcare Sciences, Health Education England, the Academy of Healthcare Science, and other bodies, as well as forge stronger links with the IBMS. I think pathologists should also join in the effort and it was encouraging to see that the College has launched a workforce survey in haematology, but discouraging to read from the president’s July newsletter: “We launched the haematology workforce survey in December but to date the response rate is only 33%, which is very disappointing. We know you want us to help, so thanks to those who have responded to this already. Please pass this to your local head and encourage them to participate!”

The College forewarned us of these problems in their 2017 document on essential service laboratories and more recently, in the July Bulletin, Prof Peter Johnston commented that the workforce was too small. He also commented that there are problems when different members of the same team are employed by different organisations. To quote directly:

Developing an inclusive workplace cultureThere are challenges in departments where, for example, the biomedical and administrative staff are employed by a different organisation from clinical scientist and medical staff. Finding common ground and opportunities for socialisation within and beyond work are relevant. Devoting time to conversation across the workforce can develop inclusivity and bring out commonality. Improved interaction with ward and primary care staff could help to raise our profile and encourage others to consider a career in pathology.

We see fewer people scrutinising the results so that figures well off the normal scale and needing to be repeated are identified by GPs rather than during the authorisation process (described further in Contracting and Monitoring for Safety).

Too many automated systems are being used that are not sentient and do not have sufficient quality control features to tell when the result is so extraordinary it needs to be rechecked. The lesson is obvious, if you are going to replace people with automated systems you need to make sure they work just as well or the problems of human error will be replaced by a variety of system

errors. Machine learning can be very impressive but it still requires monitoring and oversight. The highly experienced team that produced the most widely used automated anticoagulant management software described how they spend more time testing and debugging the programme when they develop it in the first place, as only real-life experience can determine how safe and effective it is.

One of the standard reasons given for automation is to avoid human error. Error management, whether human or not, is a very important part of the safety strategy and NHS England’s new report is reviewed in this issue.

Whilst I welcome progress through the intelligent application of automation and appropriate use of AI, we must not forget that pathology needs people. And it will continue do for the foreseeable future. A comprehensive review of staffing is urgently required as we begin to realise the limitations of automated systems.

ReferencesPicture credit – https://xkcd.com/1838/

Professor Peter Johnston, Fiona Addiscott, REVIEWS 186, July 2019 Number 187

The Bulletin of the Royal College of Pathologists


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A new problem has arisen as a result of changes sweeping through pathology, in particular the confidence of users in the quality-assurance of outsourced services. Following Carter’s recommendations, more networks are being formed leading to different working relationships between the laboratory staff and the consultants who take responsibility for the work. When much work is done in remote hubs and the consultants are based in hospitals, the physical separation makes routine monitoring more difficult. Where work has been outsourced, quality and safety is not assured by daily oversight of work but by contracting based on key performance indicators (KPIs); I consider this as too blunt an instrument to be fit for this purpose.

I have heard the dogs barking at night. This issue has been brought home to me as a result of the experience of one GP I used to know when I was a hospital doctor. I met him at a regional event and at first didn’t recognise him. Then he reminded me that I had once lectured to the medical department about the wonderful new drug that was to replace Warfarin. Knowing that I was not easily offended, he reminded me that I made that bold prediction 10 years ago and that we still prescribe more Warfarin than any equivalent drug.

I took it on the chin with the comment that sometimes I had to own up to a mistake. His reply was to wish that the current providers of the pathology service to his surgery would do just that. His confidence had been shaken by significant errors from a service that shows little interest in delivering safe and reliable results. He told me personally of a patient who was reported to have a PSA of over 80, when a few days previously it was reported as five. More recently he had a report of HbA1c level of 450mmol/mol, when the previous result, just three months earlier, was 53mmol/mol.

Concerned that his patient may have developed carcinoma of the pancreas, this caring GP sped round to the patient’s house to find the patient grateful to see him, although somewhat bemused by an unexpected home visit. The GP later saw a series of extremely high HbA1c results before the penny dropped. These reports were erroneous: falsely high, not true.

I was naturally concerned to hear this news and advised him of the procedures to follow. He told me that the laboratory staff had not been interested in hearing about the abnormal PSA result, which must have come from another patient. They said that trying to identify the patient would be, “Like searching for a needle in a

haystack”. This made me more concerned. As I hoped he would not lose faith in pathology, I suggested that – being myself a retired laboratory doctor familiar with error reporting – I could use the established procedures to obtain an explanation and reassurance that lessons had been learned.

Surprisingly, I was told by the laboratory manager that the matter had been closed, although the GP had received neither explanation nor apology. Moreover, the abnormal result remained on the patient’s result file as he could not remove it.

I was sure that pathologists should do better than this and I was concerned about the reliability and accountability of the service. A pathologist of my acquaintance told me that the service was effectively out-sourced but they were happy with it because the KPIs were in order. I asked the local CCG lead how they oversaw quality and safety in pathology. I was told that this was a matter for the Joint CCGs (a partnership of five CCGs).

I wrote to the chair of the Joint CCG Committee, and to help him I included an extract from the NHSI guidance. I followed this up with a question to the senior officer for safety for the Joint CCG, who advised me that the chair of the committee had stated that: “The document in the link that Mr Watts shared, from April 2018, was aimed at Trusts who are consolidating their Pathology services and provides them with guidance on the governance for this consolidated approach.”

This means we have real problems, possibly a perfect storm. Here, reportedly, is a service in the NHS which sometimes gives unreliable results; the consultant pathologist seems concerned only about KPIs with which he is satisfied, and the CCG partnership with overall responsibility for quality and safety responds to evidence-based reports of wrong results with obfuscation.

KPIs are not a comprehensive measure of qualityLooking into how and why such errors may occur is difficult as an outsider. These may be sporadic errors which might afflict any service from time to time or they may represent systematic problems with one or more analyses or instruments. My argument from a few anecdotal case reports is about the management of quality and our users’ confidence in their service. Quality assurance should be built into laboratory practice, and questions of accuracy and precision of results and any reported problems should be of intense interest to laboratory managers.

Pathology is a fairly small world and at another

Contracting and monitoring for quality and safety


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gathering I met a biomedical scientist with inside experience, who commented: “That is the sort of problem that should be easily picked up by experienced staff if you have a batch of results and are familiar with the normal distribution. One of the new ways of working I regretted having to do was not looking at all of the results being sent out, and simply concentrating on the QC results, which were often only run a few times a day. Rather than the old safer method of running QC at the beginning and end of a relatively small batch and only releasing patients results if QC was OK. These days you can automatically send out many hundreds of results before you are aware of a problem. Unfortunately, we have sacrificed quality for speed and non-human intervention with too much reliance on IT and total belief in instrumentation, along with totally distancing the work from the prime reason for getting the results right, i.e. the patient.”

The brave new world of pathology provision needs careful monitoring. A few wrong results raise issues of national significance far beyond localised examples. For me, one of the great joys of haematology was the

patient contact and being present in the lab, knowing the importance of the work being carried out there and what the results mean to the patient and their clinician. I am told that the service in question operates away from the hospital site and that the staff who previously enjoyed a degree of patient contact, if only indirectly through the consultants’ visit to the laboratory, now see even fewer people, staff morale has plummeted, and there is a high dependence on locums.

As far as I can tell the KPIs are largely about turnaround time and other easily quantifiable measurables. Clearly, they may not tell the whole story of analytical precision. Laboratory errors waste time and money, inevitably leading to duplicate testing. The GP wastes time dealing with a wrong result. Patients suffer anxiety on being sent on unnecessary two-week wait referrals for suspected cancer. And the hospital specialists waste more time and money, and displace capacity in the NHS for everybody else.

But surely in 2019 we should live in a golden age of laboratory precision? Analytical platforms, their instruments and reagents should be close to perfection.


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Laboratory quality has been developing for two decades and strict accreditation regimes have been active for years. But the birds in the trees tell you unhappy stories about alleged laboratory errors.

With outsourcing you hand over controlOutsourcing can be beneficial if carried out with proper regard to quality and safety. Previously, tests carried out in-house with the supervising consultant’s presence in the lab were an integral part of the QA process. If a service is taken away from the constant gaze of a consultant then there needs to be a system just as good to replace it, to respond to the early signs of poor performance, and not wait until the GP has to ask if a report is so abnormal that it might not be real.

While this example involves chemistry, I know of concerns from all the specialties. In cellular pathology, one consultant has been surprised to find that the cutup was carried out by an unqualified member of staff and then to find that this employee had in turn been trained by unqualified staff. Previously, most consultant heads of department would interview, appoint and oversee the development of new staff but now it is done by the company.

I consider that this service was designed in a spirit of optimism, with inadequate reality testing before it went live. The crucial point is that the monitoring of the service by consultants appears to be carried out remotely through the KPIs, and that the contracting process is to blame for these unhappy events: the separation of the laboratory from the hospital, and the remoteness of the scientists

from the patients. Is this reasonable? I believe there are important implications for pathologist

if the services are to be outsourced because they will then have less control over the laboratory staff who will be employed by another organisation. Quality control, if monitored through KPIs, will need to be written into the contract so that sufficiently sensitive and realistic KPIs can be developed. Alternatively, regain control of the process by re-employing staff in the hospital.

Surely the principles of quality management are applicable to all types of service? Perhaps the surge in patient demand and laboratory workload forces laboratories these days to seek process efficiencies? Perhaps there is a necessary compromise between the desirable features of volume, speed, economy, and precision? Is there an over-reliance on instrumental platforms and their intrinsic precision over common sense and relating the reported results to clinical reality? How can we maintain the confidence of service users without regular contact between clinicians and laboratories?

What do the readers think?Over the years, the ACP has produced many excellent “broadsheets” along the theme of “How to....” do something properly. As the role of consultant pathologists changes perhaps we need a “How to” broadsheet to address quality management and maintain user confidence in all pathology services, whether in-house or outsourced?

Eric Watts is Editor, ACP news.The views expressed in this article are his personal

views and not the official policy of the ACP.

Funicular railway at Devil's Dyke


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The pathology workforce and mental illness; it’s time to start talking – Dr Matthew Clarke (ACP Trainee Communications Officer, Assistant Editor ACP news)

I work at the Institute of Cancer Research and I recently walked in through the front entrance to be greeted by a large animal-shaped model wrapped in a lot of packaging! This was not what I was expecting to see when I arrived at work and began to wonder if I was still half asleep having arrived at 7am. However, it certainly caught my attention and others’. Several predicted that it was in fact “dolly the sheep”! However, after it was unwrapped it transpired that it was a large model of a black dog with the name tag “Elvis”. And it had arrived for very good reason: it was there as part of a campaign to increase awareness of mental illness and to encourage those who are suffering to seek help; a very worthy and extremely important campaign.

The black dog has been used as a metaphor for mental illnesses such as depression for many centuries, even going back as far as Ancient Greece and featuring in classical mythology. One of the more famous associations is attributed to Sir Winston Churchill, who described his black moods as a “black dog”. The symbolism behind the use of the black dog for this campaign centres on showing how mental illness can be powerful, dominant and unpredictable, similar to a dog. However, one of the important things about dogs is that they can also be trained, and this is what the campaign is trying to show;

mental illness can be managed, and you can have more control. You are not alone and help is available.

Mental illness is not a new problem and definitely not just a problem of the modern era. I think it has been around for as long as we have been aware and conscious of illness, but sadly it has not been recognised as important when compared to other more familiar forms, or what is often termed “organic illness”. This has fostered negative views and stigmas to be associated with those who suffer with mental illness, and means that they often don’t seek the help they need.

Some very famous doctors are known to have suffered with mental illness. One from history who I particularly admire is Dr Thomas Addison, famous for the discovery of “Addison’s disease”, amongst many other achievements in a glittering career. However, he was known to suffer with what was described at the time as “melancholia” (or depression in modern terms), or “overwork of the brain”. He retired to Brighton and in 1860 committed suicide. Sadly, the same situation is faced by many doctors each year, and we are still placing unnecessary obstacles in the way to prevent or make it difficult for them to seek help.

Mental illness often reveals itself in very different ways and I have often wondered how many people throughout history have been burned at the stake or met other horrible ends because of the manifestation of mental illness. I think if we knew the figure it would be frightening. Our understanding of mental illness and its causes is limited and, as with other things where we lack understanding, we tend to deny that it is actually real. The stigma can be seen all around us. Even in applications or forms that I have completed for various everyday things, there are often questions asked about mental illness which always appear to be very obscure and separate from other illness-based questions. There should be no need for this.

The pathology workforce is currently, and will continue to be, under a significant amount of pressure. There are currently 10-12% of vacancies (and this number is rising), and the number of histopathology requests has been rising by 4.5% each year since 2007. Only 3% of histopathology departments have enough staff to meet the demands placed on them. The number of attendances in hospitals and GP practices is increasing year on year, which has a huge impact on the pathology services. As we know, around 70% of patients in hospital have some involvement with a pathologist at some point in their journey; the issue continues to be how many people and


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tests are represented by that figure of 70%. Alongside this, we are facing the problem of the actual number of consultants who are in post, and the number of those who will be at retirement age in the not too distant future; will there be enough trainees to step into these posts and to cope with the increasing demands on the service? That remains to be seen and certainly the College is doing a lot to try and plan for this. For the first time in living memory, all 75 posts for histopathology trainees were filled this year, which is fantastic news and credit should be given to all those who have been involved in careers events and taster days. However, we now need to try and maintain this for next year and also to try and push for the same in the other pathology specialties. So how is this relevant to mental health?

Well, it is extremely relevant. In the current health service, the work-life balance of its staff is pushed to the limit, with the balance often forced to tip the wrong way. It is a common theme amongst medical staff to go above and beyond the call of duty to meet the demands of the service, and I’m sure we will all have lost count of the number of hours that we have effectively worked for free throughout our careers. When work starts to take time out of your personal life, and also when it is highly pressured work with a significant amount of responsibility (as is the case for those who work in pathology and most other healthcare specialties), there is less time to relax and switch off and this can be dangerous territory. Not being able to exercise, not eating well, being alone and away from support networks are all possible triggers. We are not altogether clear about the biology behind what happens in the brain at such times, but it is well recognised that such scenarios can be the seed bed of mental illness.

However, this is not the only thing that can tip the balance. There are many other commitments that healthcare professionals undertake in addition to their daily workload. They are often involved in committees and different societies, which are unpaid roles yet lead to increasing demands on time and responsibilities, in addition to an already highly pressured working environment. This can all encroach into home life and again contribute to a shortening of the time available for rest. To use an analogy, if you are holding a set of slide trays and the number you are holding continues to increase, making them more difficult to carry, it only takes one or two extra to be added or something to trip you up before it all comes crashing to the ground; we need to be helping each other to prevent this.

One aspect we often forget to think about with our medical colleagues is the impact of personal life. Relationship breakdowns, bereavements, bringing up

children, financial worries, amongst many others, can all contribute to an increasing burden on the mind. But again, do we do enough to acknowledge this? I don’t think so. And I think it partly stems from the pressure of workload on our shoulders and the watchful eye of colleagues checking that everyone is “pulling their weight”. I heard recently from a junior doctor who had to leave the ward due to being unwell and was subsequently sent home by the consultant as they could not feasibly continue their work; however, not a single bit of concern was shown by the other colleagues for their care, either at the time or when they returned to work. It was in fact a member of the cleaning staff who got some soup for the unwell doctor and showed some compassion. What has the situation come to where we can’t trust that someone is genuinely unwell and support them? If someone is not “pulling their weight”, or their productivity has declined, there is likely to be a good reason behind this; ask and don’t judge before you know the background.

I mentioned previously that the perception of mental illness often suffers from not having what we often describe as an “organic” cause. As doctors, we are taught to listen to a history, perform an examination, develop ideas of what the illness could be, perform tests that are likely to confirm this, and then treat to make the patient better. Mental illness does not often conform to this protocol and can take a much longer period of time for both diagnosis and treatment. One such example of this issue (although not a common issue for pathologists) can be shown by the diagnosis of “pseudoseizures”. We were taught at medical school the ways to identify a “true” seizure from a pseudoseizure. Anyone diagnosed with pseudoseizures was considered to be “crazy” or “faking it”, rather than having a genuine illness. This was often the case for other psychosomatic illnesses too, a perception that I always disagreed with. I recently read a book by Dr Suzanne O’Sullivan (Consultant Neurologist) called It’s All in Your Head; Stories from the Frontline of Psychosomatic Illness. This book shows how far some doctors have moved forward from this attitude, and has a Consultant Neurologist acknowledging the genuine nature and scientific background of these illnesses. The case examples given are very harrowing at times, but I cannot recommend this book enough and firmly believe that all junior doctors should read it to help counter the stigma associated with these conditions and attitudes to mental illness. I think patients would notice a huge difference in how they were perceived and treated.

Working in molecular pathology and science currently, I have become fascinated by the molecular basis of disease. Genetics used to strike fear into me as a medical


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student but now I cannot get enough of it, particularly when you can see the impact it is having on how we understand different disease processes. As a result, I have been reading a lot about epigenetics or the factors that can modify different aspects of gene expression. Schizophrenia is something that has cropped up in my reading on several occasions. Although having actually been known for some time now, methylation of DNA (the addition of methyl groups at different points along the DNA code) can interplay with environmental factors and contribute to the onset of schizophrenia, an example of a balance and interaction between genes and the environment. Science has provided evidence, and it will only be a matter of time before many others become apparent too. I think the lesson is not to judge or dismiss what we don’t properly understand.

I think we have all probably suffered with some form of mental illness throughout our lives, and if we haven’t yet, we will do at some point. I am very confident that I have. I think it could almost be considered as common as the “common cold”. Yes, it has different severities and manifestations but that does not mean that recognising or acknowledging it as a genuine illness is any less important. It can take different forms: drug and alcohol abuse, social isolation, anxiety, and depression. And ultimately, if not dealt with, this can lead to lead in some cases to suicide,

something we desperately need to try and prevent. Our society is becoming ever-more pressured; there are so many difficulties that families face on a daily basis just to survive. And some are not lucky enough to have a home. This, coupled with increasing demands on a healthcare service and the people working in it, means that mental illness is not going to disappear; it is going to become much more prevalent. Many more people will have black dogs following them wherever they go.

People cannot deal with it alone; they need help. The recent work that I have been involved with in relation to tackling bullying and harassment in pathology is attempting to change a culture that has been ingrained in medicine for a long time (please see the RCPath website for details about this work and support). The attitude to mental illness is something that needs to change alongside this. Mental illness is not a sign of weakness, it does not make you less of a person, it does not mean that you cannot work in a particular position, it doesn’t mean that you can’t cope in a high-pressured environment; it means you are a human being suffering with a genuine illness for which you need treatment, whether that be rest, counselling, cognitive behavioural therapy, or pharmacological therapies, amongst many others. Whichever it is doesn’t make it any less genuine, as long as it helps you to get better.

Support is out there and doctors need to know where to find it. It could be as simple as talking to your friends or even your GP. All hospitals also have counselling services for staff, and taking advantage of mentoring schemes which are often available within departments maybe of help. There is also an NHS Practitioner Health Programme that is a self-referral system for doctors with mental illness or addiction problems. And the BMA provides counselling, drug, alcohol and addiction services. The Samaritans can always provide support for those in need, and can be of immense value at times where suicidal intentions are becoming more than just a thought process.

As pathologists, we are trained to look at our cases for the fine details and features that may indicate a disease process and help us to make a diagnosis for a patient. We can do this for our colleagues and friends, too; look out for the subtle signs that something may not be right, and make that important step of asking them “Are you ok?” This might be all that is needed to help them take the first step to face their illness and put a lead on the black dog.

A vase which dates to 400BC depicting Orestes undergoing a purification ceremony to remove the 'furies.' In the story, Orestes displays many of the

signs of depression


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HS healthcare has transformed looser, informal collegial networks of care into tighter, more managed “production units”. We have turned families into factories. What have we lost?

For more than 40 years I have worked as a frontline NHS doctor, mostly as a psychiatrist and GP. With other news watchers, I join the surges of angry moral revulsion when hearing of the latest exposure of gross neglect of care, or even darker cruelty.

Yet my outrage, sadly, is not shocked: I have long considered such events almost inevitable. For in our eagerness to exploit the efficiencies of industrialisation we have sacrificed the caring human heart of healthcare. We see “treatments”, but people become invisible. This is – at least sometimes – the price we pay when we create a culture that excessively objectifies and commodifies the complexly human.

I remember a different ethos. At the start of my work in the NHS – before our hermetic rhetoric of measurement, quantification, computer-coding, and managed goals and targets – I thought of my working milieu as a (mostly) good-humoured, well-functioning family. Complex tasks were shared across disciplines with welcoming courtesy and cooperation. Roles and experience were sensibly recognised and respected, but rarely rigidly enforced. Likewise inter-professional boundaries: we usually accurately understood others’ competence and responsibility and adjusted our activities and encounters accordingly. There was often considerable overlap of skills and practice: this would now be regarded as ‘untidy’ and inefficient, but actually was usually to everyone’s benefit – we could provide a more seamless service: it was easy to refer patients across to colleagues whose work and language we understood, and who were often personally known to us. Although one practitioner might be best suited to a particular task, others could expediently temporise and substitute themselves when necessary; like well-functioning families, where good-faith prevails, this would be guided by open dialogue – by sense and sensibility. The result? Patients rarely got lost within or between systems; personal attachment and knowledge guided a sense of continual care. Practitioners, too, enjoyed this broad conviviality. We can see these principles operating in well-functioning families: the healthy resilience both of the entire group, and its individual members, depends on an ever-changing mixture of structure and flexibility.

In human families there are essential jobs to be done; the ‘infrastructure’ for the security and welfare of all. But beyond that families exist to play, provide nourishment, pleasure and meaning for one another – and then create new life that transcends and may surprise them all. These life-affirmations all had their equivalents in my first two decades of NHS work. I felt part of a large “organic” network of care – colleagues then seemed like relatives of many kinds, who also ranged in familiarity, seniority, wisdom, and power. There were other subtle fruits from this family-like network of care: we knew and understood real families far better than we do now. I remember many helpful conversations with “family doctors”, helping us understand the struggles, yearnings and sorrows of the ailing within their patients’ families. Within this family-sensitive, vast, sprawling NHS “family” I had myriad and mostly good contacts with my healthcare “siblings”. I appreciated then – more now – that I was part of one of the best kinds of “Confederate Socialism”.

It was not to last. For the last two decades we have seen a progressive dismantling of this family ethos. Successive think-tanks, management consultants, specialist committees, and then briefed-politicians have adopted the mindset of the engineer, the industrialist and the market-economist.

Healthcare is now forged as a kind of Civic Engineering or, even, a project for Venture Capitalists. Some forms of healthcare submit well to these approaches: the elimination of Poliomyelitis and the spur to advanced pharmaceuticals are respective examples of clear successes. The treatment of certain well-defined physical illnesses – for example, the surgical remedy for the blocked coronary artery, or opaque eye lens – are now routine “products” of these approaches.

But we must beware of losing our balance, for our new managed healthcare culture is now evolving more like an insect colony than a human family; roles set rigid, repetitive, prescribed, and dictated. Skills become narrow and executed without either consciousness or view of the whole. Care is reduced to a complex system of interlocking, algorithmically proceduralised tasks: an Airfix kit of (non) human engagement.

In contrast, a healthy human family is like a garden: growth is facilitated, protected, tended – never coerced. Relationships are nourished and encouraged as ends in themselves, not for any external ‘product’ (though often this may be spawned). How different this is to

From Family to Factory: the dying ethos of personal healthcare– David Zigmond


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our insect-colony-like healthcare factories where all human conduct is mandated and managed by the group’s circuit-board. Relationships and communications are subsumed to a strict division of labour – rarely are they ends in themselves. Individual variation is likely to be perceived as subversion. The group’s totalitarian function commands all.

Clearly the ethos and activities of the family and the factory both have essential – yet very different – places in our complex lives. This extends to our healthcare. An important task needs to be discerned: the necessity for wise and flexible judgment as to how to balance these opposing principles in all our important human projects. Failures are common. For example, attempting to “manage” family life by uncompromising parental authority will not work for long; eventually myriad forms of unhappiness, subversion and defiance will obliquely countermand.

Yet, as we have seen, our factory-industrial approach has procured us massive benefits, otherwise unreachable. But, when overused, this approach can alienate, erode and destroy important human bonds and understanding. In healthcare we must be vigilant, for these conundrae and complexities demand our endless capacity for fresh and creative compromises.

Our factory-type healthcare will deal poorly with those many human ailments that need different kinds of personal engagement for their relief and transcendence. These require healing encounters that mobilise the sufferer’s internal resources for immunity, growth and repair. These are subtle and delicate activities and – importantly – cannot develop in a factory culture, whose structure and function both depend on rigidity (like a vehicle chassis). They can only emerge and thrive in a family-type milieu where structure and function and strength are linked to flexibility and elasticity (like a tyre). The general principle for healthcare is that while factory-type management may be best for conduction of less psychologically demanding tasks (“Science”), it is much less suited to socially and psychologically complex situations, where subtle, imaginative induction is required (“Art”).

We need these kinds of inductions for any successful attempt to understand personal experience and meaning. For these there are no adequate plans or maps – for while personal experience and distress may contain universal themes, they are always – in some ways – unique. The factory cannot recognise this and thus can only hinder us. Our ideas of faulty biomechanics are essential in many of our healthcare encounters but we will often need, also, other approaches of flexibility and imagination. We need

some understanding of this person’s life, experience, struggles and relationships: holism and semiotics – this is that as well as this. In this culture, the power and meaning of personal attachments will extend far beyond procedures. This is what happens in good families.

The price of short-circuiting all this is high: it is what we have now. I am told there is much academic, systematic research into such matters. In my realm – a veteran frontline doctor – what do I experience? I now inhabit a world much richer in precise, high-technology interventions and informatics, and much safer from evident rogue or incompetent practitioners. Yet it is a world more humanly impoverished: of human connection, knowledge, understanding, affection or enduring personal concern. I now attend many meetings with harassed, dead-eyed, fatigued, dispirited doctors. They say: “I do what I have to” and talk of earliest-date retirement – despite being better remunerated than ever before. Our meetings are pressure-cookers of abstracted management: Agendae, Goals and Targets, budgets, performance indicators, Care Pathways Exception Reporting – a new lexicon of depersonalised care. It is many years since I sat together with colleagues to better personally understand and develop our frequent and inevitably flawed, fragile and evanescent human work. The factory has driven out the family; I am frustrated and sorrowful. I still have some cohorts; displaced older members of a now-homeless family. We commiserate.

What of patients (“service users”!): what do I hear? Those most satisfied – I fear transiently – are those plucked with timely and efficient specialist intervention from cardiovascular or malignant catastrophe: the life-saving coronary artery stent or hemicolectomy. Well-managed factory-healthcare does well here; these beneficial matchings must be acknowledged and continued.

But I hear many more stories of another kind; of vulnerable, fearful people (all of us, sometimes?) feeling personally insignificant, unknown and unanchored in a large, complex, indecipherable system. There is a new kind of anomie in our healthcare; I hear it routinely from intelligent, conscientious, alert people – that they do not know the name of their GP (“the surgery is so big and busy: I see somebody different each time”). Likewise the elderly or mentally anguished (“No, I can’t remember the name of the clinic or the doctor, there are so many … they said they’ll send me another appointment. Yes, I’ll do what I’m told …”). From older patients I hear laments for the loss of smaller, friendlier practices and the hospital general physician who saw them through many travails (“Dr X and his staff knew me and my family; I didn’t have to explain … I felt understood and cared

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for …”). Wanting to continue my ethos of family doctor, I frequently extend my interest and the interview, to develop better personal understanding. Younger patients are surprised – positively and appreciatively (“No one before has shown the interest to speak with me like this”). As a family doctor this was easy; it is much more difficult as a “primary-care service provider”.

There will be many more sickening healthcare atrocities. These will usually occur within forests of managing regulations and procedures. In the shocked tumult, listen for the displacing, buttressing countercharge: “Inadequate resources”!

I do not usually believe this. The impoverishment is of another kind.

Healthcare is a humanity guided by science.

Further reading: notesBeing a busy single-handed practitioner I do not have time or facilities for systematic or quantitative research into the issues that so concern me. Others do, with my respectful gratitude.

My research remains qualitative, informal and vernacular: exploration is of people and situations known to me. For interested readers I have listed some relevant writings that explore some themes more fully. I attach

brief notes for descriptive guidance. All are available via my Home Page (http://www.marco-learningsystems.com/pages/david-zigmond/david- zigmond.htm).

• The Psychecology of Gladys Parlett. An elderly woman suffers unarticulated grief and loneliness. Written in 1988, the professional responses forewarn our over-schematised services.

• Five Executive Follies. A lengthier and more systematic dissection of factory-type thinking and management.

• Why Would Anyone Use An Unproven Therapy? The importance of the implicit and rarely-spoken in healthcare. The difficulties of researching these.

• Eric: Another Case of Hypertrophic Obstructive Management … What happens to vulnerable, inarticulate people in our complex system of industrialised specialisms?

• Edward: Shot in His Own Interest … The human connections throughout healthcare are often much richer, more complex and influential than we are encouraged to think.

Copyright © David Zigmond 2012

Artist’s view of the Dyke


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The death of the Tirpitz – Mike Kearney

When I lived in Tromsø, from our house at Elverhøy just below the top of the island, there was an unimpeded view of the south end of Håkøya, where Tirpitz was finally anchored. I looked out at this scene almost every day, weather permitting, for 30 years [1]. I can remember the unsightly heaps of rusting anti-submarine netting which surrounded the Tirpitz, at Åsland on Kvaløya, and just north of Håkøya. These were removed in 1997. I sometimes talked to our neighbour, Larsen, who lived in a small wooden hut just below our house. On 12 November 1944, he witnessed the death of the Tirpitz [2].

My wife, Rigmor, then three years old can remember being lifted up by her older brother, Erik, at the window of their hut at Workinnmarka on the west side of Tromsøya; they could see the newly arrived Tirpitz at her anchorage off Håkøya. Rigmor also remembers the Germans billeted on them at their small house in Tromsø. In 1962 she once met Tait, who led the attack on the Tirpitz. He stopped and gave her a lift when both were working at the NATO headquarters at Kolsås, near Oslo. Group Captain Tait DSO, DFC, retired in 1964.

The earthquake bomb was the invention of Barnes Wallis, of Dambusters fame. It was called the Tallboy and

was much larger and heavier than the bouncing bomb; it weighed 12,000 lbs, of which 5,000 was explosives, and was 21 feet long. It was aimed like a dart, and could penetrate earth 80 feet before exploding. A direct hit was unnecessary, as its powerful shockwaves passed more easily through earth or water, than through air.

The Tirpitz was no longer seaworthy, due to damage caused by repeated British attacks. Its guns could still inflict

1. The south tip of Håkøya, where Tirpitz was anchored

2. “Mission Accomplished”, showing the death of the Tirpitz, painted by Mark Postlethwaite


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considerable damage on Arctic convoys, even when it was a permanent floating coastal battery. Accordingly, Tirpitz left Kåfjord near Alta on 15 October 15 1944, at a speed of seven to ten knots, escorted by tugboats and destroyers. She anchored the next day at Håkøya. A Norwegian agent in Tromsø, Egil Lindberg, radioed the new position of the Tirpitz to London. The Tirpitz was

now 320 km closer to Britain and was just within range of bombers from airfields in Scotland.

Churchill had decided that Tirpitz had to be destroyed. Wing Commander James Brian “Willie” Tait led the final attack on the Tirpitz. The Lancaster bombers of 617 and 9 Squadrons of the Royal Air Force took off from airfields in Scotland on 12 November 1944. Weight was reduced by removal of armour plating and machine guns, and range was extended by the addition of extra fuel tanks. They were each armed with a single Tallboy bomb, but were virtually defenceless against air attack, as they only had rear gun turrets, and were not accompanied by fighter plane escorts. At the last moment recent intelligence informed them of a squadron of Messerschmitt Bf 109G fighter planes stationed at Bardufoss airfield, 45 miles and 10 minutes flight time from Tromsø, whose mission was to defend the Tirpitz.

Tait’s Lancaster crews realised that they were almost certainly flying to their deaths. Their rendezvous was at Torneträsk Lake in northern Sweden. The Lancasters then flew northwards. Tait spotted the Tirpitz, even though it was 20 miles away; it was a clear winter dawn, and he was struck by the peacefulness of the scene.

The 18 aircraft of 617 Squadron came in from the south east, led by Tait [2]. At 8.41am he dropped the first bomb from 16,000 feet and it was a direct hit on the Tirpitz. By 8.44, all 617’s Tallboys were gone. Then seconds later, the bombs from 9 Squadron’s 10 aircraft were falling into the inferno. Only three aircraft from 617 Squadron and one from 9 Squadron claimed direct hits on the Tirpitz. The speed of the bombs and the almost instant eruption of explosions made reports sketchy, and most speak of the aircrews seeing their Tallboys fall into the cauldron of smoke and fire; later reports confirm three direct hits.

The Tirpitz slowly capsized until only the red painted hull and the propellers were visible above the water line. Churchill’s beast had been slain. By then the attackers were on their way home.

From a hut on Håkøya, Gunvor Wibe heard the attack on the Tirpitz. On looking out she saw its upturned hull and could hear the cries from the sailors in the water.

On board were 1,700 men; about 640 sailors were rescued from the water and 971 were killed, drowned or suffocated, trapped inside the Tirpitz. Only 87 were rescued by cutting holes in the bottom of the hull. The town of Tromsø was undamaged by the precision bombing of the Lancasters, which suffered no losses.

The Messerschmitt Bf 109G fighters stationed at Bardufoss airfield were commanded by Major Heinrich Ehrler, one of the Luftwaffe’s most experienced pilots, with 199 kills. The reasons for the delayed take-off are both

3. The shell fired from the Tirpitz, Sjursnes

4. The inscription on the plinth bearing the shell, Sjursnes


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complex and obscure; communications and organisation were chaotic. Furthermore, their aircraft were parked at the wrong end of the runway and inexplicably a Junkers plane was given priority to land, over the fighters taking off. The clerk who noted the details of the Lancaster sightings wrote down the wrong coordinates, and logged the incursions at 125 miles to the north, over Hammerfest. When the fighters finally arrived it was too late. The sky was empty, and the Tirpitz had been sunk. The British bombers were on their way home to Scotland, and they had been incredibly lucky. Had the German fighters arrived a few minutes earlier, it would have been a very different story.

The delayed take-off of the fighters was the subject an official investigation. Major Ehrler was the scapegoat. He was court-martialled and sentenced to three years in prison. However, he was exonerated after serving only a month in prison. He died on 4 April 1945, in action over Schaarlippe, near Berlin. He had just shot down two American bombers; then he sent a message on the radio to a comrade. He is alleged to have said: “I’m out of ammunition, I’m ramming. See you in Valhalla.” He then rammed his aircraft into an American bomber and died.

In the autumn of 1967, an unexploded shell from the Tirpitz was found in a bog 800m from Sjursnes on the west side of Sørfjord, about 34 km from where the Tirpitz was anchored at Håkøya. After it was made safe, it was mounted on a concrete plinth at Sjursnes [3]. Also on the plinth is a figure showing the trajectory of the shell, and a photograph of the attack on the Tirpitz [4].

The Tromsø Defence Museum is 4.5 km south of Tromsdalen. It was built as a coastal artillery battery by the German navy in 1940. It houses a wealth of Tirpitz memorabilia and is well worth a visit.

In 1984, on the 40th Anniversary of the bombing, a memorial to the Tirpitz was dedicated. It consisted of a simple slab of steel armour-plating from the hull of the Tirpitz [5,6,7]. Rigmor and I recently re-visited Tromsø, and once again went to Håkøybotn to see the Tirpitz memorial. Flowers, now faded, had been left on the plinth; a small bush partly obscured one side of the memorial. It was sad to see that this small place of remembrance was apparently uncared for. Rigmor returned to the car, while I wandered down to the shore to photograph the craters left by the Tallboys. A lower crater, covered at high tide, was surrounded by seaweed [8]; the edges of a higher crater were covered by tall grasses and wild flowers [9]. The silence was only broken by the screaming of the gulls above me, the agitated piping of a pair of oystercatchers in front of me, and the call of an unseen curlew behind me. It was a very lovely place.

5. The Tirpitz memorial, Håkøya. The horizontal structure to the left of the memorial is part of a salvage platform,

but marks the position of the sunken Tirpitz

6. The front of the Tirpitz memorial

7. The inscription on the Tirpitz memorial


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AcknowledgmentI am grateful to artist Mark Postlethwaite, who painted “Mission Accomplished” and allowed its reproduction here (www.posart.com)

References• Kennedy L. Menace: The Life and Death of the Tirpitz,

Sphere, London. 1981. • Bishop P. Target Tirpitz: X-Craft, Agents and Dambusters

- The Epic Quest to Destroy Hitler’s Mightiest Warship. HarperCollins, London. 2012.

• Asmussen J, Åkra K. Tirpitz, Hitler’s last battleship. Midt-Troms Museum, 9329 Moen. 2015.

• Knowles D. Tirpitz. The Life and Death of Germany’s Last Great Battleship, Fonthill Media, UK. 2018.

8. The lower Tallboy crater

9. The upper Tallboy crater


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This document was published in July, 20 years after the first major work on the subject “To Err is Human” in America, and our NHS’s response “An Organisation with a Memory”. Those were breakthrough publications, bringing a much-needed and long-awaited focus onto a subject that should be central to all aspects of medicine.

There have been some impressive examples of success in improving safety but they have not been universal. The authors state: “The NHS does not yet know enough about how the interplay of normal human behaviour and systems determines patient safety. The mistaken belief persists that patient safety is about individual effort. People too often fear blame and close ranks, losing sight of the need to improve.”

This surprised me, so I read it again but they really do say “The mistaken belief persists that patient safety is about individual effort”.

I regard this as an unfortunate start to an important document, which led me to doubt the value of the rest of the material.

If they had said safety is not only about individual effort, the document would be more credible. While their statements are correct they are not sufficiently focused on safety. It would have been better to see this document as a description of professionalism that underpins safety and then to have an additional section about learning from errors as that area has not been addressed adequately.

I suspect that these comments are directed more toward NHS managers, and for those of us working in pathology departments who can claim well-documented success in several areas it would have been more useful to celebrate where success has been achieved. Vide infra. There is insufficient recognition of the need to report and to analyse near misses, which can be highly valuable in preventing harm. There is insufficient recognition of the barriers to safety; in this respect they should champion whistleblowers, valuing and supporting their efforts.

The value of the “An Organisation with a Memory” document from 2000AD was its clarity. It recognised and described how errors occur and stated that impartial investigation and making a point of learning from mistakes was the best way forward.

This approach has been demonstrated to be highly successful through the Serious Hazards of Transfusion (SHOT) initiative, which has halved transfusion-related deaths, as described in the autumn issue of ACP news 2018.

Given their statement about mistaken beliefs, what do they suggest now is the way forward? Working your way through the 84 pages you will find well-intentioned

statements; for example:“We are not here to curse the darkness, but to light the

candle that can guide us through that darkness to a safe and sane future.” (John F Kennedy, 1960). JFK’s quote describes our patient safety journey in the NHS, towards understanding and proactivity, from talking about harm to talking about safer systems that provide the right care, as intended, every time and learning from what works, not just what does not. It also speaks to the idea of doing that in a just culture where psychological safety means we will hear more, learn more and can act more to improve care.

Too often in healthcare we have sought to blame individuals, and individuals have not felt safe to admit errors and learn from them or act to prevent recurrence. The willingness to support the development of this strategy, however, has amply demonstrated people’s desire to make the NHS safer.

And this is how they intend to proceed – addressing these challenges will enable the NHS to achieve its safety vision; to continuously improve patient safety. To do this the NHS will build on two foundations: a patient safety culture and a patient safety system. Three strategic aims will support the development of both:

• improving understanding of safety by drawing intelligence from multiple sources of patient safety information (Insight)

• equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system (Involvement)

• designing and supporting programmes that deliver effective and sustainable change in the most important areas (Improvement).

It’s hard to avoid feeling that they have composed the document around presentational features such as the repetition of “I” in respect of insight, involvement and improvement at the expense of convincing content.

My suspicions were strengthened by a later paragraph:This strategy sits alongside the NHS Long Term

Plan (LTP) and the LTP Implementation Framework. Local system plans to deliver the LTP will include local elements of the strategy: opportunities to improve patient safety are greatest at the point of care. NHS England and NHS Improvement regional teams will support delivery.

This suggests a centralised bureaucracy at the expense of empowerment of those working at the coalface.

This is where the document is most disappointing; safety is everyone’s responsibility, it is part of the code

The NHS Patient Safety Strategy: safer culture, safer systems, safer patients


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of conduct of being a professional. We individually and collectively take responsibility for what we do irrespective of what some distant command centre may choose to do. We have seen too many examples of individuals being held to blame for mistakes where the root causes were beyond their control for us to believe that a distant regional team will do more than we can do for ourselves.

Giving the authors benefit of the doubt, they continue with their best intentions:

Our vision for patient safety Our vision is for the NHS to continuously improve patient safety. Safety is not an absolute concept and has neither a

single objective measure nor a defined end point. Rather, it responds to patient needs and system priorities. The gold standard for safety will continue to be refined by new research and innovations; providing definite benchmarks on a never ending mission.

While continuously improving means there is no ‘target’ to achieve, the impact of doing so can be estimated. Better incident reporting and response could save an extra 160 lives and £13.5 million (more details to be found in the appendix).

The following two boxes are direct quotes from the document:

Features of a patient safety culture The key ingredients for healthcare organisations that want to be safe are: staff who feel psychologically safe; valuing and respecting diversity; a compelling vision; good leadership at all levels; a sense of teamwork; openness and support for learning.

Psychological safety for staff To work at our best, adapting as the environment requires, we need to feel supported within a compassionate and inclusive environment. Psychological safety operates at the level of the group not the individual, with each individual knowing they will be treated fairly and compassionately by the group if things go wrong or they speak up to stop problems occurring. It means staff do not feel the need to behave defensively to protect themselves and instead opens the space in which they can learn.

DiversityTeam psychological safety is characterised by a climate of inclusivity, trust and respect, where people feel able to thrive as themselves. Valuing diversity plays a critical role. Recognising how beneficial difference, be it in age, gender, ethnicity, power or diversity of thought, is for team working, communication and performance, is vital. These differences stimulate learning and creativity if harnessed in the right way. Leading collectively through the team enhances the voice of even the least powerful roles and so enhances safety. Working in a deficit-based manner which can undermine, humiliate or at worst discriminate against those who are different, leads to fear and decreases team psychological safety and workplace learning. Valuing diversity plays a CRITICAL ROLE.

Compelling vision Before leadership can be practised well, there needs to be a vision of what we want to achieve. A good understanding of why we are doing something and where we want to get to pervades the successful system: the vision needs to be explicit, not reliant on assumption. Organisations that emphasise the importance of long-term thinking and strategy and have high aspirations for the teams within encourage pride and positivity in the workplace.

Leadership and teamwork Compassionate leadership creates psychological safety and encourages team members to pay attention to each other; to develop mutual understanding; to empathise and support each other. Such teams are also highly innovative. The way leadership is practised through the organisation is critical to its success, with clinical leadership being particularly important to safety. Furthermore, feeling part of a team protects individuals against the demands of the organisation they work for and if they have clarity about their role in the team, they are less likely to burn out and more likely to operate in a safe way.

Open to learning To develop a culture of learning, the system must focus on what needs to change rather than punitive actions. An organisation that identifies, contains and recovers from errors as quickly as possible will be alert to the possibilities of learning and continuous improvement.


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This is all true but it has all been said before and it would have been more useful to identify the barriers that prevent this vision and these principles from operating in everyday practice. Shortages of staff and frequent use of locums readily spring to mind.

They continue with what is becoming more like a gospel:

Kindness and civility At its core, a positive culture requires kindness and civility. The importance of individuals’ day-to-day behaviour in relation to safety is increasingly recognised. Civility is seen as nice, tame and safe, but when it is missing, we start to see its importance. Studies have shown that where people are rude and disrespectful, safety is compromised.

What can we do? If people are rude, we need to figure out why but not judge – understand their context. Most incivility arises from ignorance not malice. In many instances the person may not be aware their actions are hurtful. Most people are rude only rarely and when they are it is for a reason.

This also is true and those who have attended the ACP’s leadership events may have heard this and possibly worked through examples dealing with such issues.

Again I have to acknowledge that there is truth in what they say but it is what they are not saying that concerns me. The problems I have encountered have mostly been because of inadequate staffing and resources. I can handle rudeness but it matters not a jot whether you turn the other cheek or give like-for-like in a slanging competition unless it achieves a solution. We are aware why some people are rude – it may because they’re not up to the task or that for many who enjoy the exercise of power, being forceful can be seen as a legitimate strategy to get rid of a doctor who requests more resources merely for improved safety.

It is a simple truth that managers rate themselves as successful by driving through big projects such as mergers or through demonstrating success in financial management. I have sat on management boards where the executives listen attentively to the financial matters – easy to understand – the Trust is either in the red or in the black. When safety is discussed it is usually brief and unless the Trust is an extreme outlier in mortality stats, the discussion moves swiftly on. To change this embedded culture will need time and a radical change in how we choose our top managers and Non Exec Directors, who set the tone for hospital policy and culture.

In my experience, managers, finance directors and execs are busy defending their positions and do not want to hear requests for more resources. They will gain more plaudits by staying within budgetary limits than investing in safety unless we can demonstrate that best practice = safe practice = efficient practice. One of the most powerful pieces of evidence we can use is a benchmarking study demonstrating that we are under resourced, but this appears to be out of fashion. Hopefully, like all fashions, it will come round again and the sooner the better.

We need to improve handling of safety concerns so that managers do not employ shoot the messenger tactics to discourage criticism. In August, millions of people were affected by a power cut because of failings in the National Grid, it is refreshing to hear one of their execs comment that they could make the grid more reliable, but it would cost more to run. One can generalise this principle across many industries; in health, acknowledging the problem and investing in best practice would both improve safety and improve efficiency.

Instead of mentioning rudeness as a problem it would have been more useful to advise on how best to go about making changes. Senior managers will always have people bringing them problems so you’re more likely to get changes made if you present them with a solution. In respect of safety, that means presenting the benefits first and then stating how the costs will be covered. Taking a whole organisation, or if possible whole health economy, approach and demonstrating for example that an extra BMS on overnight will mean a better service – speeding up diagnoses and treatment of emergencies will make the hospital more productive and therefore more prosperous. This will sound more positive than a simple request for an extra person in the Department.

One interesting idea they could have imported from the business world was mentioned to me by a friend who works for IBM. If an employee raises a concern and is unhappy with the manager’s response, he or she has the right to bring it to higher management for a second opinion. This is regarded as a useful way to ensure that ideas are considered on merit, and makes the managers evaluate suggestions from subordinates carefully rather than dismissing them as a means of maintaining their power base. Maybe this is part of the culture change the NHS would like to bring in?

They have a special section for primary care, pointing out that it is the first point of contact for most patients, with the highest volume of work with 307 million patients seen last year.

Pathology has two specific mentions in respect of anticoagulant management and management of


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antimicrobial resistance, and is mentioned indirectly in respect of the medical examiner scheme.

In respect of forthcoming changes, there will be a Healthcare Safety Investigation Branch (HSIB) and patients will be involved, as shown in the diagram of potential roles of patient safety partners. They state:

The HSIB provides expert and impartial insight into systemic safety risks. These risks encompass system-wide factors that can contribute to serious failures of care, such as ambiguous regulatory requirements or inappropriate commissioning. Through professional safety investigations, we make evidence-based recommendations to enable change for safety improvement and learning, helping to counter the blame culture which exists in parts of NHS organisations and healthcare professions.

Safety, they state, is a priority for the CQC and they mention priority areas within the document –

unfortunately so often that almost everything is a priority – but they have not listed them in priority order. One area I would regard as priority is investigation of deaths aka medical examiner.

The medical examiner system This, they report, will be a transformative part of the NHS safety system, giving the bereaved a voice, while ensuring that the period after death is as problem free as possible. Several important inquiries have recommended this system be established. Critically the system will knit together the good work already underway as part of Learning from Deaths. They have several aims for the system:

• provide a better service for the bereaved and an opportunity for them to raise concerns about care with a doctor not involved in that care

• enhance patient safety by ensuring that all deaths are scrutinised by an independent medical examiner so that any issues with the quality of care can be identified and acted on

• ensure the appropriate direction of deaths to the coroner

While this will initially be a non-statutory system, it will be established in statute and the Department of Health and Social Care (DHSC), its sponsor department, will take the necessary legislation through parliament in due course. England will have seven regional medical examiners to help implement the new system by providing direct support and supervision to medical examiners working in the system and ensuring they have links to regional teams.

In 2019/20, Acute Trusts in England are being asked to establish medical examiner offices to scrutinise the deaths occurring in their Trust. Over the course of 2020/21, the service will be expanded to encompass all deaths, including those occurring in the community and in independent providers. Each medical examiner office team will:

• agree the proposed cause of death with the qualified attending practitioner to ensure the death certificate is accurate

• for non-coroner cases, discuss the cause of death with the next of kin and establish if they have any concerns with the care provided

• act as a source of medical advice to the local coroner and facilitate notification of deaths to them appropriately.

Fig 1 Summary of the NHS Patient Safety Strategy

Fig 2 Potential roles of patient safety partners


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At a local level, medical examiner offices will inform the selection of cases for mortality review and support other clinical governance processes, helping to identify where greater scrutiny may be needed or where systemic patient safety issues warrant an organisation-wide or broader response.

SummaryIn summary they have made a statement and they have specified what they want to happen and what the new system will be. The business of changing culture, which is what they want to see, is different from setting up a new system. It involves engaging with the hearts and minds of everyone involved and good intentions are only one part of what is required.

I remain concerned that they have not used one of the best examples of success in improving safety, i.e. the experience of SHOT in blood transfusion. The lesson from SHOT, which can easily be generalised, was:

1. report incidents2. investigate thoroughly with a fair blame philosophy3. share the learning experience through professional

networks and publications4. when necessary revise guidelines5. monitor performance

One other important aspect of error management is to deal with the problem itself and all those affected by it, i.e. make good the harm done and ensure all patients and staff have the reassurance of knowing that lessons have been learned. I have been involved in investigating complaints in many situations, including being a professional adviser to the Ombudsman, and I have been very impressed at how forgiving most patients and their

relatives will be knowing that their concerns have been taken seriously, and that they have not suffered in vain. The most telling response from patients is along the lines of: “Compensation? No, I just want to know that it will not happen to anyone else.”

On reflection it may be that they consider the previous documents too authoritarian in style but I would have preferred more emphasis on individual responsibility. To ensure everyone is doing the right thing the right way on the right patient or sample. If necessary evoking the image of Lord Kitchener with the slogan “Who is responsible for safety?” with the obvious answer, YOU are!

With these qualifications I wish the project well; I hope the leaders will make an effort to learn from the good work done by the SHOT initiative, which continues to make real progress in all the complex areas of safety systems and human behaviour necessary for success.

I look forward to an update when new systems have bedded in.

A day out at the Dyke


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“The Fugldal – the bird valley – a cul-de-sac where it looks as if anyone venturing must be in constant danger of a cannonade of ice from the fringe of gigantic glaciers which enclose it everywhere except at its narrow entrance. How delightful it is to look back upon our crossing of Fugldalskar! Surely there is no more romantic a glacier pass in the whole of Norway! See those huge black ice-capped precipices of Jæggevarre. See below them that large secondary glacier. See, too, how far its snout projects into the dark waters of Fugldalsvand, and tell me if you can where this scene has a rival.”

WC Slingsby, 1899

The traverse from Fornesdalen to Fugldalen via Fugldalsskar is one of the finest ski tours in Norway, and passes through spectacular mountain scenery. It is 18km long and rises to 1120m at Fugldalsskar (Fig. 1). It was first done by Slingsby and Hastings on 29 July 1898; they left Jøvik and ascended the Fornes glacier. They crossed Fugldalsskar and descended into Fugldalen. After reaching the shore of Sørfjord they returned along

the coast to Jøvik. They did not use skis. (Fig. 1,2)Fugldalen rises steeply from the shore of Sørfjord, where

the river flows in a gorge with broad level banks, making it easy to ski up. In summer it is better to walk along the south edge of the gorge, where there are magnificent views of the valley, with the summit of Jiehkkevárri in the distance. The valley floor soon flattens out to a broad open sunny landscape.

The lower and upper valleys are separated by a 200m cliff with a waterfall, which is easily climbed on the north side. The upper valley is narrow and dominated by the great north face of Jiehkevárri. The icy waters of Fugldalvatn lie 1500m below the summit of Jiehkevárri, making this one of the tallest cliff-faces in Europe. The sense of being in a great open air cathedral is overpowering. Some say that the upper valley is a gloomy and sunless place; this is not so if you are here in the early morning or late afternoon, when Jiehkkevárri does not block the sun. The Fugldal glacier is well seen from the summit of Jiehkevárri (1834m), and the mountains of north Lyngen are seen through the gap of Fugldalsskar (Fig. 1).

A ski traverse from Fugldalen to Fornes via Fugldalsskar – Mike Kearney

1. Fugledalsbre, and Fugledalsskardet from Jiehkevárri


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Børre and I once did this traverse in May, starting at Fugldalen (Fig. 2), and finishing at Fornes on the southern shore of Kjosenfjord. In lower Fugldalen it was spring, with only a few remaining patches of winter snow. It was now light all day, and there was no danger of being benighted. By 7am we lay stretched out on the boilerplates above the Fugldal waterfall enjoying a second breakfast. I have been here several times, sometimes alone, sometimes with friends, and in all seasons. The feeling is always the same. I am lost in wonder at the great cliffs of Jiehkevárri above me, with their rock pillars, cornices, tottering seracs, and hanging glaciers.

It was windless and the sun beat down on us. We waxed up and set off across the frozen lake, with only the gentle hiss of our skis on the snow breaking the silence (Fig. 3). We climbed the gully to the east of the ice fall (Fig. 4); this is crevassed near the top and care should be taken here. A safer but less spectacular route is found on the western side of the ice fall. We began to climb the gentle slopes of the Fugldal glacier. As we climbed higher the view opened out, with magnificent views of the north face of Jiehkevárri

(Fig. 5). On reaching Fugldalsskar (Fig. 6), we took off our anoraks and stopped for lunch before entering the snow basin. This is a large rounded depression in the snow with a 20m high vertical ice face on the south side, and is easily by-passed to the west. The V-shaped pass of Fugldalsskar is very narrow, so that if you are on skis only one person can pass at a time. I checked that my camera was around my neck before descending, and to my horror it was not there; I must have left it behind when we stopped for lunch. It took only half an hour to go back and get it while Børre waited for me, but I dread to think of the consequences if I hadn’t noticed.

We crossed onto the Fornes glacier and began to ski down. Far below us, in the distance, we could see our final destination of Fornes on the southern shore of Kjosenfjord. Suddenly my Kandahar ski binding broke, and I had no spare one with me – I was in big trouble. Fortunately Børre had a spare boot-lace with him, and we replaced the broken binding with this. The makeshift binding broke each time I made a turn, and each time we repaired it, the boot lace got shorter but held until the

2. Fugldal in early May, with Jiehkevárri in the distance, and Skarveknausen to the right

3. Børre skiing across Fugldalsvatn, with summit of Jiehkevárri above

4. Børre and the ice-fall of Fugledalsbreen 5. North face of Jiehkevárri from Fugldalsbreen, spring


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glacier ended.It was late evening when we reached the ice fall, which

ended at a 300m cliff (Fig. 7). We took our skis off and descended the steep snow slope to the east of the ice fall and reached the valley floor. Here we put on our skis again (Fig. 8). We were very tired after skiing down the 3km long Fornes glacier. To our delight the river was frozen, consisting of a thick layer of ice, and covered by a little powder snow. We glided for the next 4km, as if in a dream, using only our arms and ski poles. Alas the ice became thinner and the boulders more frequent, forcing us to take off our skis. We stumbled down to the coast at Fornes, tired but very happy.

Finally, a few words of advice that might come in

useful sometime: never forget your camera, and always carry a spare ski binding!

I think that it is a mistake to think that you can conquer mountains; you may reach the summit, and you may get to know them and yourself better, but in the end they will always conquer you.

References1. Hastings G. New expeditions in 1898. Northern Norway, Lyngen district. Alpine Journal 1899, 19, 356-363.2. Slingsby W. C. Mountaineering in Arctic Norway. Alpine Journal 1899, 19, 414-437.3. Turkart 2781 Lyngenhalvøya Sør. Scale 1/ 50 000. Nordeca ISBN 7046660027813

6.Claus at Fugldalsskaret 7. Fornes and Kjosenfjord from the ice-fall of Fornesbreen

8. The icefall of Fornesbreen from the Fornes River


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In the developed world we are well aware that treating cancer can be very expensive. In low income countries there are many serious problems regarding access even to the most basic aspects of medical care, so organising cancer prevention care poses great problems.

Browsing through health-related stories on the net I came across two uplifting articles of how people are rising to these challenges. The source of these articles was the Twitter feed of NPR, an independent, non-profit media organisation that was founded on a mission to create a more informed public. They report that every day, NPR connects with millions of Americans on the air, online, and in person to explore the news, ideas, and what it means to be human. Through its network of member stations, NPR makes local stories national, national stories local, and global stories personal.

The following two reports are from the “Goats and Soda” pages of their website, subtitled “Stories of life in a changing world”.

The first is an extract from a report is by Matthea Roemer, graduate student at the Johns Hopkins Bloomberg School of Public Health. She recently spent six months in Burkina Faso as a university-funded global health fellow to conduct family planning research. She was working with JHPIEGO, an international non-profit health organisation affiliated with Johns Hopkins University. The group was founded in 1973 and initially called the Johns Hopkins Program for International Education in Gynaecology and Obstetrics, but is now referred to simply as Jhpiego.

A crowd is waiting for a cervical cancer clinic on wheelsLow and middle-income countries like Burkina Faso bear 70% of the global burden of cervical cancer. In sub-Saharan Africa, 34.8 new cases of cervical cancer are diagnosed per 100,000 women annually, and 22.5 per 100,000 women die from the disease. These figures compare with 6.6 and 2.5 per 100,000 women, respectively, in North America.

Medical professionals in Burkina Faso say the highest death rates occur in regions like Pabré – outlying areas where the nearest health centre may be more than 15 miles away.

Even if there is a local health centre, it often does not have the resources or providers trained in performing cervical cancer screening and treatment. These women typically do not have the time or money to travel to the capital where screening and treatment is offered at the major hospitals.

Dr. Jean Lankoande, a professor of gynaecology/

Cancer care in low income countries – Matthea Roemer

Burkina Faso

Women wait outside a maternal health facility in Pabre, Burkina Faso, to be screened for cervical

cancer in this minibus. The vehicle is outfitted with a metal exam table and a nitrous oxide gas tank.


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obstetrics at the University of Ouagadougou, started Stop Cancer du Col de l’uterus au Burkina (SCCB) in 2012. It is funded by private donors.

The SCCB team’s efforts to serve remote areas in Burkina Faso are a “critical first step to build trust and deliver community outreach to women who need it the most,” says the executive director of the Global Coalition Against Cervical Cancer, who is not affiliated with SCCB. “The next phase is how do we get [HPV testing] available to all women, no matter where they live.”

How to bring cancer care to the world’s poorest children – Patrick AdamsIt is one of the great achievements of modern medicine: with advances in treatment, cure rates for children with cancer in North America now exceed 80%, up from 10% in the 1960s. Yet for kids across the developing world, the fruits of that progress remain largely out of reach. In low and middle-income countries, restrictive access to affordable treatment, a shortage of cancer specialists, and late diagnosis dooms more than 80% of paediatric patients to die of the same illnesses.

That’s one measure of what’s known as the “global cancer divide” – the vast and growing gap in access to quality cancer care between wealthy and poorer countries, and the suffering and death that occurs disproportionately in the latter.

Nowhere is that divide more pronounced than among children, and it’s driven in large part, experts say, by perceptions of paediatric cancer care as too costly and too complicated to deliver in low-resource settings. Those assumptions, they say, prevent policymakers from even considering paediatric oncology when setting national health priorities.

But one hospital in Rwanda is rewriting that narrative.Built and operated by the Ministry of Health and the Boston-based charity Partners In Health, the Butaro Cancer Centre of Excellence is unique in the region: a state-of-the-art medical facility providing the rural poor with access to comprehensive cancer care. And a new study shows that Butaro’s paediatric cancer patients can be cared for, and cured, at a fraction of the cost in high-income countries.

“There’s this myth that treating cancer is expensive,” says Christian Rusangwa, a Rwandan physician with Partners In Health who worked on the study. “And that’s because the data is almost all from high-income countries.”

Published in 2018 in the Journal of Global Oncology, the study showed that for patients at Butaro with nephroblastoma and Hodgkin lymphoma, two common

childhood cancers, a full course of treatment, follow-up and social support runs as little as $1,490 and $1,140, respectively.

Much of the savings, the authors report, come from the low cost of labour, which for the entire cancer centre amounted to less than the average annual salary for one oncologist in the United States. They also cite strong partnerships with Harvard and the Dana-Farber Cancer Institute, whose Boston-based specialists volunteer their expertise on difficult patient cases via weekly video conferences with Butaro’s general practitioners.

“Most people don’t think about childhood cancer in terms of return on investment,” says Nickhill Bhakta, a paediatric oncologist with St. Jude Children’s Research Hospital in Memphis, which has put in place similar partnerships with institutions in Singapore and China. “But there’s a growing body of literature showing that, for governments, treatment is surprisingly cost-effective.”

Bhakta says some of the most compelling evidence for the cost-effectiveness of care in poor countries comes from Uganda, where in March, researchers reported remarkably low costs of treating Burkitt’s lymphoma (BL). The most common childhood cancer in sub-Saharan Africa, BL is rapidly fatal, often within weeks. Yet when treated promptly, intensively and with supportive care, more than 90% of children survive the disease.

Worldwide, childhood cancers are relatively rare. But as Bhakta and colleagues reported in February in The Lancet Oncology, they’re a far bigger problem than previously believed. Close to half of all children with cancer go undiagnosed and untreated, they found, suggesting that the already low survival for these cancers in low and

Rwanda


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middle-income countries “is probably even lower”.A new study from July, also published in The Lancet

Oncology, provides another way of looking at the global burden of childhood cancer. Using a measurement called disability-adjusted life years (DALYs), researchers found that childhood cancer results in the annual loss of an estimated 11.5 million healthy life years, mostly in low and middle-income countries. This compares with around 37 million years of healthy life lost due to malaria and 7.6 million from tuberculosis globally. Lisa Force, a paediatric oncologist with St. Jude who led the study, says DALYs allow policymakers to better compare diseases and prioritise them.

“The naysayers will say, ‘we don’t have paediatric oncologists in Africa, how would we possibly address this problem?’” says Felicia Knaul, a professor of public health at the University of Miami. “And that’s why partnership models, like those supported by Dana Farber and St. Jude, are so important – they’ve shown that you can bridge that gap and have a tremendous impact.”

In 2009, Knaul, then director of the Harvard Global Equity Initiative, led a push to expand cancer care across the developing world, where a growing burden of disease had garnered little attention globally. “We challenge the public health community’s assumption that cancers will remain untreated in poor countries,” she and colleagues wrote in a 2010 “call to action” published in The Lancet, noting “similarly unfounded arguments” against the provision of HIV treatment.

In the early 2000s, more than 20 million people were living with HIV in sub-Saharan Africa, yet fewer than 50,000 had access to antiretroviral therapy. Though the life-saving drugs were, by then, widely available in the US, sceptics warned that treatment in Africa wouldn’t be cost-effective. Prevention, they asserted, was the only feasible way forward. “The two most important interventions are monogamy and abstinence,” Andrew Natsios, then head of the US Agency for International Development, told reporters in 2001. “The best thing to do is behave yourself.”

Two decades later, echoes of that attitude reverberate in the global cancer divide; even as cancer rates continue to climb across the developing world, low and middle-income countries account for just 5% of global spending on the disease. Still, recent years have seen important gains.

In 2017, the World Health Assembly, the World Health Organization’s decision-making body, adopted a resolution on cancer that for the first time urged its member states to address childhood cancers. And in 2018, St. Jude and the WHO launched the Global Initiative on Childhood Cancer, a five-year, $15 million partnership aimed at ensuring that all children with cancer can access high-quality medicines. Their goal: to cure at least 60% of children with the six most common types of cancer by 2030.

“Here in the US, it was the suffering of children with acute leukaemia that drove Sidney Farber to develop our first real chemotherapy drug,” said Meg O’Brien, vice president for global cancer treatment at the American Cancer Society. “I don’t think Dr Farber or any of the tens of thousands of oncologists, nurses or scientists who have worked in cancer research or treatment in the years since would be content to see that what we consider one of our greatest triumphs in the battle against cancer has yet to reach children in low and middle-income countries.”

Patrick Adams is a freelance journalist based in Atlanta, GA. Find him on Twitter at @jpatadams, reproduced with permission.

CreditsNPR. “Goats and Soda”, Wikipedia

The full article by Matthea Roemer is available at:https://www.npr.org/sections/goatsandsoda/2018/02/04/577690494/a-crowd-is-waiting-for-a-cervical-cancer-clinic-on-wheels?t=1565428424303 Excerpt reproduced with permission.


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“Somewhere in between” was the title of an exhibition at the Wellcome Collection. It included an extensive collection of artwork exploring changing attitudes to HIV, entitled Alien Sex Club. It reflects a new optimism and the difficult subject of sexual risk taking, and was created by John Walter and Alison Rogers, a specialist doctor and researcher in HIV.

John Walter is an artist, curator and writer. He achieved his doctorate in the Department of Architecture and the Built Environment at the University of Westminster. His work considers complex and uncomfortable subjects, including sexual health, drawing audiences in through an exuberant use of colour, humour and hospitality.

The exhibition was vibrant and spectacular. Although many of the references were beyond my ken, the exhibition made an important contribution to understanding the spread of HIV, as John Walter explained: “During the early AIDS crisis of the 1980s and 1990s, many public sex environments (often including cruise mazes) were closed by law. More recently, cruising for sex has moved online with apps such as Grindr, Scruff and Hornet gaining in popularity. However, many men still want to

meet in person and anonymously for sex, despite the risks involved. Rates of HIV are going up in the UK among gay men with around 3,500 new cases of the infection diagnosed in this group every year. Anti-retroviral therapy (ART) helps HIV-positive patients stay healthy with near normal life expectancy but the long-term physical effects of ART are still unknown, and its long-term cost is of increasing concern. It is estimated that ART costs around £500,000 per person for a lifetime of treatment.”

He describes one show he did earlier: “I have cultivated a position as playing the jester as a strategy for luring people in so that I can address uncomfortable subjects such as HIV. ‘Turn My Oyster Up’, the installation I made for this year’s Whitstable Biennale, was a good example of this; I hosted a gin and cake bar that became the stage for video and performance that enabled a conversation about slang and sexual risk. Some visitors came for the food and drink only, but others stuck around and got involved more deeply, some of them by accident, but this was a generous way of engaging them in the themes I want to discuss.”

He continues: “In contextualising my paintings I’ve

Art and Science? Or Somewhere in between? – Eric Watts & John Walter


Articles

made complicated installations that involve sculpture, song, video and collaboration.

“I was trying to make bigger environments for my work to live in and give them a place in the world. I started to use architectural devices to organise different things and ‘Alien Sex Club’ (‘ASC’) grew out of that. It was based on my experience of going to places of cruising in London and thinking, ‘What is this spatially? How does this exist?’

“I researched ‘ASC’ as a PhD within a faculty of architecture, which may seem counter-intuitive, but actually it was a great way of investigating all of the spatial properties of the spaces of cruising. That became a way of unlocking HIV and all of the subject matters that it contained.”

Entering the maze“ASC is a maze based on this idea of a sex club, sauna or gay bathhouse. The idea of a cruise maze is an emblem

more than a reality. There’s something aphrodisiacal about the idea of a maze, because it’s a space you can get lost in. ASC is a space where you can meet lots of different strangers in safety. When you’re in the installation, you are bombarded on all fronts – it’s playful, it’s not scary, it’s not dark. Everything is quite shonky, and by shonky I mean visually awkward.”

This presentation is to act as a translator of specialist knowledge and terms, e.g. viral load and pill burden, and ultimately for the visitor to emerge with a new vocabulary for talking about HIV. For me it was a fascinating glimpse into a different world, with some brilliant, sometimes mysterious artwork. More information can be found at [email protected].

Credits John Walter was the creator, and Wellcome Collection is the source.


Book Review

Did he save lives? A Surgeon’s Story

David Sellu

A harrowing account of the investigation of a post-operative death, made all the worse because it is true, and it has to be told.

It is a troubling indictment of British justice, an institution many of us believe to be the best in the world, but this case shows clearly how fallible it can be and it chronicles the harm done to innocent people.

David Sellu’s career would have been a remarkable story itself without the encounter with British justice. From the most unpretentious beginnings he rose to become a highly successful surgeon, valued and admired by patients and colleagues alike. His beginnings could hardly have been humbler; born in Sierra Leone, his birth was not even registered. When it was clear that he was a very bright young boy and was found a place at school, they had to guess how old he was and created a date of birth for him.

He studied under the most difficult of circumstances, having to read in the evenings and nights under a streetlamp, as electricity was expensive. Through natural ability and hard work, he won a place at Manchester University medical school and, following standard British postgraduate training, became a consultant in Ealing Hospital in West London.

One standard busy day he was asked to see a patient with abdominal pain in the nearby BMI-run hospital. He describes how he assessed the patient, gave management instructions, including nil by mouth, antibiotics, and a CT scan. He returned to see the patient had a perforated colon and later discovered that the instructions he had given were not carried out. Owing to the lack of an anaesthetic rota and a theatre dedicated for emergencies, there were delays in performing the operation beyond Sellu’s control.

Despite the standard operation for the perforation and full treatment in ITU, the patient died.

Post-operative deaths are reported to the coroner and an inquest duly followed. Death following colonic perforation is not unusual, but the inquest was. The normal order of events was changed so that Sellu was questioned earlier in proceedings and rather than following the standard procedure of establishing a chronological sequence of events, the coroner asked a rapid-fire string of questions, making it hard to give a full answer to each of them. Sellu was then asked to leave the inquest and, with no explanation, it was announced that there was to be a criminal investigation.

The questioning by the police was forceful, relentless

and prolonged. This was not a case of someone being considered innocent until proven guilty. It had all the hallmarks of interrogators doing their best to catch out a witness through repeated questioning in order to demonstrate some inconsistency, which could then be used against them.

The court case again shows that British justice has much room for improvement. The prosecution used expert witnesses to describe an ideal situation, although this actual case was far from ideal, and the judge gave directions, which the jury could not understand. In fact, the jury was so confused that they came back to ask the judge for help but he did not help them.

The result was that Sellu was found guilty of gross negligence manslaughter and sent to Belmarsh, one of the toughest prisons in the land. His account of his prison stay, moving from Belmarsh to eventually being in an open prison, is a clear and well-documented account of what could only have been a truly dreadful experience.

This book describes what I previously thought was unthinkable: that a doctor dealing with the far from


Book Review

perfect realities of medical life should be judged against standards described by witnesses who had taken no account of the actual circumstances.

Colleagues and patients who knew David Sellu and who were astonished by the verdict rushed to give support, an appeal was eventually lodged, and the verdict overturned. Every aspect of this case was also forensically examined by the Medical Practitioners Tribunal Service over a six-week period in 2018, and he was totally exonerated.

However, he and his family have suffered, justice has not been done, and the bereaved family of the patient have not been helped.

It is still hard to believe that this has happened and that an innocent man has been put through such an ordeal without even an apology, let alone any compensation.

The book describes what happened, but unfortunately it cannot explain why. The natural question is, how was this allowed to happen and what steps will the authorities take to ensure that more innocent people, only doing their jobs with no malice or intention to harm patients, are not convicted through failures in our legal system?

If a patient suffers harm in healthcare, there is, rightly, investigation and a number of measures may be taken to deal with the workers involved and to protect future patients. Doctors are not above the law. If an innocent person is wrongly convicted, what do the authorities do to address the failings by members of the legal team?

Has the coroner or the judge been asked to explain their actions? Those who hold us to account should themselves be accountable.

Sellu has the comfort of knowing that the Royal College of Surgeons, the expert body best placed to comment, has finally supported him, welcoming the news that the judges found him to have been wrongly convicted.

More important is that he should not have been convicted in the first place. The medical and legal professions have become concerned that criminal law places too much emphasis on blaming one and only one person for events that often have numerous contributory causes. Change is coming and the new role of the Medical Examiner should help to establish a better system.

Currently Sellu works part time in the UK and this is primarily to help keep his name on the medical register, to enable him to continue doing voluntary medical work in Sierra Leone. The authorities there require that all practitioners working in the country are registered with their base medical regulators.

A follow-up book is being prepared by one of the doctors, Dr Jenny Vaughan, who helped organise the successful appeal.

In the meantime, this book details the extraordinary story, which shows a real need to improve the investigation and management of post-operative deaths.

What helps to make this book even more remarkable is the generous and selfless way in which Sellu is now working on improving safety, such as the meeting at Northwick Park on 18 September where he addresses the need for a more comprehensive approach and a fair blame culture.

Eric Watts 7/8/19

Do you report liver biopsies?

Are you a trainee interested in liver pathology, or preparing for FRCPath?

The UK Liver Pathology Group (UKLPG) was formed in 2016 with the purpose:

To promote excellence in liver histopathology services in the UK and Ireland, across all levels of specialisation, through professional collaboration in education, quality assurance and research.

We provide an annual programme of CPD meetings, including:

Annual Liver Pathology Update meeting: 7 November 2019, Cambridge

This will be the 14th annual update meeting for pathologists in tertiary centres and general pathologists with an interest in liver pathology. It includes discussion of the EQA cases, for which a concise MCQ format is also provided to maximise educational value for non-EQA member.

Liver biopsy in the assessment of medical liver disease & histopathology workshop on liver pathology: 5 and 6 March 2020, Royal College of Pathologists, London

The first day of the course on 5 March is in its 10th year, and provides a practical diagnostic approach to reporting medical liver biopsies, focusing on the importance of clinico-pathological correlation in assessing common patterns of liver damage. Recommended for senior trainees in pathology and hepatology and consultant histopathologists and gastroenterologists who are regularly involved in liver biopsy assessment (without necessarily working in a Liver unit).

The histopathology workshop on 6 March is a digital slide-based workshop for histopathology trainees and consultants, with pre-view of cases followed by presentations. It covers medical liver biopsies and liver tumour pathology. Delegates can attend either or both of these days. Registration is via the RCPath website. In addition, our group participates in the liver pathology sessions in national meetings including: the BSG, BASL, BTLG, BDIAP, Pathological Society, to ensure coverage of liver CPD in their meetings.

..............................................................................................................................................

Our website has a wealth of CPD PowerPoints and lectures from previous meetings, digital slides with diagnoses, FRCPath (Parts 1 and 2) exam-based questions, and discussion from past EQA circulations.

Our core membership comprises the members of the UK Liver Histopathology EQA Scheme. We also have trainee, associate and overseas members.

For details of these meetings, and how to join the UKLPG, please see our website: http://www.virtualpathology.leeds.ac.uk/eqa/specialist/liver/index.php

The current pub sign


Do you report liver biopsies?

Are you a trainee interested in liver pathology, or preparing for FRCPath?

The UK Liver Pathology Group (UKLPG) was formed in 2016 with the purpose:

To promote excellence in liver histopathology services in the UK and Ireland, across all levels of specialisation, through professional collaboration in education, quality assurance and research.

We provide an annual programme of CPD meetings, including:

Annual Liver Pathology Update meeting: 7 November 2019, Cambridge

This will be the 14th annual update meeting for pathologists in tertiary centres and general pathologists with an interest in liver pathology. It includes discussion of the EQA cases, for which a concise MCQ format is also provided to maximise educational value for non-EQA member.

Liver biopsy in the assessment of medical liver disease & histopathology workshop on liver pathology: 5 and 6 March 2020, Royal College of Pathologists, London

The first day of the course on 5 March is in its 10th year, and provides a practical diagnostic approach to reporting medical liver biopsies, focusing on the importance of clinico-pathological correlation in assessing common patterns of liver damage. Recommended for senior trainees in pathology and hepatology and consultant histopathologists and gastroenterologists who are regularly involved in liver biopsy assessment (without necessarily working in a Liver unit).

The histopathology workshop on 6 March is a digital slide-based workshop for histopathology trainees and consultants, with pre-view of cases followed by presentations. It covers medical liver biopsies and liver tumour pathology. Delegates can attend either or both of these days. Registration is via the RCPath website. In addition, our group participates in the liver pathology sessions in national meetings including: the BSG, BASL, BTLG, BDIAP, Pathological Society, to ensure coverage of liver CPD in their meetings.

..............................................................................................................................................

Our website has a wealth of CPD PowerPoints and lectures from previous meetings, digital slides with diagnoses, FRCPath (Parts 1 and 2) exam-based questions, and discussion from past EQA circulations.

Our core membership comprises the members of the UK Liver Histopathology EQA Scheme. We also have trainee, associate and overseas members.

For details of these meetings, and how to join the UKLPG, please see our website: http://www.virtualpathology.leeds.ac.uk/eqa/specialist/liver/index.php

Documents

The Association of Clinical Pathologists Autumn 2019 ACP news · P20 CESR in histopathology: demystifying the Process – Dr Hebah Ali, Dr Vasi Sundaresan, Joanne Brinklow, Bill West