The Association of Clinical Pathologists Spring 2020 ACP news
101 years of viral epidemics Peterborough ACP Leadership Skills Course Audit of venous invasion in colonic cancer It’s the Arts! Association of Clinical Calendar of Forthcoming Meetings & Courses Pathologists DIARY DATES FOR 2020/21 Officers
President Date Title Venue Contact Details Dr C Gray
Past President Friday 6 Introduction to TBC 01273 775700 Dr W Simpson November 2020 Leadership & [email protected] Management www.pathologists.org.uk Chairman of Council Dr J L Burton Monday 9 Autopsy Update Day Royal Society of 01273 775700 November 2020 Chemistry [email protected] Secretary www.pathologists.org.uk Dr K Skordilis
Treasurer Spring Advanced Chilworth Manor 01273 775700 Prof P Twomey 2021 Leadership & Southampton [email protected] Management Course www.pathologists.org.uk Editor Dr E Watts
Assistant Editors Dr M Clarke Dr G Watson Dr T Bracey The ACP accepts no liability for errors or omissions in this calendar of meetings. Dr S Elcombe 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 Education Secretary Dr A Pugh instance. There will be a £25 administration fee per issue for entries in this table.
Management Course Organiser Dr B Wilkins
The Association of Clinical Pathologists 189 Dyke Road Hove, East Sussex, BN3 1TL Tel: 01273 775700 Fax: 01273 773303 email: [email protected] http://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]
ACP Journalism in Pathology Prize and ACP Grants and Awards for 2020. ©acpnews 2020 all rights reserved. Full details will be in the summer edition and on the website. 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 ACP news Spring 2020
Contents
P4 Invitation to contributors P5 Editorial
ARTICLES P7 ACP History – the old Boys and Girls – Eric Watts P8 ACP NLSM Peterborough November 2019 Introduction – Eric Watts P8 Challenges for delivering and developing pathology services in today’s NHS – Branko Perunovic P11 Main themes of the day – Bridget Wilkins P15 Am I a leader, manager or both? – Bridget Wilkins P16 GIRFT How Pathology Services are Commissioned - what do commissioners need from us – Dr Marion Wood P18 Leadership roles within the NHS Hospital Trusts: how is the voice of the pathologist heard – Dr Kanchan Rege P21 Pathology Networks – David Wells P25 Reflections on Clinical Leadership and Management in Pathology and Beyond – Dr Suzy Lishman P27 101 years of viral epidemics – Eric Watts P33 It’s the Arts – Carl Gray P39 The patient’s role in improving quality in immunology services – Eric Watts and Suzanne Elcombe P42 Haiku – Dr Almas Dawood P43 The role of high-fidelity simulation in BLS training – Manisha Ahuja P45 Specialist BMS reporting qualification in dermatopathology – Dr Katherine Syred P48 Audit - Comparison of venous invasion in colorectal cancer audits – Jocelyn Aldridge, Izabela Geotgiades, Elizabeth Walsh, Seemeen Umar, Matthew Toy P52 Case Report: Acardiac twinning and the TRAP sequence – Mike Kearney P53 Some memories of Rob Lindsey – Mike Kearney P54 A summer ascent of Imbodentind – Mike Kearney P57 ACP Travel fund – Harry Haynes P59 Thoracic Pathology NYC – Dr Alison Finall P62 Where are they now: Student Grant awardees P63 Humphrey Kay – Gerry Slavin and John Lilleyman
LEADERSHIP P65 Read to Lead – Getting to yes – Bridget Wilkins
BOOK REVIEW P69 Book review – That Good Night by Sunita Puri
ADDENDUM P70 Newspaper Headlines March 2020
ACP news - Spring 2020 3 Cover Picture
Emergency hospital during influenza epidemic, Camp Funston, Kansas. National Museum of Health and Medicine. Description: Beds with patients in an emergency hospital in Camp Funston, Kansas, in the midst of the influenza epidemic. Date: circa 1918 Photo ID: NCP 1603 Source Collection: OHA 250: New Contributed Photographs Collection, Otis Historical Archives, National Museum of Health and Medicine. Rights: No known restrictions upon publication, physical copy retained by the National Museum of Health and Medicine.
Invitation to Contributors
In addition to the constant flow of material from ACP Council, Trainees: Trainees are especially encouraged to submit ACP committees and ACP branches, ACP news needs new material in any and all of the above categories. These will material from you, the members of the ACP. normally be placed in the trainees’ section. Appointments committees in particular value publications in ACP news. Pathology news items (1200-1500 words): Any items related to the ACP or the College, pathologists in general, or Editorial Policy: The editor would particularly encourage medical and management matters that may have an impact on overseas contributors, material from trainees, material from pathologists. non-histopathologists, commentary on current affairs in pathology, occasional columnists, innovations in pathology, Articles (1500-2000 words): These can be papers, reviews, humorous writing on pathology-related topics, and anything essays, commentaries, critiques or polemics. Submitted articles downright cantankerous. are always very welcome, as well as suggestions for articles and/ or details of people whom the editor may approach. Format: The ACP news style guide is now available on line via the ACP website in PDF format at: http://www. Reports (1000 words): These may be personal views and pathologists.org.uk/allpagestuff/publications_frameset2.htm. reports on interesting meetings, travel or anything else of The publication is a magazine, not an academic journal, and interest to the readership. Travel reports are specifically for long lists of references are generally considered unnecessary. holders of ACP travel fellowships; however, other reports from Where given, references should be in the Vancouver style and abroad are welcomed. should be kept to a maximum of around six per article, unless absolutely necessary. Alternatively, authors may prefer to give Columns (600 words): Regular and irregular columnists a recommended reading list, or a list of relevant internet links. exercise their thoughts. Please feel free to rant. The editor prefers these as they take up less space.
Pathological creative writing: All literary forms, including All suggestions are welcome; however, the editor’s decision short stories, serials, surrealism and even poetry. is final.
Appreciations (1000-1500 words): We prefer appreciations ACP news is published quarterly. Regular publication dates are: on retirement, rather than obituaries. Please discuss these with the editor before submission. Issue Publication month Copy date SPRING February 5 December Photo-journalism: Favoured subjects include pathologists SUMMER May 5 March doing something interesting, or College and ACP officers AUTUMN August 5 June doing anything at all. Interesting or artistic photographs are WINTER November 5 September welcomed. Copy is best submitted by email, in any version of Microsoft Cartoons: Suggestions are welcomed. Word, although it should be possible to accommodate other formats. Submissions on paper by snail mail will also be Curettings: Jokes and humorous titbits are always needed. accepted. Illustrations should be sent as JPEG digital images or hard copy prints. Please do not embed images in your text. Debate: Letters to the editor are welcomed, but may be Send them as separate files. shortened for publication, or even converted into articles. Please try to refrain from writing unless you are prepared to be Please send email submissions direct to the editor at published. All criticisms of organisations or named individuals [email protected] will entitle the parties to a right of reply. Please bear in mind the UK libel laws!
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.
4 ACP news - Spring 2020 Editorial
Something old, something new, something borrowed, something about flu; this is what the spring issue contains. I had planned for the cover to have a beautiful picture of cherry blossom but most of the news in the last few weeks has been less cheerful. The coronavirus story began as an interesting development affecting a few people in a far-off land, but by mid-March it had become a national obsession. Whilst a scholarly article would be ideal, the simple fact is that our virologists and experts are far too busy dealing with the urgent issues of the day to be able to contribute at present. People in the UK have been given conflicting advice, with the tide turning from containing the epidemic to flattening the curve in the hope of developing herd immunity. Not everyone agrees, and a WHO spokesperson openly questioned whether we know enough about Your editor Covid-19 to be able to predict if herd immunity will occur, pointing out that each epidemic is different, and it in Sheffield, then bundled off to the association office for is simply too early to tell. distribution. We now have a bigger magazine with high What I have found from various sources is that quality glossy paper, content, as ever, depends on what epidemics do tend to bring out divisions in opinion, not contributors send to the editor, ever grateful for anything only amongst doctors but clearly amongst politicians as that touches on pathology or pathologists. well. Within two weeks of stating that a miracle will save Thanks as always to the many contributors; please us, Donald Trump has announced a state of emergency. consider writing something yourselves, unless of course Without wishing to present this issue as a significant you wish to know more about my various holidays! I find contribution to medical history, it is my best attempt to disproportionately more comments on the curettings than describe the situation as it rapidly unfolds as I have stated the more serious articles. I include some contributions at the time of writing the major piece of ‘101 years of that have been sent in, some of them from mysterious viral epidemics’ and the ‘addendum’ shortly afterwards. and anonymous sources on the web, all part of the rich That piece is the something new; one piece that is tapestry of modern life. something old, and also something borrowed, is a piece To return to the rapidly evolving maelstrom of news from the Journal of Clinical Pathology celebrating the about the advancing epidemic, it is hard to know what life of a great haematologist, Humphrey Kay, written by tone to set. Ancient wisdom is to hope for the best and two of our more distinguished members. This is because prepare for the worst, with the cynic’s edition ‘to expect this April is the 60th birthday of the British Society of nothing’. Haematology, and Humphrey was a founder member; he Always an optimist and hopefully a realistic one, I is remembered not only for his academic brilliance but leave you with the spring edition in the hope that there for his creative abilities, celebrated in this issue with the will be enough of us left to read and write the summer haematologist’s Song. issue. More old and borrowed material can be found in ‘ACP Unless otherwise stated, all opinions in this issue are history’; I have always enjoyed the collegial friendliness my own and do not necessarily represent the views of of ACP meetings and it is clear that the old boys and girls other members of Council; a brief summary of the March made an art form of it. council meeting will be in the summer issue. Gathering the information for this item, I learned that As always, comments and opinion are welcome. the ACP news began as a typed A5 pamphlet edited by George Pennington, a clinical scientist in Sheffield and Eric Watts then by John Lilleyman, printed by a small local company Email: [email protected]
ACP news - Spring 2020 5 Editorial
NEXT ISSUE Travel, they say, broadens the mind and on this occasion we travelled a long way to a very different culture for maximal mind broadening.
Here are two iconic images from the distant land, no prizes for guessing where and more photos to follow.
Can you guess where this is? There will be plenty of information and travel tips in the summer issue.
www.pathologists.org.uk ISSN No. 0260-065X
6 ACP news - Spring 2020 Articles
ACP History – the old Boys and Girls – Eric Watts
The main picture shows, from left to right, Gerry Slavin, Peter Lachmann, Sylvia Lachmann, Diana Winfield, David Winfield, Brenda Slaving, Pat Jarrett, John Jarrett, Joyce Graham, David Graham, Pat Lauder, Ian Lauder, Rosalind Timperley, Jill Ames (with Jess the dog), Tony Ames, Jenny Palmer, Patricia Lilleyman and Kel Palmer. Photograph taken by Walter Timperley.
One of the fine institutions, or possibly more of a satellite and moors. The old group came together from the four activity, of the ACP has been the walking club set up by corners of the United Kingdom and even from Florida, Walter Timperley, neuropathologist at Sheffield, and John USA and soon re-established the camaraderie that (later Sir John) Lilleyman, also from Sheffield. walking groups do so well. The Pathological Ramblers (PRs) appeared to be a Perhaps strangely for doctors who wish to leave the precursor unit, which had a fluctuating membership in worries of work behind them, they had arranged a guide to addition to John and Walter including at various times, show them around the village of Eyam, otherwise known Gerry Slavin, Peter Lachmann, David Winfield, Peter as the Plague Village. Apparently, the disease reached Wyld, Ian Lauder, Kel Palmer, David Graham and Rhona rural Derbyshire in a roll of ‘suiting’ i.e. cloth from Stewart. London. This parcel contained the fleas that caused the Benefiting from having the Peak District a few miles plague. The tailor was dead within one week of receiving from the city centre, they were spoiled for choice it. The guide explained how, despite the considerable of good walks and they shared their enjoyment of the efforts of the Minister to isolate people, more than 300 open countryside, fresh air (whatever the weather), succumbed. They learned few of the victims were buried and companionship with other members, leading to in the churchyard as it had been a case of bury your own the formation of the Old Boys and Girls club, first in any convenient spot. described by George Pennington in the ACP news No doubt they felt fortunate that the plague was more summer issue 1999. than 300 years ago and were able to set off to enjoy the He described their first outing, possibly tacked onto rest of the day when the heavens opened. Fortunately, a council meeting in nearby Sheffield, which had taken the area is well supplied with pubs and hotels and they place in April, the month well known for its showers were able to find shelter. The rest of the account of the which can be particularly drenching on exposed peaks weekend describes a good time being had by all. John
ACP news - Spring 2020 7 Articles
Lilleyman, then the ACP President, gave an after-dinner talk on ‘The ACP, the College and all that Gas’; the report states that John desperately tried to avoid speaking to the chosen title of his talk. The entertainment continued with the ‘inevitable rendition of Albert and the Lion’ by John Middleton. It really does sound like a lot of good fun; I haven’t heard Albert and the Lion for years. For those unfamiliar with this well-worn poem, it comes from the great era of the music hall of more than a century ago describing how an adventurous young lad, Albert Ramsbottom, teases The couple are Walter, who is normally behind the a lion in a menagerie with predictable results and camera, with Rosalind Timperley displaying one of hilarious aftermath. her paintings. Old editions of ACP news chronicle more good times up and down the country, with excellent walking terrain by Keith Shinton. If any member wants more details, I and variable weather, but always good accommodation can email them the scans of the relevant pages. Walter evening entertainment. Timperley also took numerous photos ,which can be Many thanks to Rachel at head office for searching shared through Dropbox or, if there is sufficient interest, through the back copies for these items, which also be put on the ACP website. include the visit to Totnes and the Cotswolds, described ACP NLSM Peterborough, November 2019 – Eric Watts
A lively meeting with plenty of enthusiasm, many where possible, or from other sources when developing fascinating facts, useful discussions and words of a theme from discussions held around our table over wisdom. Rather than present a blow-by-blow account of tea or coffee etc. I tried to take the occasional discreet what each speaker said in detail, I have opted to give my photograph without making too much of a nuisance impression with illustrations from actual presentations of myself!
Challenges for delivering and developing pathology services in today’s NHS
- a personal story, Branko Perunovic, Consultant Histopathologist; Clinical Director of Laboratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust
The title describes the challenges in the UK today, but Branko’s brief historical introduction shows that he was well prepared to deal with change and conflict. In 1989 he worked in a lab in Slovenia and lived through the fall of communism, the war leading to criminals in control, and hyperinflation in January 1994 of 313 billion percent. Coming to the UK must have been a welcome relief from Branko Perunovic these troubles.
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organisational form with risk and gain management agreements • Allocation of resources to develop and implement transformation programme
His next challenge was to transform the service in South Yorkshire and adjoining Derbyshire, which he undertook in three stages but first he illustrated his commitment to the task stating:
“There is no adverse situation in life from which you cannot recover.” He gave examples from the business world, such as the This was done through a three-stage program famous quote from Michael Dell, computer entrepreneur on the future of Apple Inc after Steve Jobs left: “I would Pathology 1.0 shut it down and give the money back to the shareholders”, • Transactional perhaps not the best approach. On his return Steve Jobs’ • Not responsive, passive response was, “If you want to make Apple great again, • Fragmented let’s get going. If not, get the hell out”. Apple’s funeral • Unwarranted clinical, operational and financial was officially cancelled … the rest is history. variation He gave many examples of good leadership characteristics, e.g. courage and selflessness, and Pathology 2.0 responsibility to the team. • Consolidation Branko’s key message was: • Economy of scale • Address unwarranted variation “In my opinion….. • Still transactional, discipline and cost-centre Two main ingredients are trust and loyalty, confined Everything else you can learn how to do or buy These you have to earn..” Pathology 3.0 • Provider of choice The new network is officially North Mid 1 with a • Employer of choice starting budget of £49m and projected savings of £6m. • Investment of choice He introduced this as his hobbyhorse • Delivers solutions Key features of the Transformation Plan were: • Good service and good medicine
• A common procurement strategy and He concluded with key guiding principle; here’s a implementation of a single managed service selection: contract (MSC) • A common digital strategy, including a unified Quality Laboratory Information Management System and • Have patients at heart of all services, with equity of Digital Pathology Platform access for all patients • Estates strategy • Be the provider of choice to the NHS and non-NHS • End-to-end logistics users within and beyond SYB ICS by developing • Creation of most appropriate organisational form and safeguarding a unified, comprehensive, for SYB Pathology clinically-led, user-centred, top-quality service, • Agreement of a financial model for the responsive to the needs of users and patients and
ACP news - Spring 2020 9 Articles
• Empower patients to self-manage long term conditions in partnership
Science and technology • To remain future-proof and remain open for new scientific and technological developments which can add value to clinical operations and improve job satisfaction • Organisation wide laboratory IT system • Use IT, business intelligence and data analytics to highest standards of professionalism enhance clinical pathways • Provide seven-day services relevant to user and • Ensure that all patient results, including POCT, are patient requirements available to all clinicians across primary and sec- • Safeguard all compliance and accreditation ondary care within SYB ICS and beyond standards • Proactively develop and introduce innovative IT • Develop a culture of continuous improvement of and data analytical solutions across all specialisms quality and performance at all levels of service to enable more effective patient management and support new models of care Workforce • Be the employer of choice providing exciting Research opportunities for all staff • Develop research opportunities with constituent • Positively and proactively involve all members organisations of SYB ICS, universities and AHSN of our service in the transformation process and • Develop innovative methodologies where appro- empower and support individuals and teams priate committed to the goals to make the change happen • Support staff to become active participants in • Develop all tiers of our workforce to be R&D professionally competent, productive, cost- • Bid and collaborate in the local, regional and na- effective, flexible and compatible with future tional research initiatives, programmes, projects developments and needs of the service. Ensure and trials where appropriate ‘right job right grade’ at all levels • Remain represented in relevant professional bod- • Remain active in undergraduate and postgraduate ies and organisations to increase our profile and education positive influence and facilitate collection and transfer of information, ideas and skills Innovation • To remain receptive and enhance our adaptability Value for money to the changes in the healthcare system and society, • Make best use of taxpayers money and the ability to accelerate implementation of • Deliver NHSI-assigned savings target and proac- relevant national strategic initiatives and provide tively support financial effectiveness of SYB ICS. proactive and dedicated support for transformation • Deliver procurement efficiencies from economies of the healthcare sector within SYB ICS of scale and single MES contract • Safeguard the agile service model that proactively • Develop service to safeguard the existing, and leverages cutting-edge clinical and scientific establish new, commercial ventures within the approach, technology and methodology to healthcare, R&D and in-vitro diagnostic markets optimise and integrate laboratory diagnostics into in SYB, nationwide and internationally new care models and develop innovative patient pathways to add value to clinical operations across These were only some of the highlights! At the time of his the organisational boundaries and boundaries talk our future membership of the EU was still undecided, of care and he threw in a final joke: • Develop pre-analytical, scientific and clinical Eosin’s red processes with emphasis on quality, innovation, Haematoxilin’s blue productivity, flexibility, and compatibility with the That’s all we’ll have future developments When we leave EU
10 ACP news - Spring 2020 Articles
This was another excellent presentation, and more information on the project can be accessed through this link: www.healthandcaretogethersyb.co.uk/what-we-do/ working-together-network/local-pathology-services
70 years plus – the NHS and the NHS Constitution A great start to the day and what a challenge – to cover all that this involves, seven decades of history and the constitution, too. Fortunately, there are many learning aids to help with respect to the history, in addition to the Structure-of-the-new-nhs-animation many tomes that have been written; modern technology allows condensed histories in the form of animations and second two are pledges. There was interesting discussion the King’s fund has helpfully provided many of these about the entitlement to suitable food in the case of a such as: vegan prescribed a low fibre diet. Among the responsibilities of patients was • How does the NHS work? responsibility for taking their medicines as prescribed, • An alternative guide to the new NHS in England including finishing the whole course. • How is the NHS structured? There’s plenty more to read in the Constitution document itself, available on the internet; the net also has plenty about the fact that the Constitution gives you rights to timely treatment, and the fact that waiting time targets are routinely missed so there are now waiting lists even to get an appointment. Pledges to staff are mostly described in contracts, including work to support staff to enable them to maintain a healthy lifestyle. Then, for the long-term plan, the effect on pathology includes early cancer diagnosis, and the plan aspires to world-class care. Are we getting world-class care now? There was some discussion on this. Whilst we are all aware that the NHS Bridget Wilkins explains the NHS could do better, it is well worth making international comparisons. The World Health Organization did this in They are packed with useful information and make a 2000 but the report is no longer available. I think Monaco welcome change to plodding through the paper versions. came top, with France second, and the Americans were The constitution itself is a remarkably easy read; very upset that they came 37th, well after most of Europe revised in 2015, it contains 15 pages of large well-spaced and Japan. From memory, UK was middling amongst the type and unlike many constitutions is very simple and European countries. straightforward. It states public, patient and staff rights Directly after the report there was a huge debate about and responsibilities, and includes some pledges. the methodology used, and WHO has been more cautious This gave the opportunity for the first fun quiz of the in its comments since then, pointing out that the health of day – whether certain items are rights or pledges. Try the nation depends upon a multitude of factors, including these for yourself. prosperity. They now state a well-functioning healthcare system requires a steady financing mechanism, a properly A Right or a Pledge? trained and adequately paid workforce, well-maintained • Access to treatment approved by NICE facilities, and access to reliable information to base • Access to treatment in the EU decisions on, and have not published another league table. • Entitled to suitable food Perhaps the best known international comparison is a • Access to screening regular update by the Commonwealth Fund, a private US • Access to correspondence about you foundation whose stated purpose is to “promote a high performing healthcare system that achieves better access, Perhaps surprisingly the first three are rights and the improved quality, and greater efficiency, particularly for
ACP news - Spring 2020 11 Articles society’s most vulnerable and the elderly”. They regularly of different metrics, all subject to selection bias; the UK publish league tables and other infographics, the best consistently scores well but not well enough, especially known being the overall ranking, decided through analysis in the category “Long, Healthy, Productive Lives”.
Exhibit ES-1. Overall Ranking Country Rankings
Top 2*
Middle
Bottom 2* AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US
OVERALL RANKING (2013) 4 10 9 5 5 7 7 3 2 1 11
Quality Care 2 9 8 7 5 4 11 10 3 1 5
Effective Care 4 7 9 6 5 2 11 10 8 1 3
Safe Care 3 10 2 6 7 9 11 5 4 1 7
Coordinated Care 4 8 9 10 5 2 7 11 3 1 6 Patient-Centered 5 8 10 7 3 6 11 9 2 1 4 Care
Access 8 9 11 2 4 7 6 4 2 1 9 Cost-Related 9 5 10 4 8 6 3 1 7 1 11 Problem
Timeliness of Care 6 11 10 4 2 7 8 9 1 3 5
Efficiency 4 10 8 9 7 3 4 2 6 1 11
Equity 5 9 7 4 8 10 6 1 2 2 11 Long, Healthy, Productive Lives 4 8 1 7 5 9 6 2 3 10 11 Health Expenditures/Capita, $3,800 2011** $4,522 $4,118 $4,495 $5,099 $3,182 $5,669 $3,925 $5,643 $3,405 $8,508 Note: * Includes ties. ** Expenditures shown in $US PPP (purchasing power parity). Australian $ data from 2010. Source: Calculated by the Commonwealth Fund based on 2011 International Health Policy Survey of Sicker Adults; 2012 International Health Policy Survey of Primary Care Physicians; 2013 International Health Policy Survey; Commonwealth Fund National Scorecard 2011; World Health Organization; and Organization for Economic Cooperation and Development, OECD Health Data, 2013 (Paris: OECD, November 2013).
Having dealt with the broader issues of the NHS for doing the right thing. the moment, we moved on to leadership in general and Why is leadership so important to pathology now? specifically as applied to pathology. – good leadership is essential to support one of the unquestionable constants in life – change. And change is Key and fundamental qualities of leaders – first there accelerating rapidly now; whilst the NHS is hierarchical was the collage of photos of leaders, including the easily with well-defined power structures, it has not always been recognisable, the popular and unpopular, and some less good at supporting change. well-known deserving of mention if they personified In pathology we are particularly vulnerable as we are particular qualities, such as selflessness and giving credit too easily seen as being a support service, and as such, to others. vulnerable to efficiency savings. To avoid damaging Question: what do they all have in common? – most change being imposed from the top by people who don’t essential for being a good leader is to be a Decent Human understand pathology, it is essential to be able to respond Being; perhaps we would not see all the characters in the quickly to the challenges that are continuously coming picture in that light, but each of them would certainly at us. think that they were, and that they were doing good and Change can be very stressful and occupational
12 ACP news - Spring 2020 Articles psychologists in Britain talk expansively about this, • A = Ambiguity: the haziness of reality, the poten- typically following the seminal work of Kubler Ross, tial for misreads, and the mixed meanings of con- illustrated simply as: ditions; cause-and-effect confusion, sometimes But you only need to Google ‘Kubler Ross change referred to as ‘brain fog’! curve’ to get many more complex versions, along with helpful annotations about what strategy to apply should These elements present the context in which you wish to follow their advice. organisations view their current and future state. They present boundaries for planning and policy management. The Kübler-Ross Change Curve They come together in ways that either confound decisions or sharpen the capacity to look ahead, plan Shock & Denial ahead, and move ahead. VUCA sets the stage for managing and leading. Anger Energy Acceptance The particular meaning and relevance of VUCA often Bargaining relates to how people view the conditions under which they make decisions, plan forward, manage risks, foster
Depression change, and solve problems. In general, the premises of VUCA tend to shape an organisation’s capacity to: Integration of Change For example, reading from left to right along the curve, 1. Anticipate the issues that shape create alignment, maximise communication, spark 2. Understand the consequences of issues and actions motivation, develop capacity, share knowledge. So much 3. Appreciate the interdependence of variables for management theory for practical pathologists … there 4. Prepare for alternative realities and challenges are specific challenges to consider, e.g. how would you 5. Interpret and address relevant opportunities change your department? Or how engaged are the people in your hospital or department? For most contemporary organisations – business, the At the NHS Futures website and Collaboration military, education, government and others – VUCA is a Platform, you can view examples to help to develop practical code for awareness and readiness. Beyond the effective network for change and influencing skills. simple acronym is a body of knowledge that deals with learning models for VUCA preparedness, anticipation, VUCA: Volatility, Uncertainty, Complexity, evolution and intervention. Ambiguity – the new managerial acronym Then suitably prepared, we discussed the topic we all The U.S. Army War College introduced the concept understood – hierarchies. We recognise them and many of VUCA to describe the more volatile, uncertain, of us are comfortable in them, but we then learned of complex, and ambiguous multilateral world perceived as their problems and limitations. Hierarchies are not the resulting from the end of the Cold War and pertaining best way to get the best out of human effort and are to healthcare now. The deeper meaning of each element usually too rigid. Where they exist people generally find serves to enhance the strategic significance of VUCA a way of working around them, i.e. forming an informal foresight and insight, as well as the behaviour of groups network. and individuals in organisations. It discusses systemic A good department needs to be fluid, flexible and failures and behavioural failures, which are characteristic adaptable to get to the right person at the right time. Hub of organisational failure. and spokes arrangements don’t function as networks, despite the name NHS Improvement has chosen for these • V = Volatility: the nature and dynamics of change, new arrangements. and the nature and speed of change forces and We had another good interactive session with most change catalysts. people contributing and offering suggestions of the • U = Uncertainty: the lack of predictability, the qualities required of a good leader. One of my neighbours prospects for surprise, and the sense of awareness at the table was most concerned that they had too much and understanding of issues and events. work to do and shouted out a good leader should be • C = Complexity: the multiplex of forces, the con- able to delegate. However, the word on the flipchart founding of issues, no cause-and-effect chain, and was the need to be dedicated, i.e. required a little more confusion that surrounds organisations. commitment than the status quo, rather than a lightening
ACP news - Spring 2020 13 Articles of the load. The field of management theory is rich with fascinating terms and concepts, and we had a flavour of some of them. For example, the classification of problems. Bridget introduced us to the work of Keith Grint who has a page on the Leadership Centre website about critical, tame, and wicked problems, matching them with elegant and messy solutions. It states: Grint, drawing on the ideas of Cultural Theory, suggests that solutions to problems can only be designed through understanding the values, identities and beliefs of the people involved. This is difficult because different people hold different beliefs depending on which ‘cultural group’ they belong to. Different groups have A slightly different twist on this theme comes from the different views and values that need to be considered and different cultural groups approach to global warming, included in solutions. This means that solutions should where the groups values determine their approach, be combine every voice, meaning solutions are going to they individualists, egalitarian, hierarchical, or fatalists. be ‘messy’. There was much food for thought, and hard on the The most effective management is achieved by tailoring heels of the expansive theories came a series of focused the appropriate strategy, i.e. a manager can be coercive or examples presented by Branko, who reminded us of rational for simpler problems but with more complex ones his experience in the former Yugoslavia, quipping that a deeper understanding of the emotions that compound the smell of gunpowder is a good way to make people the complexity is required as illustrated:– pay attention.
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Am I a leader, manager or both? – Bridget Wilkins
A lively session with lots of group work; in reality we are all a mixture of different types and have to perform a variety of different roles. Understanding the different personality types may help, but this is a controversial area to discussed further in a future item on Psychometric Testing – contributions welcome. To be a good pathologist one certainly needs to be analytical; to be a good communicator one needs to express oneself well, so we need to have a range of abilities to develop as a leader or manager. Do you need to be one or the other? Can you be neither leader nor manager, but make a difference? Yes, you can be a good follower and provide ideas – be creative, be intelligent, but still as a follower you can be a leader-in-waiting and a change-agent and have fun, whilst being spared the onerous weight of responsibility.
Encouraging change agents
Although it was not discussed in detail on this occasion, there is also the need to consider conflict, particularly when a member of the partners does not wish to be a follower, i.e. disagrees with the leader or their policies. in each position, and the second is a more subjective This was mentioned in a session of an earlier meeting; summary of what we want to experience from others we the leader needs to listen to and acknowledge their critics. work with in various roles – the insiders’ view(s). The most effective criticism is constructive and includes This was a very productive session, with many different suggestions for improvement. ideas presented for discussion and a good level of This session concentrated on identifying desirable agreement when it came to the final task of recording our qualities in the different roles of leader, manager, and ideas on the charts. worker. Having made our points in the discussions around our tables, we then recorded them on the flip charts. The first flipchart shows the general characteristics Picture credit Helen Bevan NHS Horizons School of we associate (objectively/from the outside) with ‘good’ Change Agents
ACP news - Spring 2020 15 Articles GIRFT: How pathology services are commissioned – what do commissioners need from us? (Including an update on progress with the GIRFT Pathology programme) – Dr Marion Wood
Dr Marion Wood, GIRFT Pathology co-lead; She encouraged pathologists to be bolder, stating retired Consultant Haematologist, East our training is extensive and unique; we should not Suffolk and North Essex NHS Foundation Trust; undervalue it. recent past-Chair of ACP Specifically • Do give advice on the value of individual tests GIRFT - • Guidance for further investigations – the possible value of more specialised tests • Getting it right first time: • Insist on right quality but at the right time Improve quality of care within NHS, by reducing unwarranted variation • The role of internal/external QC and QA National programme, (NHS Improvement) supported by Royal colleges Identify variation; understand the reasons; share best practice • Advise a full evaluation of new techniques, discuss the data • 2013 - Orthopaedics (Prof Tim Briggs) Now extended to >40 clinical specialties Pilots in Out-patients / General practice / Mental health The GIRFT story began with an orthopaedic surgeon, Tim Briggs, who shone a spotlight on variation, identifying •
Marion introduced commissioning by explaining that DEFINITION OF A PATHOLOGY SERVICE the word comes from the Latin meaning, ‘entrust’, and described the commissioning process in a different Increasing willingness to see Pathology as an end to end service. The service does not start and end at the situation. She had been involved in arranging for an doors of the lab artwork in Colchester Hospital as a gesture of thanks to Brain to Brain, encompassing organ donors; something to say thank you and celebrate • The choice of the correct test • Timeliness of collection and transport the benefits of the generosity of donors and their families. • End to end IT A challenging concept for an artist, they started off with • Effective analysis (QA and TAT) • Interpretation and advice a general approach to what the picture should look like, • Delivery of the result then refined it over many stages or iterations, with the details becoming more specific at each stage. 6 Commissioning in health business does not start with a blank sheet of paper and is usually based on historical outliers and, through encouraging them to review why activity in cost, then adding 1 or 2% per year, usually they are so different from the mean, bringing changes to adding to the activity and reducing funding. improve the standards and efficiency of care. Pathology is not visible in most activities, as it is tied up in patient management pathways and operations so that outsiders have no idea what goes on in your department Our intention unless you put on an open day to reveal how much activity takes place away from the limelight. • Measure the current variability of pathology • by geography, service, specialty, demographic • By clinical team (?) She asked what commissioners need to know: • Which tests? • Raise the profile & improve the value of pathology • For patients & families • How many? • For communities & society • Delivered how? • Create a vision for the future of pathology • What cost ? • as a template on which to plan & execute tests of change • How many in-house, how many sent away? • How is quality assessed?
16 ACP news - Spring 2020 Articles
The Pathology GIRFT project is largely based on primary care, e.g. for Hb levels when corrected for the list responses to a questionnaire that was sent to all labs. The size as shown in the slide. Possible reasons include: breadth of pathology disciplines led the team to focus on the three main phases of the testing pathway, according • Variation in individual GP behaviour to the ‘Clean’ process: ‘Clean in’ (request to receipt) / • Varying advice from specialists or local project ‘Clean through’ (lab processing) / ‘Clean out’ (result • Varying support for GPs for more complex cases delivery and receipt). and shared care arrangements, such as Disease Modifying Anti Rheumatic Drugs (DMARDs)
GIRFT Methodology Primary Care requesting patterns 13 1. Collect relevant data • National, eg: HES, professional bodies, national audits • Questionnaire: issued to all Trusts – crucial for Pathology 2. Report (data pack) issued to every trust prior to Visit (deep dive) with Path clinical staff & senior Trust managers - also feedback to emerging networks & primary care rep Highlight best practice, unwarranted variation, challenges 3. Agree an action & implementation plan, to be supported by regional GIRFT teams Variation is significantly more than can be accounted for purely by denominator (list size) issue 4. National Report published - involving Royal college & other bodies • Variation in GP behaviour? - highlight best practices, concerns, challenges; • Variation in local advice (e.g.: Hb in chronic disease test profiles or not?) - make recommendations • Variation in primary care support for more complex care (e.g.: shared care of DMARDs; other follow up)?
The laboratory can have a significant role in helping match testing to clinical question. How proactive is this?
The data have been pulled together to produce individual hospital reports, set against the background of all English hospitals. These reports are sent out ahead of a ‘Deep Dive’ visit where the results, including reasons Another area looked at is the turnaround time for tests for any variation, can be discussed. The team are keen that may be sent away to a tertiary centre, for example to identify ‘exemplars’ of good practice, to share with ANCA, the result of which may have critical implications others, as well as picking up on issues that may require for patient care. There is huge variation, from nought to further work locally. 45 days, with a median of nine days; even this seems The results so far suggest widely varying practice long for such a time-critical result. Every result above the across the domains. For example, in A&E the number median should be looked at to see if it can be improved of patients having their bilirubin measured varies from (a more intelligent approach than saying everyone should nought to 70% of attenders; similar variation is seen other be above average!) Emergency Department tests, including TSH and CRP. An electronic ordering system (NPEx) cannot only help to expedite turnaround time but also increase safety by reducing the risk of errors in transcription, amongst other things. Some centres already use NPEx, others are at the point of installing it, but many are still using traditional VARIATION systems with paper forms, and even batching up send- IN aways, regardless of the nature of the request! REQUESTS As of this March, the GIRFT Pathology team are ~ ED just over a quarter of the way through the visits, with another 25% or so planned in the next three months. Each laboratory and network gets local feedback, usually within a month of the deep dive visit. They hope to have got to the 80%+ point by the end of the year and, based on common issues found during the deep dive visits, should be pulling together the national report by then. The report There are many possible causes of over or unnecessary will have to go through an approvals process (College, investigating; one possible contributing factor could be GIRFT team, and perhaps other interested parties such the use of protocols, and this could be an area to explore as ACB, BBTS) before it is published; the aim is for in the next round. There is also considerable variation in Easter 2021.
ACP news - Spring 2020 17 Articles
Leadership roles within the NHS Hospital Trusts: how is the voice of the pathologist heard? – Dr Kanchan Rege
Dr Kanchan Rege Medical Director North West Anglia NHS FT She also took a very practical approach to the sometimes-nebulous concept of organisational goals: An excellent and enjoyable talk with a clear message to encourage people, even those who may doubt if they are • Our goal is to offer our customers great quality made of the right stuff, to have a go. She described how food at fair prices and, as a leading food retail- she worked her way up the ladder, including the courses er, we are committed to being “Best for food and and influences that helped her. health” … Kanchan took on a leadership role very early on, being • To organise the world’s information and make it the head girl at her prep school and later, becoming universally accessible and useful interested in people, she did BA in social anthropology. • … we aim to be where the growth is, enabling At the Marsden she learned from a course in Managing businesses to thrive and economies to prosper, and, Health Services from the Open University, then at her ultimately, helping people to fulfil their hopes and hospital she led the clinical business unit before becoming realise their ambitions. the medical director and deputy CEO. She described her • To deliver world-class clinical care to the children many roles, as: we treat. To undertake innovative research that will lead to new and improved treatments everywhere • Doctor, Caldicott Guardian, Exec Lead • Working together to be the best at providing out- • Responsible Officer, Medical Educa- standing care for local communities tion (e.g. mental health spokesperson) • Board member, Chair of Quality Committee This slide was not just a series of quotes for information; • Service Improvement/GIRFT, Job planning it was a thought exercise for us to work out which • Medical conduct, Research and Development organisations had made those statements. From memory, • Serious Incident Panel, Strategy one may have been Google or maybe Microsoft, and I • Clinical Excellence Awards, Accountable think one was a well-known bank. Emergency Officer If readers would like to send their suggestions, I can pass them on to Kanchan and whoever scores best could There are good and bad aspects of work – good receive a mention in the summer issue of the news! colleagues and the buzz of working with interesting A statement of values again can often be nebulous, people. Some aspects of the work might be interesting but and Trust Boards can spend a lot of time on the various also demanding, including appearance at the High Court nuances and implications. It is important to make sure defending her Trust. Terrifying, but she did feel proud they are appropriate; they do need to convey what is to have faced up to the challenge and speaking up for important to the particular organisation, and they will be her hospital. different values in a yoga class from the army The bad aspects include the loneliness of being the Her explanation of Trust values was another good only doctor on the board. To ensure she punches her full example of a clear and practical statement: managerial weight she is strict with appraisals, making As a member of the Trust Board she can be called sure they are up to standard, sending back unsatisfactory on to give an opinion on all matters, including the Key ones as she has to hold people to account. Performance Indicators (KPIs) which will be presented Her slides show that she has really taken learning about at board meetings along with finance statements, which management seriously, with some very insightful quotes:– can be very long and complex, or may be presented in a puzzling manner such as the balanced scorecard from a “Management is a set of principles relating to fictitious family business. the functions of planning, organising, directing and Her comments on this were very reassuring; you do not controlling, and the application of these principles in need to be a financial expert, but you do need to be able to harnessing physical, financial, human, and informational talk to colleagues in the finance directorate. Having good resources efficiently and effectively to achieve working relations with all the other members of the team organisational goals.” oils the wheels of the hospital machinery.
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Who should be the lead? • Not the shop steward • Not by “turn” • Not (necessarily) the most senior person in the department • Not (necessarily) the most technically proficient • Not necessarily someone who is financially trained • Not someone who avoids conflict • Not someone who uses the term “dark side”
As medical director you don’t need to know all [Editor’s comment]: I would not like to think that any- the detail of every line but if you see deterioration in one who has been a shop steward should be prevented performance, e.g. from green to red, then you know that from leading a department as there have been some this is something that needs to be looked into. fine examples of leadership within unions, including The discussion that I found most interesting and our own BMA. But I do take the point that to be a shop provocative was who should be the lead? Beware leaders steward whilst also being a manager would be a diffi- of one particular faction, e.g. unions or managers, as they cult balancing act. will have an agenda dominated by their interest rather than the altogether philosophy – you should not appoint We also had a good discussion about conflict, which is someone as a leader who avoids conflict. There will be inevitable, and to avoid it means that other people will difficulties and different ways to handle them; people have to make the difficult decisions. On the other hand, naturally seek fairness in their life but may be prepared however, someone too keen to be confrontational will to go through difficult times when they feel that their cause all manner of unnecessary problems. problems are shared.
Monthly Business Evaluation Priority KPI KPI Measure Comment Area 1 2 3
1 Working Capital Yes, Peckham remains very near London
2 Debtor Days All cash in hand, no income, no VAT Financial
3 Creditor Days Usually Thursday and Friday but Del avoids the pub on those days
4 Distribution Coverage Dominant in Peckham, South London (%) Customer 5 Quality Demerit Index Dry-clean only raincoats and dodgy watches have affected performance - amongst others
6 Sales Forecast Targets 100% success in supplying what Process accuracy (%) nobody needs or wants
7 Warehouse Storage Cost (per piece) House
8 Transport Cost Company policy to use 3 wheel Reliant Regal Logistics (per km) van for tyre economy
9 Stock Security Constant screen monitoring by Grandad or Uncle Albert
10 Training Days Rodney aka Dave already has 2 GCSE’s but Learning studies Computers at night school
ACP news - Spring 2020 19 Articles
Do you need a leadership course? read the mood in the room to avoid making enemies the • Managing yourself (MBTI) moment you speak! • Communication Being solution focused, common in areas outside • Emotional intelligence medicine, is to think about what a good solution looks • Integrity like. In general people prefer being given solutions rather • Resilience than problems. • Solution focused Some suggestions on how to get involved Kanchan reported that she had participated in seven • Departmental meetings – chair, agenda, actions and found them helpful in developing self-awareness in • Quality committees (e.g. Transfusion Committee, order to better interact with other people. Cancer Board, infection control) The MBTI is an introspective self-report questionnaire • Public Trust Board indicating differing psychological preferences in how people perceive the world and make decisions. The original versions of the MBTI were constructed by two How best to get involved? There will be committees Americans, Katharine Cook Briggs and her daughter needing professional representation, and for haematologist Isabel Briggs Myers. The MBTI is based on the conceptual the blood transfusion committee or thrombosis committee theory proposed by Swiss psychiatrist, Carl Jung. would generally be fairly low-level places to start and She found she responds best to people who speak develop leadership skills; alternatively, choose whether quickly, becoming impatient with slow speakers to the committee work is something that suits you. point of wanting to finish their sentences. These courses She summarised the different but overlapping worlds can help to develop emotional intelligence, i.e. be able to of leadership and management with a neat diagram:
Leadershp & Management
In a brilliant final flourish, she announced that like a psychotherapist a good leader should not take credit for the work they have done, i.e. the benefits come through the efforts of other people who they have helped.
Much food for thought.
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Pathology Networks – an update on reconfiguration progress David Wells, Head of Pathology Services Consolidation, NHS Improvement
David is well connected, this is how he was described by the IBMS last year. “As Head of Pathology Services Consolidation at NHS England and NHS Improvement, David Wells continues to drive the type of unprecedented change in UK pathology that has attracted global attention, especially due to his excellent work with networking and consolidation. He strives to embed pathology into the heart of healthcare by supporting the adoption of digital systems, while also influencing key national health policies and government-funded initiatives. His trailblazing approach to the modernisation of the field is ensuring the sustainability of pathology expertise for the future – but he still manages to find time to inspire future laboratory medicine professionals. In addition to being an IBMS Fellow, David is an IBMS council member for the London Region and is deputy chair of the IBMS Special Advisory Group for Clinical Chemistry and of the Membership and Marketing Committee. David has also represented the IBMS on NICE diagnostic advisory panels, and various national forums, including as an observer on the Royal College of Pathologist Council and in the Parliamentary and Science committee.”
Although David is clearly an important person, he came the cost per test has been reduced, giving resources to across as modest, and advised that he has a small team to introduce new tests. Economies of scale bring savings by carry out a lot of work with the networking project. As he buying better, and almost all Trusts are making progress followed the discussion of leadership, with many people as commitment by NHS managers is enshrined in the advocating high-profile leadership, he stated that not all long-term plan of five-ten years. leaders are visible and that their work is more to do with Data are available NHS wide; some can be found on pulling the levers that change direction. It is tough for the website model hospital, including costs per test, bank, them to be asked to work with the second set of levers, and agency levels. Because of problems with collecting e.g. digital, and they continue to refine processes mostly data hospitals are asked to send their own data. There are in high-volume, low specialism areas. annual and quarterly reports, and they now have a huge There have been successes; where we have networks, amount of data as shown:
ACP news - Spring 2020 21 Articles
There is considerable reduction for savings: a 14p re- National programme updates duction in cost per test, at 1.1 billion tests per year, Carter Efficiency fund would equate to saving the service £154 million • SoS has approved the remaining £50m Carter Cap- (my maths). He did not specify if this was an actual ital Efficiency fund for Digital Diagnostics adop- goal or simply an example of what can be achieved tion and scale up through economies of scale. He gave much infor- • Working with Office of Life Sciences to develop mation on the progress of the scheme. a how best to utilise this fund, likely to involve working with the Centres of Excellence and Inno- The outputs will be:- vate UK • Described and enabling 29 pathology networks • The key theme of this fund will be added value and • Publication of clinical and operational advice in increased adoption the form of toolkits • Split between pathology and imaging programmes • Development of specialist testing networks • Facilitating network workshops involving clinical Publications and operational teams • State of the Nation (2019): provides a public up- • Development and launch of the National Patholo- date to progress to date gy Quality Assurance Dashboard (PQAD) • PQAD: quality assurance tool for monitoring lab- • Identifying national funding and innovations oratory performance set out by the Barnes’ (2012) • Digital pathology review • Advanced Practice for Healthcare Scientists • Next - Microbiology and Histopathology ESL: provide guidance and watch points for these ser- The current situation is that there has been a move from vices in spoke laboratories competition to collaboration. Some networks are still not agreed because of slow processes, e.g. proposals having to be approved at board meetings.
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Highlights – procurement lead • Networked provider demonstrating a 20% – programme manager reduction on cost per test • Appointment of a workforce lead for the network: • Network purchasing saving £18m over life of this senior individual should be charged with contract developing a workforce strategy across the network • Provider removes consultant shortage issue by in the next 12 months and will be the main link to joining network Health Education England • Digital pathology and interoperable solution • Appointment of an IT/digital lead to develop a committed to by entire network digital technology workstream to help adopt and • Existing networks expanding, and renewing implement interoperability and deployment of commitment over longer periods digital pathology technology • Commitment extended into the Long-Term Plan and People Plan (These roles, with the exception of chair/SRO, should wherever possible be full-time roles.) NHS Digital – Unified Test List • First 350 lines of code delivered Introducing PQAD • NHS D working with NHE/I, PHE, RCPath Development and launch of the National Pathology • Seeking prioritisation list for next cohort of tests Quality Assurance Dashboard (PQAD) that will cover • Formal launch in April 2019 with the next publica- five areas: tion of SNOMED CT • General health check • Operational performance Also now asking for: • Quality and clinical governance • Confirmation of the network leadership team: • People – chair or senior responsible officer (SRO) of the • Stakeholder engagement and operational delivery network – clinical/medical director These two slides give an indication of how the subject is – network operations/integration director covered:
ACP news - Spring 2020 23 Articles
The next piece of work will be working with UKAS. He also saw a role for increased point-of-care testing The PQAD for Trust managers should set standards for and the experience gained so far will help primary Joint Ventures and RIDOR events show unsafe services. care initiatives where GPs desire quicker results for Stakeholder engagement can show operational delay, their patients. possibly through a survey of users, including patients. Another masterful delivery supported by plentiful data David commented that the NHS has not been good at and clearly presented. challenging commercial interests but could do better with the increased amount of data becoming available.
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Reflections on clinical leadership and management in pathology and beyond – Dr Suzy Lishman
Dr Suzy Lishman, Consultant Histopathologist, North leadership skills for women. The Aurora programme West Anglia NHS Foundation also helps develop leadership skills for women with an Trust; immediate past-President of RCPath international perspective. One of the unexpected challenges was to be a key figure in acquiring and then rebuilding the site for the new college. For this she had to learn builders’ language; hopefully she meant technical terms rather than the coarser expressions! She has been a champion for the medical examiner’s role and has developed a media profile; through her work for National Pathology Week and virtual autopsy performances she has been on Radio 4’s Museum of Curiosities show. As college president she has met with leading politicians and royalty. Through her high profile she has been invited to London Fashion Week and pictured with Olympic athlete Sally Gunnell. She has also appeared at Cheltenham Book Festival with crime writer Ian Rankin. An inspiring and uplifting presentation with two themes: Her more serious and less glamorous photo ‘Anything is Possible’ and ‘No Skill is Wasted’. opportunities included visiting a pig farm with CMO Suzy talked about her career path; some of the roles she Sally Davies when working on the important subject of had taken on; building contacts and networks; and lessons antimicrobial resistance. learned. She has been a mentor and coach and learned a lot through her many experiences, including the need to have a vision, to have confidence and self-esteem, whilst being able to ask for advice. A crucial point is to know oneself. To be able to ask Who am I? as integrity and authenticity are vital to success. In this respect one should avoid the Impostor Syndrome – see box for my attempt to explain this! It was clear throughout the presentation that Suzy had thoroughly enjoyed herself, made the most of every opportunity and had fun on the way.
Impostor syndrome, as described by Wikipedia, is An atypical career path a psychological pattern in which one doubts one’s accomplishments and has a persistent internalised Her career path was not straightforward, neither A to B fear of being exposed as a ‘fraud’.[1] Despite external nor straight up a ladder but more of a series of branching evidence of their competence, those experiencing this tracks some, but not all, leading on to great achievements. phenomenon remain convinced that they are frauds, This illustrates one of the major take-home messages: No and do not deserve all they have achieved. Individuals Skill is Wasted – you never know what skills you might with impostorism incorrectly attribute their success need later on as new challenges arise. to luck, or interpret it as a result of deceiving others One significant achievement was developing the into thinking they are more intelligent than they Schwartz rounds, which help all the people involved to perceive themselves to be. While early research come together as a team. She benefited from the King’s focused on the prevalence among high-achieving fund leadership programme, which helped develop women, impostor syndrome has been recognized to her confidence to stand for the RCPath Council. She affect both men and women equally. also praised the Athena programme, which promotes
ACP news - Spring 2020 25 Articles
There is plenty of further reading available on the Suzy made her many achievements look easy but net, including a neat diagram by the New York Times having to deal with all the problems pathologists have cartoonist Carl Richards, something like this: been through recently and having to face up to managers and politicians must have been hard. My question to her was: what to do when you find yourself head-to-head in a disagreement? Her answer: get people into a room, talk respectfully, sometimes agree to disagree – a policy which has served her well. Both Suzy and Kanchan, who followed, her were clear examples of people who’ve stepped up to the challenge of leadership and excelled at it. They both showed clear competence and confidence so it’s very interesting to hear the paths that they had taken and how they had grown in confidence, both through the courses they had taken, and the events that they had to manage.
Kanchan and Suzy
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101 years of viral epidemics – Eric Watts
market. In 1990, virology was very largely a skill-based discipline using materials and techniques, many of them developed in-house. The enthusiasm for quality control – an apparently sensible idea to raise and maintain uniform standards – is understandable. But, at the same time, it is antipathetic to the concept of individual skills.” He went on to describe the effect of the internal market in delegating national finances down to a local level with a concentration on spending resources on treatment in individual hospitals at the expense of maintaining a national epidemiological approach. He commented: “Does this all matter to anyone other than virologists? I think it does. During the last decade new virus activities have been uncovered all over the world. These have included newly discovered variants of old viruses, ‘new’ viruses altogether or ‘old’ viruses getting into new areas. Chicken influenza A in Hong Kong and Ebola in Africa are just two examples.” He described the need for national surveillance, predicting that it would take 15 years to rebuild the expertise.
One of the great ironies of modern medicine, where we can move quickly to provide effective treatments for dread new disease like AIDS, is that we still see old enemies emerging in new forms, leading to frightening epidemics. Lay and medical media are looking at the rare flu pandemic of 1918-19 and asking what we have learned. In this patchwork review I have selected pieces from a variety of sources, and I start with what could be seen as prophetic statements from this very periodical almost 20 years ago. If you delve into ACP news winter 2000, available on the website for members to download, you will find a paper by Dick Madeley, p. 5-6, on Virology. He began by describing recent changes: “During the last decade of the 20th century, three things coincided Dr Gray, Circa 2000 – a 21st century prophet? to alter diagnostic virology profoundly. They were, in The then Editor, Carl Gray, made a brief comment: “Viral no particular order: the advent of a rapidly increasing diseases are the most numerous in the world and the potential number of commercially produced kits, especially for for nasty new viruses is very large. If we continue to neglect molecular virology; the rise of accreditation and quality virology now, we shall reap misery in dealing with the huge control; and, finally, the introduction of the internal scale of viral illness in the future.”
ACP news - Spring 2020 27 Articles
As I write, the UK is in the grip of uncertainty over the The ship docked in Spain and soldiers were transported scale of the coronavirus Covid-19, with many different overland to the trenches. The close-packed conditions projections. The good news from China is the decline in of the trenches again provided ideal conditions for the number of new cases; the bad news in the UK is that viral spread, as well as the transport trains and vehicles containment does not appear to be working and measures carrying soldiers to and fro. Soldiers going on home leave such as cancellation of sporting and other mass attendance took the virus to the UK and other countries. The Allied events are being considered. victory celebrations took place amongst the soldiers, now out of the trenches and mixing in bigger numbers, and at The history home where mass rejoicing meant close physical contact. The great flu epidemic of 1918-19 is often known as the The major troop staging and hospital camp in Étaples Spanish flu, which is probably a misnomer as the best in France was identified by researchers as being at the evidence shows it began in USA and spread to involve centre of the Spanish flu. The research was published in most of the world. Most estimate the fatality to have been 1999 by a British team, led by virologist John Oxford. In 50 million, but some have speculated it may have been as late 1917, military pathologists reported the onset of a high as 100 million. One television documentary, The flu that killed 50 new disease with high mortality that they later recognized million, tells in dramatic fashion that it began with as the flu. The overcrowded camp and hospital were ideal transmission of an avian virus in a poultry farm to a sites for the spreading of a respiratory virus. The hospital farmer who then joined the army. He went to his basic treated thousands of victims of chemical attacks, and other military training whilst asymptomatic, spreading the casualties of war, and 100,000 soldiers passed through virus throughout the camp. The cover photo is the iconic the camp every day. It was also home to a piggery, and picture of a military hospital in Kansas. The next stage poultry were regularly brought in for food supplies from was the soldiers boarding a troopship; it would be hard to surrounding villages. Oxford and his team postulated that think of better circumstances for the virus to proliferate a significant precursor virus, harboured in birds, mutated and spread, with hundreds of men in close contact. and then migrated to pigs kept near the front.
Reconstructed Spanish flu virus
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Although hostilities ceased in November 1918, there the fatal complications of influenza. were still troop movements into the following year, and the Infection is conveyed by the sick to the healthy by virus was established in civilian populations throughout the secretions of the respiratory services. In coughing, the world. One notable exception was Australia, which sneezing, and even in loud talking, these are transmitted benefited from the quarantine effect of long sea journeys through the air for considerable distances in the form and then a rigid regime of quarantining sick individuals of a fine spray. The channels of reception are normally and close contacts who came from abroad. New the nose and throat. Zealand did not take the same measures and suffered a It is manifest that the closer the contact, the more major outbreak. readily this will transmission occur, hence the paramount importance of avoiding overcrowding and Public health measures thronging of every sort, whether in places of public There was general awareness that this was a viral illness, resort, public conveyances, factories, camps, dwelling even though viruses could not be identified at the time, rooms or dormitories. but it was known that the transmissible agent could not The sum of available evidence favours the belief be filtered out of bodily fluids, distinguishing it from that the period of incubation is about 48 hours or bacteria that could be identified in that way. somewhat less. The Royal College of Physicians of London issued Carefulness does undoubtedly decrease, and a statement – its MEMORANDUM ON INFLUENZA, carelessness increase, both morbidity and mortality; which begins with characteristic confidence: it is important therefore that the public should have a clear idea of such measures of personal prophylaxis “In view of the alarming contradictory reports of the as are available against infection: larger measures present epidemic of influenza that have appeared in the of public health administered by government or local public press, the Royal College of Physicians deem that authorities stand outside the scope of the present an authoritative statement is now in the public interest. Memorandum. The individual must be taught to realise This present epidemic is virtually worldwide, and acquiesce to his duty to the community. irrespective of race, community, or calling. Similar Well ventilated area rooms promote well-being and worldwide epidemics occurred in 1803, 1833, 1837, to that extent at any rate are inimical to infection: 1847 and 1890. A long intermission since the last drafts are due to unskilled ventilation and are harmful; widespread epidemic had already made an early chilling of the body surface should be prevented by reappearance probable, but the conditions of epidemic wearing warm clothing out of doors. prevalence on influenza are too obscure to allow Good nourishing food and enough of it is desirable: precise prediction. there is no virtue in more than this. War rations are fully This outbreak is essentially identical both in itself adequate to the maintenance of good health, although and its complications, including pneumonia, with that they may not afford just the particular articles that of 1890. The disproportionate occurrence of a special each fancy demands. Alcoholic excess invites disaster: symptom, in the case of epidemics for example nose within the limits of moderation each person will be wise bleeding in the present epidemic, does not invalidate to maintain unaltered whatever habit experience has the statement. The present epidemic has no relation to proved to be most agreeable to his own health. plague as some have suggested. The throat should be gargled every 4 to 6 hours, Although there can be no question that the virus of influenza is a living organism and capable of if possible, or at least morning and evening with a transference from man-to-man, yet the nature of the virus disinfectant gargle of which one of the most potent is is still uncertain, and is probably beyond the present a solution of 20 drops of liquor sodae chlorinatae and range of microscopic vision. The bacillus discovered a tumbler of warm water. A solution of common table by Pfeiffer, commonly known as the influenza bacillus, salt 1 teaspoon full to a pint of water is suitable for the has in the past been regarded as the probable cause nasal passage; a little may be poured into the hollowed though on insufficient evidence. There is doubt as to the palm of the hand and snuffed up nostrils two or three primary part it plays in the disease, important though times a day. it probably is as a secondary infecting agent. Pfeiffer’s Since we are uncertain of the primary cause of bacillus, pneumococcus and above all in this epidemic, influenza no form of inoculation can be guaranteed the streptococcus, seem to be responsible for most of against the disease itself.”
ACP news - Spring 2020 29 Articles
They also state that no drug has been proved to have any specific influence as a preventative, but the virus is easily destroyed, and extensive measures of disinfection are not called for. Expectoration should be received when possible into a glazed receptacle with chloride of lime. They go on to say that cloth handkerchiefs should be disinfected, and paper ones burned; today’s advice is slightly different as we now recommend binning rather than burning paper handkerchiefs, presumably as we have fewer open fires readily available for the purpose. Another suggestion of its time but impractical now was to avoid congested public transport by walking to work. It is notable that the College neatly sidesteps what they describe as “larger measures of public health administered by government or local authorities”, and stick to the responsibilities of the individual as it is precisely the larger measures which caused the greatest controversy then, and look likely to now. Historians broadly agree that most governments failed James Niven to take effective action at the right time, i.e. to stop the spread when it may have been containable. The consensus His background in mathematics was advantageous view is that they wished to avoid any actions that might for compilation of statistics, and he became president of weaken the public resolve and threaten the war effort. The both the Epidemiological Section of the Royal Society of last thing they wanted was concern among the public that Medicine and the Manchester Statistical Society, as well could lead to panic. as lecturer in public health. Spain at that time was neutral, and the Spanish In the early stages of the epidemic, he kept meticulous authorities had no such concerns and were more active records chronicling the spread of the disease and soon in warning the public of the dangers. Unfortunately, they decided to take action. He closed theatres, banned sometimes went unheeded; not all the public believed the mass gatherings, and urged the government to do the doctors, the germ theory was relatively new, and some same, unsuccessfully. He retired in 1922 suffering from found it easier to revert to more mystical if fatalistic depression, from which he never recovered. explanations. In the deeply pious Spanish city of Zamora, Public health officials at the best of times have a hard the local bishop defied health authorities by ordering a task of explaining the risk of illness and the benefits of the novena: evening prayers of nine consecutive days in measures they advise. The debate goes on whether to call honour of St Rocco. He was the patron saint of plague for a lockdown, curtailing public freedom and causing and pestilence. economic slowdown, or wait and see, risking avoidable The faithful lined up to kiss the Saint’s relics when deaths. The public on the whole have been understanding, the outbreak peaked, so that Zamora went on to have the with some exceptions. highest flu-related death rate of any Spanish city. In the UK, the stance of the Medical Officer for Health USA 2020 in Manchester gave rise to the greatest conflict with America has not been affected early in the epidemic but government. Dr James Niven gained great credit by mid-March over 1,000 cases had been reported. Ocean dealing effectively with many public health problems in liners, referred to as floating petri dishes, were kept off Manchester. During his 28-year term of office, the city’s the coast in California. population grew from 517,000 to 770,000, but the death Commentators have speculated that the virus could rate per 1,000 population fell from 24.26 to 13.82 in 1921, affect the presidential election in November. Public health largely as a consequence of his work. Among the notable officials have warned against large gatherings and both strategies that he pursued was the conversion of 85,000 Bernie Sanders and Joe Biden have responded, cancelling houses to ‘water closets’ from ‘pail closets’, and a more planned events. President Trump, however, is too keen on intensive slum clearance programme than had existed the buzz he gets from the big rallies to the point that they previously, which resulted in the demolition of 23,000 are part of his political identity, attributing his success to unsuitable houses. rallies he held at crucial sites in the 2016 election. He has
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SARS Coronavirus staged almost 100, even since being elected. ventilation is required. The Italian experience has been The website Politico has stated that the Trump that such ventilators may not be sufficient for the more campaign has identified 1.4 million potential voters from severe cases and that ITU ventilators, designed with more their events, and some Trump allies have claimed that the severe pulmonary disease in mind, will be needed for the public health advice is a Democrat plot to weaken the most severe cases. Trump campaign. Hospital colleagues are thinking seriously and realistically, but sadly there are signs of panic as Back home well. Fear can cause the most extraordinary irrational In the UK, as I write, life continues pretty much as normal behaviour, from kissing the relics of St Rocco to bulk with no major events cancelled to date (11.30 Friday 13 buying of toilet rolls. We live in interesting times; the March), and very few facemasks being worn even on summer issue will hopefully be able to report on how crowded London tube trains at rush-hour. well we have coped. The old saying that time heals all ills March 2020 has been a month of uncertainty and may be partly correct, certainly the coming of summer speculation; rather like the AIDS epidemic in 1985, we with the warmer weather is something that most experts have forecasts of doom contrasting with the Keep Calm agree should bring an improvement. At this stage most and Carry on approach. We do have reports from Italy of experts are predicting that the arrival of summer should increasing numbers of deaths due to pneumonia, at the at least bring improvement. same time that we hear that most people only have a mild illness. Picture credits Hospitals are having to think how best to cope with Reconstructed Virus Picture credit: Cynthia Goldsmith, the more severe cases. The Italians have been more Content Providers(s): CDC forthcoming with their experience than the Chinese in Dr Terrence Tumpey: Cynthia Goldsmith; this media comes respect of treatment of the pulmonary complications. from the Centers for Disease Control and Prevention’s Public One possible approach for hospitals is to cancel elective Health Image Library (PHIL), ID #8243. surgery then use the ventilators available in theatres when Glass Virus - www.lukejerram.com/artworks
ACP news - Spring 2020 31 Articles
To ban or not to ban a gathering? Local Authority advice, Essex, 14 March 2020
A practical problem: do thousands of people squashed together for an event like a half-marathon race, constitute a potentially dangerous gathering for viral transfer, i.e. would you cancel it? The race director has been working hard with local experts trying to keep everyone both happy and safe. I present it as a real-life example of the practical difficulties involved. Good old British compromise is still the order of the day, the local half-marathon is due to take place on the coming Sunday. It involves 3,000 runners who usually congregate in the gymnasium of a local school to drop off their kit bags with tracksuit and other post-race essentials. This means there are three occasions when people are squashed up close together, dropping off the kitbag pre-race, being in the enclosures at the start, and collecting the bags post-race. During the race itself people stretch out, the leaders taking around an hour and 10 minutes and tail enders more than twice as long. These days I’m one of the slower runners and yet whenever I finish, I still find hundreds in front of me milling around at the finish, and a mass orgy of self-congratulation. On Friday 13 March, the race director emailed entrants to advise them not to run if they were unwell, if they had had any contact with anyone unwell, or if they had visited an affected area. They further advised that there would be no manned bag drop, that runners could dump their stuff in the gym and find them after completing the race. Sensibly they also advised runners to disperse from the finish area as soon as possible. The statement by the government on Thursday clearly advises that at this point in time their social distancing policy does not involve events of this size. A subsequent email advised runners who did not wish to take part in the event that they could still get a medal by running a virtual half marathon, explained as follows:
To do this you will need: • A confirmed entry place in the event • A running tracker that records your run, e.g. Garmin/Strava • To complete a 13.1-mile half-marathon or a 5km Fun Run before 15 April 2020.
The race director certainly deserves credit for helping those people who wish to socially isolate themselves to still get a medal. For recreational runners such as myself it is the social nature of the event, i.e. the camaraderie and the sense of celebration that is most important. The race went ahead with about 1/3 less than usual and I was very careful. I avoided the mass start and as the race goes close to my house at the half mile stage I let the bulk of runners go past and then joined the tailenders keeping a good distance between myself and the others. This still lets you have a chat and exchange wisecracks which is all part of the fun. Putting a couple of metres between you and the other runners also means you get more of a cheer and more photos taken. At the finish I went straight through, did not stop to collect a medal, or anything else and went straight home. On the same day in the Bath half Marathon one group of runners were kept apart by their fancy dress costume as they were running in a giant Caterpillar costume like the ones used in the Chinese New Year. It’s had more than one use this year!
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It’s the Arts... Carl Gray
Having admitted to being a duffer at sport [1], surely one edification of an admiring public. The performer hopes ought to be better in the case of the Arts? Unfortunately, for an audience to buy tickets, to return after the interval, this not the case. With small success in pursuing artistic and to give applause at the end. studies and practice, the following essay explores a life What counts as Art is problematic, particularly in scratching minimally on the Arts and them impinging the presentation of found and ready-made objects. ever so slightly on me. Readers of ACP news are desperate Notoriously, Marcel Duchamp (1887-1968) in 1917 for something interesting to read; but as my mother says, presented his ‘Fountain’ (Figure 1): a standard urinal “Who would want to read this?” Those of a squeamish made by an industrial sanitary ware manufacturer (signed: nature should look away now. Real Arts buffs are already ‘R. Mutt’). Was he taking a view as a conceptual artist or looking elsewhere: keenly reading the review pages of just taking the piss? Duchamp was actually a successful their newspapers where they can find their full-strength and influential artist in other media. Tracey Emin (1961- Arty twaddle. Every man is his own critic. As always, ) offered her own untidy bed – ‘My Bed’ (1999) – as an the reader is put in two minds to decide whether this is artistic, somewhat autobiographical, statement of what quite good enough to be decent pseudo-intellectual tosh? the bed purportedly had experienced. No one asked the Modern artistic theory holds that all ‘responses’ to Art are bed about how it felt to be exposed to public view and equally valid, but perhaps we are missing the point? ridicule. But Miss Emin is now a Professor of Drawing and Royal Academician and has had a very successful What are the Arts anyway? artistic career. The public can take their own view of The Arts are creative human activities, usually producing course; some may prefer something with more technical a tangible artefact that is appreciated as possessing skill in it, others like a concept when they see one. some intrinsic value or conveying some important Art has gone through major historical movements and human emotion. The oldest known works of art are cave fashionable changes over the ages. A friend of ours at a paintings: daubs of men and bison, many thousands of party remarked to our astonishment that he had been an art years old. These were the first selfies: celebrating a man student long before becoming a prominent businessman. and his mates at a successful hunt. The Arts traditionally are counted as Architecture, Sculpture, Painting, Literature, Music, Performing, and Film. Painting includes drawing, etching, print-making and nowadays computer graphics. Literature is all forms of creative writing, including drama, fiction in all forms, and poetry. Music obviously includes organised sounds in all genres. Performing includes drama, opera, musicals, and ballet. And film of course includes television, cinema in all its forms, and computer games and virtual realisations. Ceramics is probably a branch of sculpture and stand-up comedy is a form of performing. The ‘Decorative Arts’ just squeeze in, employing craft skills to decorate homes and gardens, to create furniture, or textiles for clothing. Conceptual Art is everything else. Just as sporting lives can embrace watching sport enthusiastically instead of actually, er, doing it yourself, pursuit of the Arts can be undertaken actively or passively. The active artist has some time and some skill – oil painting perhaps, or casting molten bronze – which is exercised on raw materials to become the artistic product. Musicians actually play the tunes whilst dancers dance the moves. The artist hopes perhaps for a patron to purchase the work of art and put it on show for the Figure 1
ACP news - Spring 2020 33 Articles
He told of the embarrassing occasion of his first life simply attend as the audience at a performance or quietly drawing class. As a student he had been confronted with go around looking at art in galleries and museums and so the undraped female form for the very first time in his on. The Internet has liberated access to all forms of art in young life. His initial sketches had unfortunately made recorded pictures and soundtracks. Reading AN Wilson’s parts of the lady’s outline too square. Two of us present biography of Prince Albert [2], he refers to a particular immediately and simultaneously exclaimed that, “It must fresco painting in the royal residence at Osborne House: be Cubism!” Picasso has his legacy, even in Harrogate. ‘Neptune Resigning the Empire of the Seas to Britannia,’ The Arts have enjoyed royal patronage since 1754 by William Dyce (1806-1864) (Figure 2). This was in the Royal Society for the Encouragement of Arts, reportedly Queen Victoria’s favourite painting. Not Manufactures and Commerce (RSA). Sir Robert Peel set actually illustrated in Wilson’s book, this picture can be up a parliamentary committee in 1835 to inquire, “Into found in seconds on the Internet. Wilson finds homoerotic the best means of extending a knowledge of the arts and elements in the painting, which also slaps on the royal of the principles of design among the people, especially flattery with a trowel. among the manufacturing population, of the country”.[2] Participation in television and film is of course mostly The Prince Consort, Prince Albert, had been President limited to the professionals; the product is intended for of the RSA from 1843. The eventual result of these transmission to large remote audiences and is indeed aspirations was The Great Exhibition, held at Crystal recorded for posterity. ‘Reality TV’ puts members of Palace in 1851. the public on the screen; unfortunately, they are awful. There are leading Art competitions – Leeds Piano Study of the Arts is termed Aesthetics and leads onto Competition, the Turner Prize, the Mann-Booker Fine Art and connoisseurship and expertise in the history Prize – whose entries and adjudged winners are often and provenance of artworks. A parasitic profession of controversial. Art Critics inhabits the media, forever commenting on Even the ACP touches upon the Arts: the Editor must the latest performances, productions, competitions, and choose the front cover for each issue of ACP news. exhibitions. We know what we like! But public criticism He has not disclosed the artistic process by which this by a well-informed expert in the field can guide the is achieved. punters in what to see. Feedback systems – ‘Rotten If not themselves artists, consumers of the Arts can Tomatoes’ for films, for example – compile data on public
Figure 2
34 ACP news - Spring 2020 Articles reactions, producing critical scores which may be helpful Cambridge and a biologist so he did not hold with exam in deciding what to see. But only if your own preferences boards doing vague general studies; he wanted ‘factual accord with public opinion. content’. So, we had an elderly gentleman, alas I have And of course, the Arts are big business and forgotten his name, a retired don who gave us illustrated commercially based upon huge money. As Fagin tells us talks on the history of Fine Art from start to finish, one in ‘Oliver’: “In this world, one thing counts. Heaps of hour a week for two years. He was particularly keen on cash, large amounts ...” Single old master paintings can the old masters and apocalyptic visions, Hieronymous change hands for immense sums. Blockbuster films make Bosch especially. Despite our initial indifference to the millions of dollars in their first few days’ release. The subject, the regular portrayal of naked bodies often in West End of London with its scores of theatres fills up states of Hellish torment and destruction increasingly nightly with patrons paying large ticket prices. The best struck a chord. In his gentle way, treating us as Men of performing artistes can fill the big city arenas to sell-out the World – well, Boys of the World at least – he gained audiences, and why not? our attention, trained us in an appreciation of Heaven and Hell, men and women, war and peace, Adams and Eves, Artistic training angels and devils. Fine Art was the Internet of its day; he Children mostly start their artist careers at home and of course did not say this because our schooldays had no primary school: painting, snipping and modelling, and computers. The historical images left to us as paintings on learning their musical instrument. Those with talent and canvas or cave walls record the world view of the chaps perseverance can progress to exams and certificates in who painted them in times long gone by. each discipline. Pupils good at snipping, for example, can do surgery. You can perform in school plays, the school Performance artist orchestra, and the extra-mural debating society. (Why CP Snow famously advised that an educated person was everything intra-mural or extra-mural? Who cares should have some understanding of both Science and about the bloody walls, anyway?) the Arts; he was pushing Science in the 1950s against In primary school, in the school play, I was cast as the the Arts predominance of the Establishment. Feeling sailor. My only action was to raise my arm in a salute. As the gaps in what was then termed a ‘rounded’ education the terrible time approached, my arm froze, and I died or, even worse, a ‘Prince Charles personality’, I have a death of paralysed incapacity: “Come on Mr Sailor. attempted some active artistic endeavours since. My list is Where’s that salute?” very small. In the dance class, we developed a three-part dance At school the music master’s name was A. Sharp, but routine to the Sirtakis tune (by Mikis Theodorakis) of this had no effect. (If you like nominative determinism: ‘Zorba the Greek’, the 1964 film. Readers will recall my father knew a Sergeant Sargent and a Constable that this has a slow ostinato rhythm at first and then Constable.) As my own children attempted their speeds up as the melody comes in on the bousoukis. On instruments, we attended a mixed adult-youth music demonstrating this at home to my family, they simply fell centre. As my daughter took up the flute, with no previous about shrieking with uncontrolled laughter. Dismay and musical training himself, her father tried the clarinet. discouragement have lasted for ever. My family often Clarinet is an instrument which makes a noise easily recall this with cutting ‘Zorba the Greek’ remarks before at first but becomes progressively harder. The modern collapsing once again in hilarious reminiscence. instrument (in B flat) is a compromise between two earlier As a child I enjoyed painting and drawing. On the final versions, now combined. In consequence, unlike the flute occasion, an admittedly poor painting of a green car was or oboe, the three-octave range requires different fingering ridiculed by the art teacher, a known swine: “It looks like for each note of the three octaves. I romped through the an exploding Chinaman!” he exclaimed. A tiny Rembrandt exams – Associated Board of the Royal Colleges of Music died inside me and I have never attempted painting again. – grades 2, 3, 4 and 5, just keeping up with my children. Choosing Science instead of Arts, I chucked the ghastly The exams are fiendish: with the expected scales and Arts people forever. prepared tunes one also has to sight read and even sing In the Sixth Form we had the dreaded ‘General Studies’. a piece of sight reading! To progress beyond Grade 5 There were a few hilarious discussions of mammalian in an instrument, you must first pass Grade 5 Theory of reproductive functions and the remote possibility of Music. So it was that a middle school with small desks their ever finding application in one’s personal life as and chairs with other scholars, generally aged 5-11 years, some sort of human being having relationships, whatever found a larger candidate. For the compose-a-tune bit for they were. The Head Master was a traditionalist from a stringed instrument, I put in some double-string notes.
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(This did it, awarding me my only distinction grade ever finding the people to join in. My latest idea may never in my whole education.) In the music centre orchestra, be realised. I eventually made first clarinet. We performed in public concerts in churches, bandstands, and even the concourse Consumer of the Arts of Leeds City Station. Standing in on occasion for the Notwithstanding my dismal achievement as an artist, as absent percussionist, the timpani sounded but triangle an Arts consumer I have been much more diligent. For somehow failed to deliver its single note, the very last many seasons, starting as a student, I attended the Leeds note of one piece, red faces all round. I should like to Orchestral Concert series in the Town Hall. Eventually, have been a tympanist! When the music goes right it feels realising that I had heard the entire classical repertoire very good indeed, playing in an ensemble and striving for several times over, I got bored. I now attend classical perfection. I did pass Grade 6 Clarinet (it goes up to Grade concerts only a few times a year but usually finding very 8) with the minimum pass mark, but the notes were on the good ones. In recent years I have attended the Berlin stave. This was the glass ceiling of musicality: fingers, Philharmonic in their home town and the Los Angeles nerves, lips and brain had reached their limit. Getting no Symphony Orchestra likewise. Both were surpassingly better, there is always someone better than you. The time excellent. Curiously, I have never much wanted to go to commitment is large and the annoying habits of fellow the opera, but in Italy this year we went to two different players in one’s ensemble group – “It’s F sharp there!” operatic concerts and enjoyed them both. “Yes, thank you, I know...” do eat into you. I still have the General Studies have had their lasting effect in turning instrument, which is a very good one. My trunk of sheet me into an Art Buff who will always visit the principal music was destroyed in a garage flood. Perhaps I shall gallery on major city breaks. Over the years I have seen start again? almost all of them, with only St Petersburg still to do. Making a crisis out of drama, I have done some stuff Some paintings follow me around: first seeing Picasso’s in amateur theatre. Starting with hospital panto, then iconic ‘Guernica’ on exhibition in New York and finding writing and performing in local comedies. At my worst, it again a decade later in its permanent place in Madrid. I conceived, wrote, directed, and acted in my own There is also a version made as a very large curtain at the comedy, ‘The Strumpet of Knaresborough’, at the Fraser United Nations, again in New York, and a public wall in Theatre, Knaresborough in autumn 2017, and appeared the actual Gernika near Bilbao in Spain has a life-size in the Mike Harding Christmas play, ‘Comfort and Joy’, version in ceramic tiles. in autumn 2018. ‘Strumpet’ filled the theatre and made Last autumn, we attended the William Blake exhibition money; the audience loved it and the cast had great fun. at Tate Britain in London. This had remarkably gathered But it was a nightmare to do. The dress rehearsal was almost all his stuff in one place. It was heaving with Blake ruined by the principal man speaking one sentence and lovers of all ages on a rainy early evening. then being called away to do some emergency surgery. I have just returned from a cultural city break in The cast never attended in full until the first night, which Amsterdam. The Rijks Museum and the Van Gogh was cutting it a bit fine. The emotional burden upon the Museum are worth half days of anyone’s time. writer and director is severe: the impending disaster and The Rijks Museum was in the closing days of its financial risk are all your own fault. In ancient Greek blockbuster exhibition: Rembrandt-Velazquez. The drama Hubris is followed by Nemesis. As you lurk behind Curator had cleverly juxtaposed pairs of works on the curtain, which soon will open to reveal you speaking various themes by the Dutch and Spanish masters, who the opening lines – if you can remember them – anxiety worked in the same era but in different countries and and tachycardia reach an extreme peak. But, as the curtain very different circumstances. Rembrandt (1606-1669) closes finally to tumultuous applause, it does feel very was a jobbing artist seeking clients; Velazquez (1599- good. Somehow, it really does go alright on the night. 1660) was an appointed court painter with the King of But how? As they say in ‘Shakespeare in Love,’ “It’s a Spain as his patron. The collections were supplemented mystery?” In five productions, with me contributing by other contemporary Dutch and Spanish artists. (The in various ways, the company has sold the seats and Prado Museum in Madrid must have a few blank walls made a profit for the hospital charities. Yet the company currently.) Viewing two side-by-side self portraits of the dwindles, and it is almost impossible to find enough artists as young men, I overheard an argument between people to commit to the time needed to learn lines, to turn an elegant English gentleman and a forthright American up to rehearse, and to perform. Young people, especially gentleman over the hands in the Rembrandt painting. young men, are very scarce in Am Dram. Ideas are easy; Objectively, the hands are not as good as the face and it is the production and execution which are arduous, and the Englishman felt that they may have been delegated
36 ACP news - Spring 2020 Articles to apprentices in Rembrandt’s studio. The American loudly disagreed: the hands were by Rembrandt himself and no one else. He knew this because he himself “was a painter!” So there! I happened to meet the Englishman later in the café: the Rijks Museum is a lovely caff with quite a nice gallery attached. He was indignant: “I myself am a painter!” he declared, “I am sure the hands are not as good.” The conversation was then joined by a nice Dutch lady who was pleased that two Englishmen – the English artist and me – had travelled all the way to Amsterdam to discuss the hands in one self-portrait. She herself thought, with creditable loyalty to the Dutch artist, that the hands were good enough. You do meet very nice people in the café society of Arts museums. Vincent van Gogh (1853-1890) was the quintessentially tragic artist (Figure 3). Short of money, he never sold a painting in his lifetime. Despite his talent, he suffered from severe mental illness, famously mutilating his own left ear and finally shooting himself in the chest at the age of only 37. Yet his pile of unsold works now forms the basis of the finest single artist collection anywhere in the world. Famously a student of thick paint, one of Figure 3 his seaside views has a microscopical demonstration. The viewer can see sand grains blown in the wind and stuck I do know people who are excellent musicians and in the wet paint. Readers may be interested in Vincent’s accomplished painters; theirs is a heavenly plane. But notorious ear injury: a new study by Bernadette Murphy as in my sporting life, and despite being rubbish at it, has set this to rights [4]. I feel that there really is some value in doing the Arts, The newest museum in Amsterdam is Red Light even at my ignominious level. And if you add up all the Secrets: the world’s first Museum of Prostitution. I had attendances at artistic events – films, plays, concerts, been in tarts’ boudoirs already: professionally, exercising exhibitions, performances, creative writing, and your my profession, not theirs. We must add the Erotic Arts to own artistic hobbies, and classes training you in stuff – the list. And Wine Appreciation. it’s quite a slice of your life. As it happens, the Arts which Our own Mercer Art Gallery in Harrogate has no embraced me are the ‘team sports’: ensemble playing permanent exhibition and its own collection is kept in an orchestra or taking part in amateur dramatics. You in storage. But last year it excelled itself with a major depend on your team and they on you: you have to ding exhibition of the works of William Powell Frith (1819- the note or speak the line at the right moment, or you 1909) who was born locally. Frith was the pre-eminent mess it up for everybody. Fortunately, unless you have a painter of Victorian genre scenes, typically large crowds house full of critics, the audience doesn’t know what to with each individual done in detail. In Harrogate, we saw expect; they don’t experience the mistakes as such. Even most of his work collected together for the first time, in one’s worst moment – obviously drying on a key line including his three greatest works on loan, ‘Life at the – the audience thinks it is funny and part of the joke. But Seaside’, ‘The Railway Station’, and ‘Derby Day’. ‘The ensemble playing is ephemeral, leaving no permanent Railway Station’ is owned by Royal Holloway College, record. If we did water colours or large equestrian London, where it hangs high on a wall. The Director told bronzes, we would still have a pile of them in the shed, me that people came all the way from London to see it at like Vincent van Gogh, after our death. eye-level and close-up. The Mercer did remember to get You ask me what is my own favourite painting? The their own Frith painting out of the basement. This year one I would have over my own mantelpiece has already their next exhibition is some excellent Turners. been bagged by Matthew Clarke [5]; as illustrated in ACP Writing essays for ACP news and its long-suffering news, last edition. Lady with an Ermine (1489-90) by readership must be a form of creative writing and Leonardo da Vinci (1452-1519) is sublime. It is a Polish therefore literature. My previous article for ACP news national treasure held in the National Museum, Krakow was on the Arts [3] and this is yet another. (Figure 4).
ACP news - Spring 2020 37 Articles
It’s the Arts! Even passive enjoyment of the Arts is enjoyment of the Arts. We often see films and plays and visit galleries. We live in a golden age – here he goes again – of cinema and especially TV drama. The UK is very rich in the creative arts, with abundant artists, actors and directors: after Hollywood and Bollywood, London is the next artistic powerhouse. Unfortunately, for me, Sport and the Arts have been a mixed bag. I have tried this and tried that: gained some experience; no great success, some enjoyment. This is the story of the dilettante over the ages: jack of all trades but master of none. I could write the ‘Bluffer’s Guide to...’ well, several things. But how can anyone rise above mediocrity without inborn talent? How can cowering school children learn anything at all? How can cowering professionals find time for anything outside work? Of course, I am grateful to school for starting the enjoyment of the Arts and everyone who has helped in Figure 4 joint artistic endeavours. It is the Age of the Arts, and perhaps in retirement the readers and I shall have the How have the Arts been for you? time (and money) to spend on the Arts. Doctors, and Would you like to do more in the Arts? Then do something especially pathologists, should be learned and cultivated, extra-mural. Tear down that wall! Find a creative moment. with refined tastes and emotional intelligence, erudite Go on! Pick up a paintbrush or ballet shoe or two. Get out and refined, introverted or egotistical, yet fun-loving and your old cello. Write an arty essay or critical response funny. Much of our professional time is spent making for ACP news. Start your novella about interesting vegan diagnoses of malignancy or infection and managing motorcyclists. Arrange ready-made sanitary ceramics serious diseases of existential importance to our patients. upon your desk. Leave your un-made bed in a narrative Doing the Arts somehow balances our exposure to human mess, ripe for biographical interpretation. Make a spring misery with positive input, granting exposure to tangible eco-message sculpture out of plastic materials found in artefacts possessing some intrinsic value or conveying the environment. some important human emotion. This all might be rubbish; but it’s the Arts ...
References Legends to Figures 1. Gray C. This sporting life. ACP news 2018; Winter: 24- 1. Fountain, Marcel Duchamp, 1917. 28. 2. Neptune Resigning the Empire of the Seas to Britannia, 2. Wilson, AN. Prince Albert. The man who saved the William Dyce (1806-1864), Osborne House. monarchy. London: Atlantic Books Ltd, 2019, p. 150- 3. Self Portrait, Vincent van Gogh, 1889, Musée d’Orsay, Paris. 151 and 223. 4. Lady with an Ermine, 1489-90, Leonardo da Vinci, 3. Gray C. Sicily, Florence and Lake Garda – corpus and Czartoryski Museum, Krakow, Poland. corporeality. ACP news 2019; Winter: 11-15. 4. Murphy, B. Van Gogh’s ear: the true story. London: End note: Chattto and Windus, 2016. ISBN: 9781784740610. Carl Gray is a Consultant in Histopathology and Forensic 5. Clarke, M. The travelling trainee; a Leonardo da Vinci Pathology at Harrogate District Hospital, Harrogate, North painting, a salt mine, and the pathologist of Auschwitz. Yorkshire HG2 7SX. Email: [email protected] ACP news 2019; Winter: 42-45. Dr Gray is the President of the Association of Clinical Visitor details Pathologists. This essay expresses his views in his personal Red Light Secrets. Museum of Prostitution. Oudezijds Achter- capacity only and not the policy of the Association. burgwal 60, 1012 DP Amsterdam. www.redlightsecrets.com.
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The patient’s role in improving quality in immunology services – Eric Watts and Suzanne Elcombe
service. Accreditation is a voluntary process for services to engage in. Services participating in primary immunodeficiency accreditation work to an accreditation pathway which involves self-assessment and improvement against the standards. The standards have been developed with a multi-professional group of clinicians, managers and patient representatives. Services can take anywhere between 12-24 months to be ready for an assessment, though this timeframe does vary depending on the support and time available in the service; there is no set deadline to have an assessment, and the QPIDS team understands The Royal College of Physicians of London there are many factors influencing how services progress. Services that are awarded accreditation submit evidence Patients will increasingly be used for medical committees annually to demonstrate that they are continuing to meet with varying degrees of acceptance by the profession. the standards and have a five-yearly onsite assessment The Royal College of Physicians of London formed carried out by our experienced assessment team. a Patient and Carers Network and has used the representatives to get to grips with the hard work of Accreditation pathway assessing and accrediting services. Immunology involves By participating in accreditation, services are enrolled a great deal of patient contact, making their contribution on an ongoing programme of service improvement. especially helpful. An overview of the accreditation pathway is shown on These pieces are reproduced from the colleges Patient page 52. and Carers Network (PCN) annual report and from their website. Tracking progress In 2018/19 the PCN has had continued involvement in Participating services have access to the accreditation RCP accreditation work, including Quality in Primary standards via a bespoke online self-assessment tool. The Immunodeficiency Services (QPIDS) and Improving webtool allows services to review: Quality in Allergy Services (IQAS). The lay assessor role in this scheme is to ensure that the patient voice is • which standards they meet and have evidence for heard and that their feedback informs the assessment of • which standards they meet but service standards (www.qpids.org.uk/www.iqas.org.uk). need to collate evidence for “It has been a great pleasure to be involved in the RCP’s • which standards they are not currently meeting. accreditation work across the country this year – it is an honour and privilege to hear the real experiences of Undertaking the self-assessment enables services to patients and carers, and ensure that their authentic voice target their team’s improvement efforts and work towards and journey are assimilated into the full accreditation achieving QPIDS accreditation. process. This is a true team focus that demonstrates the Once a service can demonstrate evidence to meet the benefits for all when collaboration between clinical and standards, an accreditation assessment will be organised. lay is embraced.” – Sharon Ann North, PCN member. This involves bringing together a multi-professional assessment team to review the evidence submitted by the What is accreditation? service. An onsite assessment will also take place, usually Accreditation is a supportive process of evaluating the lasting one day. quality of clinical services against established standards. There are three possible outcomes of an accreditation Accreditation promotes quality improvement through assessment: accreditation awarded; accreditation not highlighting areas of best practice and areas for change, awarded; and accreditation deferred. Accreditation encouraging the continued development of the clinical deferred indicates that the assessment team felt that a few
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Accreditation Pathway areas of the standards needed improvement or additional services. The standards have been released alongside a evidence to demonstrate full achievement. A service has set of clinical quality and workforce metrics census, to be a maximum of six months to improve on those standards captured annually. before a final outcome is reached; at the end of this The revised standards have been aligned with a period, accreditation is either awarded or not awarded. As nationally recognised standard owned and published by accreditation is an ongoing process of improving quality, the British Standards Institute, which are specifically for recommendations for improvement are to be expected as clinical service accreditation schemes. For a summary part of the assessment. of the changes to the standards please see the IQAS Accreditation is awarded for five years and then standards update summary. another site assessment will take place. Between the site During extensive consultation on the standards, assessments, there is an annual remote review of key we received responses from a wide group of people, pieces of evidence to show that the service is maintaining including services, allergists, immunologists, societies, the QPIDS standards. dieticians, allergy regional networks, and allergy services in devolved nations. Assessment teams Work has been undertaken on all the feedback provided The programme provides a comprehensive training during the consultation. Each person who provided package for supporting assessors. Typically, the feedback will be contacted individually. assessment team consists of a doctor and nurse who work Who is eligible to register with IQAS and to work in an immunology service, and a lay assessor representing towards the standards? the patient voice; they may not have personal experience The revised standards are for both general and of using an immunology service. specialised allergy services. Assessors undergo a blended training programme of both face-to-face and online learning to fully understand Services planning their assessment the accreditation pathway, the standards, and how to Services already registered with IQAS were required carry out assessments. to submit their self-assessment and provide a date for their assessment visit, in order to be assessed on the The revised standards have now been launched previous standards. However, they may choose to be IQAS has launched updated standards for allergy services assessed on the new standards instead, which is also in April 2019, for both general and specialised allergy perfectly acceptable. Any service that is not ready for its
40 ACP news - Spring 2020 Articles
General Food Drug Allergen- allergy challenge challenge specific services tests tests immunotherapy
Specialised allergy services ✓ ✓ ✓ ✓
General allergy services ✓ Optional Optional Optional
accreditation assessment by this time will be assessed on so I wanted to share a little of the background with you! the new standards. The IQAS team will have individual Clinical immunology was amongst the forerunners in conversations with any services aiming to be accredited developing a national accreditation scheme for centres within the next six to eight months. looking after patients with primary immunodeficiency. The programme was developed and run by the UK Comment by Suzy Elcombe of the North East Regional Primary Immunodeficiency Network (UKPIN) for over Immunology & Allergy Unit and assistant Editor 15 years, but in 2015 was moved over to the Royal College ACP news of Physicians and evolved into the Quality in Primary Continuous quality improvement and patient centred care Immunodeficiency Services (QPIDS) accreditation are the buzz words of the day, but how can you prove that scheme. This was shortly followed by the development of your service delivers these? This is where accreditation the Improving Quality in Allergy Services (IQAS), which comes in, with processes of self-assessment and external launched updated standards for allergy services in April peer review against set standards. 2019, for both general and specialised allergy services. In this edition of ACP news we highlight two recent For both the QPIDS and IQAS schemes the standards sit reports from the Royal College of Physicians patient alongside an annual census capturing data sets concerning carers network on the two accreditation schemes relevant clinical quality and workforce metrics. to clinical immunology and allergy. These schemes may The standards cover six areas, which are slightly not be familiar to the majority of ACP news readers, and different for each scheme, but encompass the same
ACP news - Spring 2020 41 Articles
principles of continuous quality improvement, safety and remotely assessed by the assessment team who provide patient centred care. For QPIDS, services are assessed feedback and usually the request for further evidence. The against: organisation and administration; staffing; assessment team comprises a consultant immunologist, facilities; clinical care; home therapy and audit; and immunology nurse specialist, and a lay person, who then education and management. IQAS standards are set visit the site and tour the facilities, meet relevant staff and against: the patient experience; service structure; facilities; patients. This cumulates in a feedback session at the end quality and safety; audit and research; and training and of the day, with review of all the evidence with the service development. Both QPIDS and IQAS standards have and the outcome of your accreditation visit. The service been developed following extensive consultation with is accredited for five years, but an annual renewal must healthcare professionals in the specialities, patient be made to ensure continuing adherence to the standards groups, and societies. and continuing quality improvement within the service. The process of accreditation starts with registering with Accreditation is certainly something that is developing the relevant scheme and declaring intent to work towards throughout healthcare services, being encouraged by the accreditation. The first stage of accreditation is then self- Care Quality Commission (CQC), and as such I anticipate assessment via an online platform for gap analysis to more schemes emerging in other clinical pathology the standards and the collation of evidence. This is then specialities.
Haiku – Dr Almas Dawood
The essence of haiku is ‘cutting’ (kiru). This is often represented by the juxtaposition of two images or ideas and a kireji (‘cutting word’) between them; a kind of verbal punctuation mark that signals the moment of separation, and colours the manner in which the juxta-posed elements are related.
Traditional haiku often consist of 17 on (also known as morae, though often loosely trans-lated as ‘syllables’), in three phrases of 5, 7, and 5 on, respectively.
Our first venture into this form of Japanese poetry as a summary of on Quality Improve-ment, written by Dr Almas Dawood, ST3, London North West University Healthcare NHS Trust.
On Quality Improvement: a haiku Review the guidelines! See how we compare with them This way we improve.
42 ACP news - Spring 2020 Articles
The role of high-fidelity simulation in BLS training – Manisha Ahuja
Figure 1: A simulation room at the Royal Victoria Infirmary, Newcastle A simulation is a means to replicate reality in the best trainers can watch their colleagues’ performance and give possible way, without any real- life consequences of feedback after the session. actions taken. The use of simulation in medical education The immunology team undertakes a variety of allergen allows learners to have a more comprehensive and challenges and testing in clinics and a day unit. The staff immersive learning experience and is now widely used are trained in treating anaphylaxis, with competencies across the UK in medical schools as well as postgraduate reassessed on a yearly basis. The standard training education. As a clinical teaching fellow in Newcastle involved a lecture on anaphylaxis recognition and upon Tyne Hospitals over the last two years, I had the management followed by CPR and BLS skills using opportunity to train in the use of high fidelity simulation mannequins. in acute medical scenarios. The feedback from the We designed six anaphylaxis scenarios for the team learners was brilliant - they all felt that playing through using a high-fidelity SIM-MAN in a mock ward. Three the acute scenarios, and seeing the consequences of their scenarios presented anaphylaxis in different ways. chosen actions in real time, allowed them to learn much Two scenarios mimicked anaphylaxis but with an more effectively than going through written cases or just aim to diagnose different conditions (e.g. asthma and describing their intended actions in OSCE/PACES style urticaria). One scenario progressed to cardiac arrest environments. with a communication section to explain events to the We decided to see if using high fidelity training “patient’s” family members. available at the North East Simulation Centre would be Sim-Man has the ability to “speak” through an a useful addition to the yearly BLS training received by embedded microphone, and can blink, dilate pupils and the immunology department at Newcastle. We therefore simulate heart and lung sounds. It is connected to monitor designed scenarios tackling different learning objectives which shows real time observations (such as heart rate, for both the medical and nursing teams, focussing respiration, oxygen saturations, ECG, temperature, blood particularly on anaphylaxis. The simulation centre also pressure and CO2 if on ventilation) that are controlled has the facility to record simulations and broadcast them externally by the trainer who can observe via a two way directly into a debriefing room where other learners and mirror. Scenarios begin with a team of 2 – 3 learners
ACP news - Spring 2020 43 Articles
assessment and administer treatments. The SIM-MAN will respond to interventions in real time with changes in measurable observations. The SIM MAN can also be programmed to deteriorate into a cardiac arrest to assess BLS techniques. After the sessions, the learners were taken to the debriefing room to discuss their experience with the rest of the team who had been watching their progress through the monitors. Feedback from these sessions was very positive. Our colleagues found it very useful to practice with the equipment used on the ward in response to real time changes in the scenario. They also appreciated feedback on their CPR techniques, as the SIM-MAN can demonstrate their rate and depth of compressions as well as success of rescue breaths. We have now incorporated simulation in the training of all staff members with more scenarios planned next year around the role of human factors in resuscitation. The simulation centre is also looking into virtual reality as part of simulation to make training even more immersive! Figure 2: The debriefing room with live video streaming from the simulation being summoned by a “nurse” who is seeking review of Manisha Ahuja an ill patient. Once in the room, the learners can interact ST3 Clinical Immunology and Allergy with the SIM-Man directly to take a history and examine. Royal Victoria Infirmary As the patient deteriorates, they can follow the A to E Newcastle upon Tyne
Figure 3: The control room with two-way mirror looking into the simulation room
44 ACP news - Spring 2020 Articles
Specialist BMS reporting qualification in dermatopathology: a trainer’s perspective – Dr Katherine Syred
Dr Katherine Syred, Consultant Histopathologist
University Hospitals Plymouth has been in the vanguard of detailed portfolio is submitted, which includes a detailed having one of the first dermatopathology BMS trainees in case log with evidence of case reviews, a clinical audit, the country. My aim is to share my experience as a trainer 360 degrees feedback, supervisor’s report, case study, in this relatively unchartered territory, and highlight the and workplace-based assessments. This is submitted demands, expectations and potential rewards which this and formally assessed. Subsequently, the stage A exam qualification brings to the department. (equal to the ST1 examination) must be taken. This This qualification is jointly accredited by the IBMS/ includes microscopy stations, macroscopy, and more RCPath and covers the curriculum, training and generic competency/knowledge based OSPE stations. examinations required to report in dermatopathology. Stage B and C together last at least 12 months. Again, [1] There are four stages of training, A to D. Stage A this is assessed by a detailed portfolio in both stages. The (minimum 12 months) is an introduction to histopathology emphasis shifts to inflammatory skins and naevi, atypical and practical training in dermatopathology. This needs a melanocytic lesions/other malignant lesions, such as minimum of 750 cases and should finish with a trainee adnexal tumours and Merkel cell carcinoma. Stage C fully competent in cut up of most common specimens, commences after successful submission of the stage B and an ability to compose reports on a wide range of portfolio. Stage C finishes with an exam that echoes Part specimens with an emphasis on benign conditions. A 2 RCPath with 20 surgical short cases, macros, long cases
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Attributes required by the BMS reporting Trainee Examples.
A highly advanced level of organisational - Detailed, prescriptive and highly structured stage A,B and C and administrative ability portfolios including case studies and documentation - Organising weekly soft tissue teaching for senior trainees as well with a senior soft tissue colleague.
Self motivated and diligent Able to work on own for sustained lengths of time and be self- disciplined (contrasting to more controlled laboratory environment)
Intelligent and enquiring mind Stage C requires ability to diagnose difficult melanocytic lesions and inflammatory skins
Eligibility Criteria (1): HCPC registered biomedical scientist Essential
Essential Be a member or Fellow of the IBMS
Essential Have at least 7 years whole time equivalent post – registration
Strongly recommended: Strongly recommended to complete the diploma of Expert Practice in Histological Dissection. (including the skin option.)
and OSPEs. Stage D is post qualification ‘perceptorship’ be difficult with the conflicting needs of a busy pathology stage. This is 12 months and includes a gradual emphasis service, and it has been essential that I have received on independent sign out. adequate support for this time through job planning. A The individual undertaking this qualification in our degree of patience and time input is required at the stage department has 11 years post registration laboratory A of training in order to address the clinical aspects of experience, an MSc in Biomedical Science, and dermatopathology and instil this clinicopathological also did the IBMS Expert Advanced Dissection approach into the trainee. qualification. Hence there was an excellent knowledge In many respects the development of the BMS trainee base in anatomy, physiology, pathology, and laboratory is analogous to that of medically qualified trainees. The processes to build upon. Nevertheless, it was important trainee inevitably develops more acumen and autonomy to ensure that the knowledge base from which to start over time. Further, an aptitude for microscopy is not a training was equal to that of an ST1 trainee. We spent prerequisite for admission to medical school, and not all considerable time in stage A doing tutorials, discussing BMS staff will find microscopy easy either. fundamental pathological processes, such as chronic and The timeframe in which the BMS trainee became a acute inflammation, granulomas, neoplasia and genetic net contributor to the department and the skin MDT was syndromes and how these present in the body, including phenomenal. They have taken over pre-review of reports inflammation, immunology, and common cutaneous of squamous cell carcinoma lesions, stratifying them presentations. A degree of ‘unpacking’ and explaining by risk, which was formerly done by a senior clinician, the background to these common entities is required. So, consequently saving considerable MDT time. Clearly, the a specific challenge as a trainer has been to impart some qualification with its narrower focus on dermatopathology focused medical/pathological knowledge in a targeted allows the individual to develop a more rapid expertise way in order to highlight the clinical relevance of the and depth of experience in one organ system. The BMS specimen. Obviously, these tutorials have helped to keep trainee has also become the lead contact for IMF skins, my general medical and pathological knowledge fresh and improving turnaround time from 19 to seven days. As updated by reading up about topics and then discussing part of continuous service development, the BMS trainee together, often using white boards or diagrams. This can has taken on numerous audit projects, which again freed
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up consultant time. It was agreed that attendance at Attributes specific to the trainer for such a qualification skin cancer update meetings would be an integral part include patience and a willingness to explain and of the BMS’s training and subsequent dissemination of impart the background knowledge to a given entity new knowledge and novel techniques in the department to a much greater degree, for instance explaining that would be part of the job plan. In this regard the trainee inflammatory skin disorder such as Sweets syndrome is responsible for presenting audits and updates to the may have many causes, and brain storming what these department at the weekly audit and management meeting. causes might include. Another example is Erythema Adoption of novel immunhistochemical techniques Nodosum, where making the diagnosis is not adequate, within the department as a result of the trainee’s input and some knowledge of potential underlying multisystem was a concrete benefit to the department. In this respect, granulomatous disorders is required. This knowledge the dermatopathology team has been strengthened, and cannot be taken as tacit, and a high degree of frank and Stage C requires ability to diagnose difficult melanocytic our depth of knowledge improved by being able to attend clear communication is required to assess and develop lesions and inflammatory skins more update meetings. Further, it has of course been the knowledge base of the trainee, especially in stage A. extremely important that day-to-day reporting has been Overall, I have found it extremely rewarding to be shared with a team of four pathologists who regularly educational supervisor to our trainee undertaking this report dermatopathology and another who has a soft qualification. It has forced me to update some fairly basic tissue interest. This has enabled our trainee to gain a pathological principles and improved my knowledge breath of experience in reporting styles, approach, and in complex areas. As these posts are inherently service individual variance in interests and thresholds for various orientated, the degree of direct contribution to MDT and entities. In this respect I am extremely grateful to my reporting numbers are significant in stages B and C. I colleagues in Plymouth who have been willing to offer would encourage people to consider encouraging suitable such excellent teaching. individuals to pursue this rewarding qualification. It also I cannot, however, stress enough the importance of provides BMS staff with a potential avenue for career ensuring that the attributes of individuals attempting this development, which will suit some highly motivated and qualification match those in the table above. Individuals capable individuals. who are intellectually able but lack organisational ability or the ability to develop this with time, will struggle with Derriford Hospital Plymouth, [email protected] the portfolio demands of the documentation, which are 1. Guidance to candidates and Trainers for considerable and constant. In this respect, the assessment Advanced Specialist Diploma (ASD) in is dual in that both the portfolios and the examination are Histopathology Reporting Dermatopathology, formally assessed. Furthermore, the ability to be self- Institute of Biomedical Science and the Royal disciplined with time contrasts sharply with the controlled College of Pathologists, Chris Ward, July 2017. laboratory environment.
Curettings
In pursuit of a healthy life I take a regular walk in the country and have often seen a farmer standing on his own, in his farm, doing very little. I’ve seen him so often that I sometimes give a nod, last time he nodded back so I said hello.
I asked if he was having a good day, politely mentioning that he did not appear to be very busy and that I hoped he was enjoying his quiet contemplation ‘Oh no I’m busy right’ he replied telling me that he was working hard on getting an 0BE, ‘How come I asked?’ He proudly replied that he had received privileged information and that he could achieve his ambition by being out standing in his field!
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A Tale of Two Audits: A comparison of current practice in two District General Hospitals looking at the impact of routine elastin staining to detect venous invasion in colorectal cancer resections – Jocelyn Aldridge, Izabela Georgiades, Elizabeth Walsh, Seemeen Umar, Matthew Toy
Dr Jocelyn Aldridge, Histopathology ST3, We conducted two concurrent audits to assess the Dr Izabela Georgiades, Histopathology Consultant, rates of reported venous invasion in colorectal cancers at Harrogate District Hospital Harrogate District Hospital and York Teaching Hospital Dr Elizabeth Walsh, Histopathology ST2, over the period 1 October 2018 – 1 October 2019. The Dr Seemeen Umar, Histopathology ST5, results were then assessed for any significant difference Dr Matthew Toy, Histopathology Consultant, in reporting rates in Harrogate, where elastin is used as York Teaching Hospital standard, compared to York, where elastin is not used Introduction as standard. Bowel cancer remains a significant cause of morbidity and mortality, with 42,804 new cases diagnosed in Audit standard the UK in 2015. Bowel cancer accounted for 12% of The audit standard is set by the Royal College of all cancer cases in 2015 (UK), and the incidence has Pathologists in the colorectal dataset as: “the frequency of remained stable over the last 20-30 years. Largely due venous invasion, including intramural (submucosal and to the bowel cancer screening program, bowel cancer intramuscular) and extramural, should be at least 30%”. survival has more than doubled in the last 40 years in the UK, with 57% of patients with bowel cancer surviving Method: Data collection over 10 years in England and Wales. Bowel cancer still Data for all colorectal cancers reported between 30 accounts for 10% of total cancer deaths (2016, UK).1 September 2018 and 1 October 2019 at Harrogate District Using datasets to provide a uniform template for reporting Hospital were collected using the combined LabCentre of malignant specimens has helped to standardise and computer records and reporting system. Similar data were therefore enhance the prognostic power of the histology collected from York Teaching Hospital via its reporting report.2 Specific histological parameters have been system, Telepath. shown to be prognostically significant in predicting an Relevant information was gathered from the datasets individual cancer’s behaviour and response to treatment, included in the pathology report. This included (but was and therefore are pivotal in the MDT discussion in not exhaustive of): specimen type, tumour type, deepest determining the best management plan for each patient. level of venous invasion, and T-stage. Four cases from In colorectal specimens these core features include lymph York and one case from Harrogate were excluded from node involvement, venous invasion, and peritoneal further analysis for incomplete data. The results were involvement. Extramural venous spread is a well- tabulated in Excel. established independent prognostic indicator and there is also some evidence that intramural venous spread is of Method: Statistical analysis prognostic importance, particularly for pT1 cancers.4,5 The data were then analysed and compared to the Assessing venous invasion is a requirement of TNM 8. standards set by the Royal College of Pathologists Both “local peritoneal involvement (LPI) and extramural colorectal dataset. The Chi2-test was used to compare the venous invasion (EMVI)…may be used to select patients rate of venous invasion detected in the colorectal cancer for adjuvant chemotherapy”.3 The Royal College of specimens between the two hospitals and whether these Pathologists recommends that the reporting of these is positive specimens showed intramural or extramural regularly audited to ensure each department is reporting venous invasion. The tests were based on observed values within expected standards. The Royal College currently showing no difference in venous detection between the recommends the use of special stains as a helpful aid and two sites. suggests the regular use of elastin should be implemented by departments not meeting the recommended standards Results – Harrogate for reporting venous invasion. A total of 90 colorectal cancer resections in Harrogate
48 ACP news - Spring 2020 Articles were reported between 1 October 2018 and 1 October reported as having venous invasion, figure 1. Of these 2019; 89 were included for analysis. The tumour 52 cases positive for venous invasion, 37 (71%) were diagnoses and T-stage are displayed in Tables 1 and 2, reported as having extramural venous invasion, 15 (29%) respectively. had intramural venous invasion, figure 2. Of the 89 colorectal cancer cases, 52 (59%) were
T Stage Number of Cases ypT0 1 ypT1 0
Tumour Type Number of Cases ypT2 1 Adenocarcinoma 79 ypT3 0 Mucinous Adenocarcinoma 3 ypT4a 1 Adenocarcinoma with ypT4b 0 Neuroendocrine Differentiation 1 pT1 9 Neuroendocrine Tumour 1 pT2 11 No Residual Tumour 5 pT3 42 Total 89 pT4a 16 pT4b 5 Table 1: Harrogate resections, Primary Tumour Diagnosis No T 3 Total 89
Table 2: Harrogate resections, T-stage
Venous invasion Venous invasion
29% 41% Identified Extramural Not identified 59% Intramural 71%
Figure 1: Rates of reported venous invasion in Figure 2: Proportion of intramural and extramural colorectal cancer resections in Harrogate District venous invasion reported in Harrogate colorectal Hospital cancer resections
Results – York In York Teaching Hospital, 210 malignant colorectal of those, 78 were extramural or ‘probable extramural’, cancer specimens were processed during October 2018 and 17 were intramural and ‘possible intramural’ (Figure – October 2019. The primary tumour diagnoses and 4). Elastin was requested in one case and confirmed T-stages are displayed in tables 3 and 4. Of these cases, 95 the presence of extramural venous invasion, which was were reported as having venous invasion (Figure 3) and detected on haematoxylin and eosin.
ACP news - Spring 2020 49 Articles
T Stage Number of Cases ypT0 3 ypT1 0 Tumour Type Number of Cases ypT2 5 Adenocarcinoma 202 ypT3 12 Mucinous Adenocarcinoma 5 ypT4a 2 Adenocarcinoma with ypT4b 0 Neuroendocrine Differentiation 1 pT1 6 No Residual Tumour 1 pT2 33 pT2/3 1 No Diagnosis 1 pT3 87 Total 210 pT4 21 Table 3: York resections, Primary Tumour Diagnosis pT4a 29 pT4b 9 No T 2 Total 210 Table 4: York resections, T-stage Venous Invasioninvasion Venous invasion
18% ExtramuralIdentified + 18% Extramural + 45% Probable Probable 55% 82% IntramuralNot + 82% Intramural + identified Possible Possible
Figure 3: Rates of reported venous invasion in Figure 4: Proportion of intramural and extramural colorectal cancer resections in York Teaching venous invasion reported in York colorectal cancer Hospital resections
Results – comparison (59%) and 95 of 210 cases (45%) were reported as having Harrogate District Hospital identified a significantly venous invasion, respectively. These results demonstrate higher proportion of specimens with venous invasion that both Harrogate and York histopathology departments than York Teaching Hospital: 52/89 (59%) vs 95/210 are exceeding the recommended 30% minimum reporting (45%), (p = 0.037) (Table 5). However, when analysing standard for the detection of venous invasion in colorectal the difference between extramural and intramural rates, cancer resections set by the Royal College of Pathologists. there was no significant difference in reporting between Elastin staining is used routinely at Harrogate to the two hospitals (p = 0.0124) (Table 6). facilitate the identification of venous invasion. A comparison with York, which uses H+E alone routinely, Discussion demonstrated a significantly higher detection rate Ninety cases of colorectal cancer were reported at of venous invasion in Harrogate. The Royal College Harrogate District Hospital and 214 cases reported at currently recommends the use of special stains as York Teaching Hospital over a one-year period from a helpful aid and suggests the regular use of elastin October 2018 to October 2019. Eighty-nine and 210 should be implemented by departments not meeting the cases were included for analysis. Of these, 52 of 89 cases recommended standards for reporting venous invasion.
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“Venous invasion is [a well-established] independent reassuring. No change to current local practice is needed predictor of haematogenous metastasis and mortality in at present; however, this should be re-audited annually colorectal cancer yet remains widely underreported. Its to ensure that these standards are sustained. It may be detection may require recognition of subtle morphologic prudent for more centres to consider adopting routine clues, which at times are only unmasked with an elastin elastin use to increase their reporting rates of venous stain.”6 Both departments are meeting and surpassing invasion beyond the minimum standard. the pre-determined standards, which is important and York Teaching Harrogate P value Hospital [n=210] District Hospital (%) [n=89] (%) Cases with 95 (45) 52 (59) identified venous invasion 0.037 Cases without 115 (55) 37 (41) identified venous invasion Table 5 York Teaching Harrogate P value Hospital [n=95] District Hospital (%) [n=52] (%) Extramural 78 (82) 37 (71)
0.0124 Intramural 17 (18) 15 (29)
Table 6
References 1. Bowel Cancer statistic, Cancer Research UK, https://www.cancerresearchuk.org/health- professional/cancer-statistics/statistics-by-cancer-type/bowel-cancer/incidence 2. Branston LK, Greening S, Newcombe RG, Daoud R, Abraham JM, Wood F et al. The implementation of guidelines and computerised forms improves the completeness of cancer pathology reporting. The CROPS project: a randomised controlled trial in pathology. Eur J Cancer 2002;38:764–772. 3. Interobserver variation in the reporting of local peritoneal involvement and extramural venous invasion in colonic cancer. Littleford SE, Baird A, Rotimi O, Verbeke CS, Scott N. Histopathology. 2009 Oct; 55(4):407-13. doi: 10.1111/j.1365-2559.2009.03397.x 4. Royal College of Pathologists Standards and datasets for reporting cancers. Dataset for histopathological reporting of colorectal cancer, September 2018. Authors: Dr Maurice B Loughrey, Royal Victoria Hospital, Belfast H&SC Trust and Queen’s University Belfast, UK, Professor Philip Quirke, Leeds Teaching Hospitals NHS Trust & Leeds University, UK, Professor Neil A Shepherd, Gloucestershire Cellular Pathology Laboratory, Cheltenham, UK. 5. Identification of objective pathological prognostic determinants and models of prognosis in Dukes’ B colon cancer. Petersen VC, Baxter KJ, Love SB, Shepherd NA. Gut 2002; 51:65–69. 6. The impact of knowledge transfer on the detection of venous invasion in colorectal cancer. Kirsch R1, Assarzadegan N2, Messenger DE3, Juda A4, Riddell RH5, Pollett A5, Streutker CJ6, Divaris DX7, Newell KJ8, Price RG9, Smith S10, Al-Haddad S11, Parfitt JR12, Driman DK12. Hum Pathol. 2017 Sep; 67: 45-53.
ACP news - Spring 2020 51 Articles
Case Report: Acardiac twinning and the TRAP sequence – Mike Kearney
This was an apparently normal singleton pregnancy to the formation of an acardiac fetus, namely the TRAP with a full-term normal delivery, however a placental sequence (twin reversed arterial perfusion). abnormality was seen. The placenta was fixed, and sent This reversal of blood flow has been demonstrated for pathological examination. in several similar cases by Doppler sonography. The size and shape of the placenta were normal, and the Deoxygenated blood from the pump twin is now perfused attachment of the umbilical cord was eccentric, 4cm from to the acardiac twin via the arterial shunt. The present the placental edge. case shows probable regression of the arterial shunt, There was twin monoamniotic-monochorionic which probably explains the survival of the pump twin. placentation as a second umbilical cord and fetus were The incidence of acardiac twins is about 1 in 35,000 present; the amnion between the cords was continuous, pregnancies, and about 1% of monochorionic twins. In the with no evidence of a septum. The second cord was 13cm acardiac fetus the heart is absent, or severely malformed; long, and terminated in a macerated fetus, CR-length 8cm and is among the most severely malformed fetuses found. (corresponding gestational age about 16 weeks). The aim of modern fetal medicine is to abolish the There was severe holoprosencephaly, with a proboscis TRAP sequence by selective feticide of the acardiac 1.7cm diameter. The face and ears were absent. There was twin by ablation of the umbilical cord and /or placental phocomelia, with almost total absence of the limbs, with a anastomoses. The perinatal mortality of the structurally rudimentary foot attached to the rump. normal pump fetus is 35-55%, but with treatment this is There was strangulation of the second cord, 3mm improved, with survival rates above 70%. diameter, due to torsion, close to the umbilicus; next to this was a 3cm segment of cord which was oedematous. The References placental attachment of this umbilical cord to the acardiac 1. Kraus FT, Redline RW, Gersell DJ, Dickie JM. Placental fetus, was very narrow, and a string-like cord 2-3mm Pathology. Washington, DC. American Registry of Pathology/ in diameter (arrow) connected the two umbilical cords, AFIP. 2004. which were 3.5cm apart. This was probably the remains 2. Baergen RN. Manual of Pathology of the Human Placenta. of an arterial shunt carrying deoxygenated blood from 2nd ed. New York. Springer. 2011. the morphologically normal (pump) fetus to the acardiac 3. Redline RW, Boyd TK, Roberts DJ. Placental and fetus. It was arterial as it crossed over an underlying vein. Gestational Pathology. Cambridge, Cambridge University This shunt would explain the sequence of events leading Press. 2018.
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Some memories of Rob Lindsey, 1945-2009 – Mike Kearney
It was autumn, and about 50 years since Rob and I were We continued downwards to the western shore of wild camping in Glen Affric; a remote, and lovely glen Loch Affric. in the Western Highlands of Scotland. After climbing Many years later, Rob was killed instantly in a collision Sgurr na Lapaich (1036m), we slept on the summit of with a motorcycle; he was riding his bicycle on the Mam Sodhail (1181m). The next morning we awoke to a moorland road from Buxton to his home in Whaley dull, grey day, and it was drizzling steadily. The afternoon Bridge. It is ten years since Rob was taken from us, but found us descending the long easy ridge over An Tudair he lives on in the photographs and memories of his family (1074m), to Glen Affric. and many friends. The clouds parted briefly, and the rays of a watery sun Rob was a social worker, and held a senior post in the lit up the desolate landscape. In this photograph Rob is Department of Social Services, Manchester City Council. gazing at the myriad small streams and lochans, which Rob was one of my closest friends, his hobby was cycling, glittered like diamonds on the sodden ground below us. but we shared a love of wild places.
ACP news - Spring 2020 53 Articles
A summer ascent of Imbodentind – Mike Kearney
It was the big rock and snow mountain which stands up something. I could not resist the urge, even though I had so grandly above the Andersdal (Goverdalen). It had no to catch a bus in Tromsø the following afternoon. I threw name, and was not in the neighbourhood of any river some gear into a rucksack, raided the refrigerator, and or farm after which we could call it, so I felt justified in was off. It was about an hour’s drive to Lakselvbukt, on calling it the Imbodentind. The rocky walls supporting that fine July evening in the late seventies. its ice-cap, and themselves rising from extremely abrupt I left my car at a nearby farm, and the farmer walked snow slopes, were most imposing from their smoothness over to talk. He told me that Store Lakselvtind (1,616m) and steepness. was first climbed by some Swedes in 1946. I knew of this ascent by Billing, Hammarsten, and Björn, but it was Mrs Le Blond - Mountaineering in the Land of the not the first. They described finding the visiting card of Midnight Sun CV Rawlence, Brasenose College, Oxford, left in 1899. This mountain was first climbed by Mrs Le Blond, an The Rawlence brothers were friends of Mrs Le Blond, Englishwoman, and her Swiss guides Josef Imboden and and their climb is reported in the Alpine Journal [3]. I his son Emil, on 15 July 1899 [1,2]. I think that the view knew all this as I had spent hours in the dusty library of from the summit of Imbodentind is one of the finest in the the Alpine Club in London, and in the local collection of Lyngen Alps. Tromsø municipal library; I was very familiar with the Seen from Jiehkevárri, Imbodentind (1,565m) is part of early history of climbing in Lyngen. the Lakselvtinder range, and is the last peak on the ridge I tried gently to tell the farmer this, but he wasn’t having leading eastwards, 1km from Store Lakselvtind (Fig.1). any of it. I could see that he was becoming angry; he was a This is one of my favourite photographs, showing these big man, and I did not want to confuse him with facts and lovely mountains bathed in the soft golden late evening upset him even more. I made my excuses and continued light, which is so typical of the high Arctic in summer. upwards. My climb followed the original route. A walk It was a fine weather forecast for the next day; it was through birch woods was followed by a steep climb up late afternoon and I felt very restless and just had to climb a gully, which at first was scree filled, and higher up
(1) The Lakselvtinder, looking south from Jiehkevárri, summer evening
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changed to snow. The gully ended at Tomasskar, where top of Goverdalstind (1,429m) is seen in the lower right I put up my small tent at 1,350m. Even though it was corner (Fig.3). July, it was below freezing, and I slept poorly because Looking to the north-east was Jiehkevárri and its south- of the cold; it was light all night of course. After a quick west valley, and further to the right was Bálggesvárri breakfast, I crossed the small glacier and was on top of with its flat top (Fig.4). Goverdalstind and Sagbladet Imbodentind by 7am. (1,290m) are seen to the left and right, respectively, of It was a clear, windless morning, and I took off my Imbodentind. A chain of small turquoise lakes leads up anorak and sat down by the small summit cairn. At last Goverdalen to Veidalen, about 27km long, and rising to I basked in the warmth of the sun, and took in the view, 800m (Fig.4). This route avoided crevassed glaciers, so which is one of the finest in the Lyngen Alps. A small was a safe way of easily crossing the peninsula by ski brown speckled butterfly landed on my bright red snow in the spring. By using this pass, local inhabitants could gaiter, and mistaking it for a flower, delicately extended travel from Holmbukt to Furuflaten or vice versa to visit its proboscis and attempted to feed. There is magic in friends and relatives. These were the days before roads such moments. and motorised traffic. I stood up to photograph the savage wilderness; all It was the lovely symmetric pyramids of Nallangáisi around me were range upon range of mountains. Many (1,595m) and Sfinxen (1,280m) to the east which held my were old friends I knew well, others I had yet to climb. gaze, (Fig.5). Steindalstind is seen between Sfinxen and The summit of Imbodentind is very small and falls away Imagáisi, above Steindalsbre. This glacier leads down steeply on all sides; this means that when you stand up Steindalen, past Steindalshytta, which is one of the few and turn around you experience a 360o panoramic view. It was simply stunning. This is a large and complex area, with many mountains, glaciers, valleys, and their names to memorise; it is highly recommended that this article is read in conjunction with map 4. You never know, you might even be tempted to visit this lovely country. However, it is a very expensive one for most tourists! In the foreground to the west was the small glacier of the Square of Heavenly Peace (Den Himmelske Freds Plass), so named by Tromsø Climbing Club to commemorate the massacre in Tiananmen Square in 1989. Behind it were Tomastind (1,554m) and Store Lakselvtind (1,616m), separated by Tomasskar (Fig.2). Far below me, and further to the north was the deeply crevassed Goverdalsbre, with Platåtoppen (1,572m) and Titind (1, 329m) behind. The (2) Tomastind (L), and Store Lakselvtind (R), from Imbodentind
(3) Platåtoppen (L), Titind, (centre), and Goverdalstind (4) Jiehkevárri (L), and Bálggesvárri (R), from (R), from Imbodentind Imbodentind
ACP news - Spring 2020 55 Articles open huts in Lyngen with sleeping room for 30 people. glacier, following in my upward tracks. On reaching Steindalen eventually leads down to Elvenes on the coast, Tomasskar, I collected the rest of my gear. I descended and Storfjorden; the view leads further eastwards to the the gully, returned to my car and drove back to Tromsø. Swedish border. Looking now in a south-east direction, Rigmor, Charlie and I were even in time to catch our bus the gentle whaleback peak of Imagáisi (1,505m), not the later that afternoon. So ended one of my shortest and summit marked on the map, is a popular ski tour in the most enjoyable mountain days. spring (Fig.6). The next picture (Fig.7) shows Ellendalen My final picture (Fig.8), was taken on another trip. in the foreground, with popular Ellendalstind (1,345m) It shows the southern end of the Lakselvtinder and was on the left. Looking almost to the south is Guhkesgáisa taken from the summit of Vartinden (1,151m), which is (1,580m) with its great north face, which is for hard just over 10km from Imbodentind. Store Lakselvtind is climbers only, especially in the winter. There are easier the highest peak, and Imbodentind is the farthest peak on ways up but finding the way down can be difficult. The the extreme right; the Square of Heavenly Peace is seen small blue lake on the right is Ellendalsvatnet, and the below and to the left of it. ridge above it is called Ganesoalgi, but is really part of Now I am just an armchair mountaineer and climb no Guhkesgáisa. Vartinden (1,151m) is the horseshoe-shaped more. Instead I am ensconced on my sofa, looking at my mountain with a flat summit, seen behind Ganesoalgi. It pictures on my iPad, and a glass of single malt whisky was now about 10 am, and I had spent about three hours on the table next to me. I have only to close my eyes, on the summit; it was time to go down. and I am standing on top of Imbodentind again. Some I reluctantly shouldered my pack and ran down the memories are very precious.
(5) Nallangáisi (L), and Sfinxen (R), from Imbodentind (6) Sfinxen (L), and Imagáisi(R), from Imbodentind
(7) Ellendalstind( L), and Guhkesgáisa(centre), (8) The Lakselvtinder (R), looking north from from Imbodentind Vartinden, summer afternoon
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ACP Travel fund: Perplexing Problems in Breast Pathology (USCAP), Palm Springs, California, 16-18 January 2020 – Harry Haynes
Shining some light on the issues of the day such as tall cell carcinoma of the breast with reverse Harry Haynes polarity (IDH2 mutated) as well as periductal stromal tumours. Also included in the sets (and prompting some Introduction debate) were the ‘trip up’ cases such as benign epithelial Palm Springs is a desert resort city located just over 100 inclusions in sentinel lymph node biopsies and a variety miles from Los Angeles and about a two-hour drive out of metastatic malignancies presenting as breast masses. of the sprawling metropolis through the California desert. It is of course interesting to reflect on differences in Palm Springs was popular with mid 20th century film clinical pathology practice between the British and stars, seeking refuge from the hurly burly of Los Angeles American systems. For example, the opinions of specialist and Hollywood. It has since developed into a popular hematopathology colleagues seem to be routinely sought holiday resort with abundant modernist architecture and in overwise benign sentinel lymph node biopsies in ample hiking opportunities in the surrounding mountains. routine breast pathology practice. In addition, our I went to Palm Springs to attend the United States and American colleagues have not widely accepted the B1-B5 Canadian Academy of Pathology (USCAP) course on classification of needle core biopsy or vacuum assisted difficult and recently updated topics in breast pathology. biopsy specimens, preferring instead to rely on text The course aimed to cover difficult and challenging aspects descriptors. Interestingly, there is little use of the vacuum of routine diagnostic breast histopathology reporting, assisted excision (VAE) technique in the USA, most/all focussing on practical problems in daily clinical practise worrisome (B3 equivalent) lesions proceeding instead to and which may result in diagnostic error. I attended this open diagnostic excision in routine clinical practice. In a course as part of my professional development in my area similar fashion, the course attendees I discussed the cases of interest in breast pathology and to enable me to interact with were not fully familiar with the British concept with the international breast histopathology community of an ‘atypical intraductal (epithelial) proliferation’ to learn more about the challenging aspects of the work (AID[E]P), preferring instead to designate as atypical as I prepare for consultant practice. ductal hyperplasia (ADH) on needle core biopsy and, as above, proceeding to a more invasive excision. Although The work part this seems unlikely to alter clinical outcomes (especially The USCAP course is delivered in a specially developed with the relatively high published upgrade rates for AIDP department in downtown Palm Springs with individual needle core biopsy diagnoses), it if of course interesting microscopes as well as multihead facilities for the rapid to reflect on the factors that may drive these decisions viewing of a diverse range of cases. The USCAP teaching in very different healthcare systems. Similarly, although courses are offered throughout the year on a variety of many course attendees worked in larger academic histopathology topics and are popular with pathologists units, some pathologists from smaller private practices from across America as well as Canada and visitors from discussed with me the issues inherent in working within Australia and New Zealand. A number of renowned a system with a higher level of (financial) scrutiny which American breast pathologists delivered the structured presides over clinical decisions, particularly with regard sessions. These took the form of rapid slide review and to additional ancillary immunohistochemical tests. note making (familiar to anyone who has attended a UK FRCPath exam revision course), followed by multihead The non-work part discussion and learning point review. The Palm Springs aerial tramway is an impressive The sessions were delivered over three days and covered engineering feat, transporting visitors to over 10,000 feet a full range of benign, premalignant and malignant breast in just under 10 minutes. The tram cars themselves rotate topics, including papillary lesions, mucinous lesions, 360° giving fantastic views of the San Jacinto mountains sclerosing conditions, and spindle cell lesions. With the during the ascent. Many visitors start their hikes through recent publication of the new WHO Classification of the San Jacinto State Park wilderness area in this way. Breast Tumours blue book, some consideration was also During my visit to the top I was shocked to find inches given to emergent and increasingly recognised entities of snow covering the mountainous woodland and an
ACP news - Spring 2020 57 Articles incredible stillness and iridescent Californian light, building were striking although I was unable to find out which contrasted with the dry heat of the desert that was what they denoted. Palm Springs also boasts a variety of just a short car journey from the ascent station. Although dining opportunities and I sampled a range of high quality the National Park is host to coyotes, mountain lions and yet affordable authentic Mexican menus. bobcats, I saw none of these but simply took the time to I am grateful to the Association of Clinical Pathologists take in the incredible views. who generously funded this trip in association with No trip to Palm Springs is complete without a visit to Health Education England Southwest. Overall, the the Palm Springs Art Museum. During my excursion this USCAP breast course was intensive and worthwhile. The was housing a collection of Lino Tagliapietra’s intricate organisation offers a variety of courses in all aspects of glassworks which, when lit, display an intricate range of histopathology throughout the year (https://www.uscap. intense colours. I also enjoyed the oil paintings of Alison org/upcoming-ic-courses/), some of which are partly live Skinner Clark from the early 20th century, capturing the streamed online. Palm Springs itself is an interesting slice light and shape patterns cast by the Californian desert. of California and provides some much-needed sunshine The giant babies crawling around on the sand outside the and light (even in winter) from the grey skies of home.
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Thoracic Pathology, New York City, 27-29 September 2019 – Dr Alison Finall
By Dr Alison Finall, knowledge that some of our patients miss out on tyrosine Cellular Pathologist, kinase inhibitor therapy because they deteriorate whilst Swansea Bay University Health Board waiting for their tumour genetic results. I found the talk by Dr Prasad Adusumilli, thoracic surgeon, to be useful in understanding what they find most useful in our pathology reports. We had heard about the importance of recognising micropapillary pattern adenocarcinoma with regard to the higher incidence of lymph node metastasis and poor prognosis, and also that spread of adenocarcinoma through air spaces (STAS) beyond the main tumour is associated with a higher incidence of margin involvement in conservative wedge resections (Eguchi et al, 2019). Dr Adusumilli asks his pathologists to recognise and report micropapillary pattern on frozen section when they can but this has been shown to be difficult, with a low sensitivity of around 20% (Yeh et al, 2015); however, it has shown to Memorial Sloan Kettering Cancer Centre be possible (Eguchi et al, 2019). Dr Buonocore showed us photomicrographs of frozen section lung with tiny This course was hosted by the Memorial Sloan Kettering foci of papillary adenocarcinoma in alveolar spaces to (MSK) Cancer Centre in upper east side Manhattan, New demonstrate the point that this can be done. I accept this York City and organised by Dr William Travis of MSK is possible, but it looks very difficult! I consider STAS and Dr Mari Mino-Kenudson of Massachusetts General when doing lung frozen sections for our thoracic surgeons Hospital. It covered all aspects of thoracic pathology here in Swansea, but I have yet to actually report any. We with particular reference to the multidisciplinary team try to limit the number of frozen sections where possible. meeting and clinical and radiological correlation with I gently encourage a pre-operative diagnostic biopsy pathology findings. The emphasis was on practical issues because we all know that there is a greater chance of error of reporting faced by all thoracic pathologists on a daily on frozen section, quite apart from the time it takes to do basis, and how collaboration with our physician, surgical, them out of the normal working day, both for pathologists oncological, and radiological colleagues can help solve and biomedical scientists. I tell my non-pathology problems. ‘It’s good to talk’ is a message that comes colleagues that it’s like trying to do microscopy through across clearly and is one that resonates with me. frosted glass. I ask people to imagine doing surgery or The first day of the course revolved around neoplastic bronchoscopy under similar conditions and I often get an lung disease and covered a range of topics from empathetic response. oncology updates, staging, classification, advances in I have not yet been asked to comment on STAS at frozen immunohistochemistry, radiological correlations, and section by our surgeons, but it may only be a matter of variants of adenocarcinoma. Dr Chang also discussed time as our service is rapidly expanding. When STAS or molecular pathological aspects of thoracic pathology micropapillary adenocarcinoma are reported at frozen in some depth. He was most knowledgeable and very section in MSK, the surgeon will convert the operative generous with his time when I grilled him about sequencing procedure from wedge to lobectomy. One can see the technologies over coffee afterwards! I was impressed utility in all this but, reflecting on my own experience to know that MSK use Idylla alongside NGS for EGFR in Morriston Hospital, Swansea, lung-sparing wedge mutational analysis in their pulmonary adenocarcinomas. resection for primary lung cancer seems to be preserved They do this as an adjunct to next generation sequencing for rare patients with limited residual lung function. I as the targeted automated PCR platform yields same day regularly report STAS and the presence of micropapillary results, something the oncologists really appreciate when pattern adenocarcinoma in my standard histopathology making treatment decisions in clinic. This is something I biopsy and excision reports. would dearly love to bring into my own department in the The second day was devoted to non-neoplastic
ACP news - Spring 2020 59 Articles pulmonary conditions, predominantly the many and varied interstitial lungs diseases. The approach was well United States 94 designed with contributions around case discussion from Canada 10 radiologists, respiratory physicians, and pathologists in Ireland 3 a collaborative MDT fashion. All were very impressive in their knowledge and the way in which they related to Mexico 3 one another. It reinforced what we who practice in this Australia 1 area all know: the diagnosis only comes from talking Slovenia 2 about the patient in detail, with all the information from all investigations before us. The faculty were fantastic; Brazil 2 they were very knowledgeable but also showed humility Qatar 2 and were willing to show a little vulnerability in sharing Portugal 3 past missed diagnoses. This is a good way to get your Netherlands 7 audience on side, I think. Anyone who hasn’t yet made an error in pathology is a fantasist or liar or hasn’t been Columbia 4 practising for very long! I particularly enjoyed the Japan 3 radiological talks that were a real insight into what is a New Zealand 2 truly skilful art, not unlike our very own craft. I learned much about the meaning of some of the terminology they United Kingdom 7 use, like mosaicism for example, also referred to as the Nambia 3 ‘head cheese’ sign by Drs Legasto and Gruden. It is seen China 3 as a result of air trapping in hypersensitivity pneumonitis. I had never heard of “head cheese” before. Beware FA list of global delegate origins vegetarians; it’s not cheese as we know it! It’s actually a bit like spam; pickled meat, often from the head of a challenging aspects of malignant pleural mesothelioma. pig or cow, set in aspic. Some call it ‘brawn’ in Britain, She included some of the challenges of pleural cytology according to Wikipedia. I digress. I might be able to have and reassured me that I’m not the only pathologist who an intelligent conversation with a thoracic radiologist finds this difficult. She recommends a histological biopsy now though. We’ll see ... for confirmation of mesothelioma where pleural fluid The third day was restricted to the morning, and focused and the accompanying cell block immunohistochemistry primarily on pleural diseases with sarcomas, thymic suggests mesothelioma for reasons which are clear to tumours, and pulmonary hypertension for good measure. see from many of the slides she showed. There are often Dr Saurer was an excellent speaker and covered some overlapping features of carcinoma and mesothelioma in mesothelial proliferations seen in pleural fluid cytology. It was particularly useful to know that many immunohistochemistry markers can give misleading results if done on cell blocks preserved in alcohol/ methanol-based solutions. It might be useful to add a disclaimer to all reports using immunohistochemistry on cytology specimens for that reason. She also reiterated that BAP1 is not very sensitive for detecting malignant mesothelioma but is pretty good in combination with MTAP, with sensitivities of between 78 and 84% (Kinoshita et al, 2018; Berg et al, 2018). Having had a couple of malignant mesothelioma cases (on clinical progression grounds) show retention of BAP1 staining recently, I think MTAP is going to be my next business case. We concluded the meeting with a few mystery cases, “Curb your ego”: my best mentors have taught me many of which had a lot of cytology pictures – a delight that over confidence in diagnostic pathology will be one’s downfall for me. Name me a single pathologist who doesn’t like a
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References Eguchi T, Kameda K, Lu S. et al. Lobectomy is Associated with Better Outcomes than Sublobar Resection in Spread through Air Spaces (STAS)-Positive T1 Lung Adenocarcinoma: A Propensity Score-Matched Analysis. J Thorac Oncol. 2019;14(1):87-98.
Qu Y, Aly RG, Takahashi Y et al. Micropapillary lung adenocarcinoma and micrometastasis. J Thorac Disease 2017;9(10):3443-3446.
Yeh YC, Nitadori J, Kadota K, et al. Using frozen section to identify histological patterns in stage I lung adenocarcinoma of ≤3 cm: accuracy and interobserver agreement. Histopathology 2015;66(7):922-938.
Kinoshita Y, Hida T, Hamasaki M, et al. A combination of MTAP and BAP1 immunohistochemistry in pleural effusion cytology for the diagnosis of mesothelioma. Cancer Cytopathol. 2018;126(1):54-63.
Berg KB, Dacic S, Miller C, et al. Utility of Methylthioadenosine Phosphorylase Compared With BAP1 Immunohistochemistry, and CDKN2A and NF2 Fluorescence Dr William Travis and me In Situ Hybridization in Separating Reactive Mesothelial Proliferations From Epithelioid Malignant Mesotheliomas. Arch Pathol Lab Med. 2018;142(12):1549-1553. quiz! They don’t exist, right? The delegates were a lovely bunch of people from all over the globe. Dr Travis showed me a list of country of origin of the participants registered for the course and the distribution was impressive. It was interesting and lovely to have the opportunity to talk to people from different centres and get an idea of the challenges they face working in healthcare. By and large they appear the same as in the UK but it’s worth noting that the man who works in Namibia probably has better access to next generation sequencing technology for testing his solid tumours that I do in Wales! I had a little time after the meeting to explore and found Manhattan a strangely familiar place to hang out, no doubt because of all the films that have been shot there. It’s a great city, where middle-aged men sing to themselves in the street quite unconsciously, and complete strangers ask how you are. I loved it! New York is like London but with better rhythm and a sunnier vibe. People are much more liberal with use of their car horns, which grated a little at 3am but hey, this is the city that never sleeps. I just didn’t know why until now! I would highly recommend this course which happens every two years. I’ll be back. Very many thanks to the ACP for their generous support The Hudson River from the top of the in helping me to attend this meeting. It was well worth it. Empire State Building
ACP news - Spring 2020 61 Articles
Where are they now? A survey of past awardees of the ACP Student Research Fund
For over 10 years the ACP has awarded small student • How did this project influence your current career research grants from the ACP Student Research Fund. direction? Most medical schools offer elective student projects in • Have you continued with any academic or labora- laboratory medicine, which often require small amounts tory work since completing the project? of funding for laboratory consumables. The ACP fund • What is your current post and broad career plans? gives undergraduates the opportunity to undertake research, to raise the profile of laboratory medicine All respondents to the survey indicated that the research within the minds of students, and to enhance postgraduate grant had a positive effect on their career progression – recruitment prospects. In turn, a successful undergraduate even if in one case, the project put them off laboratory project may lead to an intercalated degree, potentially medicine for good! Sixty percent of awardees reported acting as a springboard to an academic career pathway that they had been enrolled in or were applying for a such as the academic foundation programme or academic higher degree programme. The survey responses are clinical fellowship. presented on the following pages. The responses indicate Forty-four previous recipients of the ACP Student that the ACP Student Research Fund has had a positive Research Grant were contacted with a survey, and 10 influence on the career paths of medical students and previous recipients responded to the online questionnaire. continues to inspire the next generation of academic The survey included the following questions: clinical pathologists. All awardees are required to write an article about • Could you give the title or short sentence describ- their research experience for ACP news. Details of ing your ACP-funded research project? all awards offered by the ACP, including the Student • What were the main outcomes of the project? Research Fund, can be found on the ACP website: • Where did you undertake this project? (https://pathologists.org.uk/awards/).
62 ACP news - Spring 2020 Articles
Humphrey Kay – Gerry Slavin and John Lilleyman PostScript
OBITUARY J Clin Pathol: first published as 10.1136/jcp.2010.075788 on 4 March 2010. Downloaded from Humphrey Melville Edward Kay: an appreciation Humphrey Kay, who edited the Journal of Clinical Pathology from 1972 until 1980, has died at the age of 86. He succeeded the founding editor, Gordon Signy, and during his tenure consolidated the format of the Journal which largely holds to this day. Under his control and encouragement it became a monthly publication which attracted papers from all branches of pathology and stressed the clinical aspects rather than mere labora- tory aspects of disease. He was concerned with the concept of clinical pathology at a time when pressures from individual disci- plines seemed to be dividing pathology into independent and rather self-centred domains. This concern reflected his training at St Thomas’ Hospital and he initiated a series of reviews which crossed specialty disciplines, stressing the essential unity of clinical pathology. He recognised that managing laboratories was an important function of pathologists, to ensure the delivery of highest in also directly caring for patients with blood Humphrey has a unique place in their quality services to patients, when many gave diseases. Working at the Royal Marsden it is no evolution to his credit. His academic little thought to this and used the Journal to surprise that his particular passion was achievements were recognised when he was propagate messages concerning health and leukaemia, particularly of the young, and in appointed Professor of Haematology in 1982. safety in laboratories and the cost effective- 1968 he became secretary to the Childhood Throughout his career, a feature that ness of pathology services before it was Leukaemia Working Party of the Medical marked him was his infectious enthusiasm, a gleam in the eye of politicians. Research Council. In this role he was coupled with good humour so that in the He was a critical but always constructive undoubtedly the driving force behind most pressing circumstances laughter was editor. He was particularly kind to young or persuading a motley band of paediatricians, never far away. He was an accomplished inexperienced authors and many publica- haematologists and physicians from all over the musician. He wrote verse and (no mean feat) tions owed their acceptance to his advice UK to collaborate in a succession of multicentre won the New Statesman competition for
and sometimes major rewrites which he clinical trials for children with lymphoblastic a cautionary tale in the style of Hillaire Belloc http://jcp.bmj.com/ undertook himself. He was concerned that leukaemia. Such endeavours are now on ‘Frederick Worms, whose parents weren’t the Journal should not be parochial and commonplace for many malignancies, but were on speaking terms’. In 2002 he published should serve more than those brought up then extraordinary. The trial series took time, a volume of humorous verse entitled Poems in the British tradition. He encouraged arti- patience and persistence to garner support, but polymorphic. In retirement, he indulged his cles from overseas, with an eye for the Humphrey’s powers of persuasion prevailed. interests in natural history. He was an active wider world, and believing that the Journal When the first MRC trial began under his member of the Wiltshire Wildlife Trust and had an international function, introduced stewardship, less than 20% of eligible UK on its Council. In 1996, he was awarded the Editorial Board members from Europe and children were entered. By 1984 when he Christopher Cadbury medal of the national on October 3, 2019 at BMJ. Protected by copyright. North America. He would surely be retired, over 50% were being recruited, body of Wild Life Trusts for his conservation delighted that Editors have now come from a growing momentum that has continued to work. He served for 10 years on the National Canada and Australia. a present day accrual rate of over 90%. The Badger Advisory Panel. Humphrey was born in Croydon. When he most important outcome of the trials was, of Humphrey married April Powlett, was 3 months old he and his mother, course, an improving outlook. In the 1960s a consultant rheumatologist, in 1950. They a missionary doctor, joined his father an only around 10% of children with leukaemia had three children, two daughters and a son, Anglican minister in India. The family returned became long-term survivors. While Humphrey two of whom became doctors. April died in to England 4 years later. He was educated at was at the helm this figure went from less than 1990. He is survived by Sallie whom he Bryanston and St Thomas’ Medical School, 20% to over 50%. Today the figure is over 80%. married in 1996, his son and two daughters, qualifying in 1945. After national service in the Needless to say, the administrative and seven grandchildren and a recently born RAF, including duties with the Aden Protec- resource demands of this burgeoning great-grandson. He also leaves a stepson, torate Levies, he trained as a clinical pathologist research activity soon outstripped the orig- a stepdaughter and five step-grandchildren. at St Thomas’ Hospital, rotating through the inal support facilities (a small office in various disciplines, including a period seconded Onslow Gardens where Humphrey and one Gerard Slavin,1 John Lilleyman2 to Portsmouth. In 1956 he was appointed assistant had a Gestetner duplicator, several 1Emeritus Professor of Histopathology, Barts and the consultant clinical pathologist at the Royal filing cabinets and a coin to toss when 2 someone rang in for a randomisation), and London School of Medicine; Emeritus Professor of Marsden Hospital where he remained for the Paediatric Oncology, Barts and the London School of next 28 years. by the late 1970s the bureaucracy had shifted Medicine His initial approach was wide and not to Richard Peto’s Clinical Trial Service Unit constrained by the limitations of a single disci- in Oxford. These MRC leukaemia trials have Correspondence to Professor Gerard Slavin, 8 Normanhurst Park, Darley Dale, Matlock DE4 3BQ, UK; pline, but Humphrey was essentially a haema- since been held up as a huge success by latter [email protected] tologist. Not one who confined himself to the day oncologists and have formed a template laboratory, but one who was ahead of his time for phase III cancer studies ever since. J Clin Pathol 2010;63:283. doi:10.1136/jcp.2010.075788
J Clin Pathol March 2010 Vol 63 No 3 283
ACP news - Spring 2020 63 Article
Humphrey Kay was a truly remarkable man and he is song that Humphrey Kay wrote, sung to the tune of the remembered in this issue as one the founder members Flanders and Swan song – ‘Mud, Mud, Glorious Mud....’ of the British Society for Haematology which celebrates I am told that in the early days of the BSH they would all its 60th birthday this April. His talents and his life are sing it at the close of their meetings. nowhere better described than in this appreciation by our own distinguished members, Gerry Slavin and Unfortunately the planned 60th birthday party has been St John Lilleyman. cancelled because of Covid 19 but we can all enjoy a I have to thank Gerry for him telling me about the chuckle by singing it to ourselves.
THE HAEMATOLOGIST’S SONG An old haematologist was standing one day In an old haematology lab. He thought what a lot I I have missed that is gay Through pursuits that are dreary and drab. I’ve sat counting cells by the billion or more Till the corpuscles swim through my gaze And yet though my story be tedious and gory I will sing to the end of my days – Blood, blood, glorious blood Thicker than water and nicer than mud it’s sweeter, it’s neater, more pure yet completer, We’ll live by the litre on glorious blood The old haematologist whose story we’ve told Looked back to the days of his youth, To his work of a quality quite uncontrolled But when no one could question his truth. When clotting was simple and blood groups were few, Only God knew what lymphocytes did You could say “all that’s new is in Dacie and Lewis” And buy one for only a quid Blood, blood, glorious blood.... The old haematologist looked through the notes The case for the next CPC; There was no cause of death though the studies they’ve done Well as thorough as thorough could be Every test had been carefully repeated and checked In their efforts to keep him alive Sample spectacular, more drastic than Dracula, The total blood volume times five Blood, blood, glorious blood.... So remember whoever you happen to be, The more that comes from all that Though your blood the as blue as the sunniest sea Or as red as a cardinal’s hat. If it’s warm and it’s wet and it’s still gurgling round, It’s far better than any champagne So never mind whether a dearth or a plethora Let’s sing all together again Blood, blood, glorious blood...
64 ACP news - Spring 2020 Leadership
Getting to yes – Bridget Wilkins
Roger Fisher, William Ury, and Bruce Patton The four principles of principled negotiation are: Third Edition (2012), published by Random House Business Books, London 1. Separate the person(s) from the issue 2. Discover the interests behind positions and focus on the former 3. Create multiple options, looking for mutual gains, before deciding anything 4. Base the decision on agreed, objective criteria
Discovering the interests behind positions For example, my position might be that I want to book leave in the school holidays but, as I don’t have children, colleagues with children are always given priority at these times and I believe that I am always expected to be available. That’s my position. Examined a bit more deeply, the following might be some of my underlying interests:
• I have a particular trip in mind, only available in a school holiday • I want to spend time with other friends or family, This is a classic ‘golden oldie’ in leadership literature, including their children who will be on holiday first published in 1981. It’s still well worth a read if new • I want to have holidays when the weather is likely to you, and equally well worth re-visiting if you’ve read to be warmest and sunniest in the UK/Europe it before. On most days you can encounter something in • I want to feel that there is fair play in how leave is the national or international news that shows the ‘Getting allocated in my department to Yes’ principles in action. Sadly, the news currently also • I’m tired/frustrated/annoyed by repeatedly being reports many examples of negotiations doomed to failure asked to cover at short notice for colleagues need- because these principles are ignored; from rail strikes to ing time for childcare; I have other caring respon- climate change, from USA/China to Israel/Palestine. The sibilities (maybe elderly parents or a partner who concept of principled negotiation described in ‘Getting is unwell) and those aren’t noticed to Yes’ has proven world-wide relevance and has stood the test of time. But it doesn’t just apply on an organisational The issues underlying each of these potential interests and global scale; it is equally relevant in every person- are different and the negotiation to generate a positive to-person discussion where negotiating an agreement is outcome therefore needs to be different for each. Simply involved. negotiating to be allowed to take/not take leave in school The authors make the basic point that, to negotiate a fair holidays will produce at best a compromise and one-off and sustainable outcome, the negotiation must be about fix; at worst, a poor outcome might create unhappiness and the interests, rather than the positions of participants. increasing resentment over time, leading to deterioration Importantly, note the use of the term ‘participants’ in working relationships with my colleagues. I may have (stakeholders mutually engaged in problem solving) an additional, potentially conflicting, interest because rather than ‘parties’ or ‘opponents’ (stakeholders opposing I place high value on maintaining harmony with my one another in a dispute) from the outset. The authors colleagues. also draw a fundamental distinction between principled Broadly, interests fall into two categories – interests negotiation to achieve a wise, mutually beneficial in the substance of the issue itself (I want that holiday) agreement (win-win) and positional bargaining (win- and interests in relationships with potential participants lose or lose-win; often actually lose-lose). in the negotiation (I want to continue to have happy,
ACP news - Spring 2020 65 Leadership collaborative relationships with my work colleagues). understand their thinking. These may appear to conflict but the good news is that On the emotional front, it is important to acknowledge principled negotiation, like the approach described in the core concerns and issues of identity challenge that ‘Crucial Conversations’ (Patterson et al., 2012; see Read the other person(s) might have, empathising with them if to Lead article in ACP news Winter 2018 issue), is about possible and, if necessary, allowing them to let off steam creating multiple options rather than becoming locked without reacting defensively or offensively. into either/or choices. It is important to define interests accurately, considering Inventing options for mutual gain needs, desires, concerns, fears and motivators. One’s The concepts that the authors promote here are to avoid position is what you’ve decided on; your interests are premature judgement and consider many possible what led you to decide. For every interest, there are options rather than assuming that there will be a single usually several positions that, if revealed and explored, ‘right’ answer. They emphasise seeing the issue as a could satisfy. joint problem to solve, not just ‘their’ problem. Perhaps Each of us holds a core set of interests, of differing surprisingly, inventing options doesn’t come naturally, importance to us as individuals or in a particular situation. and negotiators may not sense much need; we tend to feel The main categories of interests are: we know the answer, plus or minus a bit of adjustment. The natural tendency is to try to narrow the gap between • autonomy (being able to direct our own actions) positions rather than broaden the options to address wider • appreciation (being valued for what we do and interests. who we are) However, either/or thinking narrows options and tends • affiliation (feeling that we belong in community to foster a win/lose approach. Solutions have to meet the with others) interests of both or all participants in the negotiation and • role (feeling that our actions support our purpose acknowledging the interests of others doesn’t mean that in life) you agree with them; it can help identify solutions that • status (feeing acknowledged for expertise/ might satisfy them as well as you. The key strategy is to authority) separate inventing from deciding and to engage in mutual brainstorming to invent multiple options. Take the best Interests can be identified by asking ‘why?’ (why have ideas from these and improve them further, still without I taken up this position?) and ‘why not?’ (what are the deciding; making a final choice will then typically be reasons why others might oppose my position?) It is easier for all involved. Brainstorming together (not important to recognise there are likely to be multiple necessarily face-to-face but contributing equally to interests on both/all sides in any dispute. the process) is often the most productive time in any negotiation. ‘Getting to Yes’ contains several good models Separating the people from the problem and strategies to support productive brainstorming, and The authors emphasise that, in any negotiation, there is the authors point out that everyone has, at the very least, always a relationship to consider as well as a substantive a shared interest in avoiding mutual loss. There is almost issue. Relationship considerations require us to pay always the possibility of a joint gain. Differing interests attention to communication, perception and emotion. are often, in truth, not barriers but enablers; something In the arena of communication, it is likely that may be of high value to you and low value to the other(s), others will hear a message different from the one you which can offer the basis of agreement. intend; misunderstanding and misinterpretation are to be expected. To avoid this, use active listening, Insisting on objective criteria acknowledgement, reflection and checking (note: using This may seem obvious, but the key point here is to some conversational and coaching skills learned through avoid, at all costs, reconciling differences on the basis of the ACP’s National Leadership Skills Programme will prevailing will. Solutions should be based on principle help you do these confidently!) Use positive language and and reason, not on pressure or coercion. Also, take any speak to be understood about your interests, not theirs. need to trust each other out of the equation. If participants The aim is to achieve non-adversarial joint problem- can agree that an objective standard or process for solving whenever possible. deciding the outcome is fair, then trust is unnecessary. Regarding perception, the key consideration is to see A memorable analogy of two children sharing a cake is the issue from the other person’s perspective and seek to presented. For a fair outcome, if one child cuts the cake
66 ACP news - Spring 2020 Leadership and the other chooses which piece they want, both will on interests, not positions, and the authors recommend have a shared interest in dividing the cake equally. Trust using negotiation jujitsu – not pushing back against or the lack of it doesn’t need to come into the equation their resistance but side-stepping and diverting energy (only parental concern about the use of knives by young into exploring interests, inventing options and seeking children!) In negotiations in general, fairness can also be independent standards. Treat their position as one addressed by strategies such as taking turns, drawing lots, possible option and assume they are genuine in seeking or letting someone else decide for both parties. negotiation. Invite, rather than reject, criticism of your ideas, ask what they would do in your situation and don’t ‘Yes, but …’ take their criticism personally. Re-cast it as an attack on All of the foregoing sounds fine in theory but you may the problem. Ask questions and allow enough silence already be thinking rather negatively about the likelihood (another great coaching technique); the others may be of applying these principles to your own real conflicts. compelled to break this silence with new suggestions. A large section of the book addresses such concerns and Another approach is to bring in a neutral or objective emphasises the vital skill of ‘knowing your BATNA’ third party to mediate. The authors describe a “one-text” (Best Alternative To a Negotiated Agreement). Your procedure, with incremental drafts being produced by a BATNA gives you power through making clear what you third party or mediator for mutual criticism without early are prepared to walk away with (or without) if negotiation expectation of agreement. This can lead ultimately to an fails. There is a great deal more about BATNAs in easy yes/no choice to either accept the mutually crafted this section of the book – too much to include here solution or reject it. Other advice from the authors is but definitely worth reading when preparing for any always to avoid agreeing in the heat of the moment; make significant negotiation. an agreement to come back later after thinking about any Here are some of the other ‘yes, but’ topics that the offer. For your part, make it easy for the others to say yes authors address: and remain appreciative of their efforts to engage.
What if they are more powerful? What if they use dirty tricks? Aim first to protect yourself from making an agreement The tip here is to negotiate about the negotiating process that you should reject (have a bottom line but be aware itself, rather than the substantive issue. Recognise that this may limit you unhelpfully sometimes); better the tactic being used (see below), acknowledge it to know your BATNA, as described above. It is unlikely explicitly, question its legitimacy and negotiate over that any arbitrarily selected bottom line truly reflects the it. We need to learn to spot one-sided ploys so that we full scope of your interests. People negotiate in order to don’t accommodate, appease or counterattack. The usual achieve an outcome better than the results they can obtain rules of principled negotiation apply but are focused on without negotiating; those results represent your BATNA, process, not the issue itself. In the last resort, turn to your providing a solid standard against which to measure BATNA and walk away; don’t play the same game that a negotiated offers. Your BATNA is better than a bottom tricky opponent (in this case, the “O” word is justified!) line and allows for more inventiveness for solutions. Also is playing. have a ‘trip-wire’ in mind, as an early warning that you are nearly at the stage of accepting your BATNA, while What are these tricky tactics? The authors describe: you still have some room to move. Consider the desirability of disclosure to the • Deliberate deception (this is different from other participant(s), which will differ depending on incomplete disclosure to maintain a safe power circumstances; it might either strengthen or weaken your balance; it’s a matter of intention). negotiating position by making the other participant(s) • Ambiguous authority – aiming for a ‘second bite’ more or less confident that you’ll agree terms in their after appearing to agree in the room. Establish their favour. Also consider what their BATNA might be. true authority and agree that nothing will be agreed Abandoning attempts to negotiate and accepting each until everything is agreed (avoid a slippery slope of other’s BATNA can be a mutually successful outcome, if concessions). both participants have attractive BATNAs! • Psychological warfare – examples include situations that establish a stressful physical environment for the What if they won’t play? negotiation, personal attacks, threats and good guy/ You can anticipate contagion if you persist in focusing bad guy routines. These build pressure, risk escalating
ACP news - Spring 2020 67 Leadership
counter-threats and make reaching decisions harder, Additionally, you may enjoy ‘The Power of a Positive not easier. Threats can be handled by ignoring them, No’ (William Ury, 2007, ISBN 9781444719925), which not taking them as having authority, regarding them as is more focused on using these concepts to achieve over-hasty or irrelevant; you can also make it riskier greater personal confidence in making decisions to say to make threats (for example, recording conversations either ’yes’ or ‘no’ when faced with important matters. for evidence). Make a virtue of communicating that There is some overlap in content between the three, you negotiate on principle only, and not in response which I experienced as useful reinforcement rather to threats. than unwelcome duplication. All three are available in • Positional pressure tactics – e.g. refusal to negotiate. paperback and electronic formats. Find out what’s behind this and suggest some ways forward (third-party mediation, shuttle diplomacy Bridget S Wilkins, ACP National Leadership Skills etc.). Insist on being principled; what are the principles programme co-ordinator they’d want to apply? • Extreme demands – ask for justification of the demand, based on objective evidence or standards, rather than accepting their assertion. • Escalating demands – notice this is happening and Be soft on the people, hard on the issue bring it into the discussion; consider taking a break to avoid pressure to agree quickly in order to avoid further concessions. • Lock-in tactics – avoid making commitment to agreement central to the negotiation; de-emphasise it and encourage ongoing invention of options. Even if blaming is justified, it is usually • Hard-hearted partner – as often happens in purchasing counterproductive a car; Mr Soft (salesman) wants to make you a favourable offer but needs approval of Mr Hard (boss) in another room. Recognise this ploy and aim for agreement in principle from Mr Soft; try to speak with Mr Hard directly (if he is real!) • Calculated delay – they attempt to defer decision to a time more favourable to them. In response, try to Acknowledging achieve credible, mutually acceptable deadlines. is not agreeing • Take it or leave it – consider ignoring this at first. Look to help them save face if they negotiate. Don’t be a victim; keep your BATNA in mind.
And finally … The final section of the book is an exploration of 10 questions about fairness, about dealing with people, Know your BATNA about practical strategies for negotiating, and about handling power imbalances. This is really helpful real- life background, with lots of examples, for some of the more complex ideas that inform principled negotiation. There is a great deal more to explore in ‘Getting to Yes’ – concepts and approaches I haven’t had space to include, as well as many illustrative and engaging real-life examples to help explain the theory. If you find the themes of this Like it or not, you are book compelling, you may also like to read ‘Getting a negotiator Past No’ (William Ury, 1991, ISBN9780712655231), which describes how principled negotiation can be used to negotiate effectively with ‘difficult’ people.
68 ACP news - Spring 2020 Book Review
That Good Night by Sunita Puri – Elza Tjio of Harrogate and District NHS trust
This is a fantastic over life’s inconsequential trivialities? What would be a offering from priority to you in the remaining 24 hours? What would Sunita Puri who, you want to tell your family? And how would you like to through her work be remembered? It is a sobering reflection, which really as a palliative care forces one to be honest with oneself. doctor, has crafted Puri has the same opportunity for introspection through this masterful her work. And in her book she articulates her thoughts account of her beautifully, furnished by the intimate interactions with experiences. her patients facing death. These are vividly written, and it I found her is almost as though you are at the patient’s bedside with instantly relatable: her, navigating their way through the uncertainties of a young female prognosis and treatment; medicine’s ‘educated guess’, as professional, with she describes it. familiar anecdotes She also considers what a good death is. This is, of about the trials course, a difficult concept, especially for many who often and tribulations contemplate death as some kind of ‘failure’ or ‘battle of being a doctor, lost’. But even trickier is what a good life is. Many of all effortlessly Puri’s patients die quickly – patients who are referred to interwoven with stories of her childhood and her parents’ her have a life expectancy of six months or less – but lives as first generation immigrants in America. Born some she describes as ‘dying slowly’. With each passing to an anaesthetist mother and an engineer father, she day, normalcy takes on a new meaning for them, as their describes her route into medicine as an attempt ‘To follow lives shrink into their homes and finally a single room. her mother’ to where she had gone. Puri alludes to the Puri understands fully the difficulties of having honest huge sacrifices her mother makes as a full-time career conversations about death. Although clearly experienced woman juggling childcare and her commitment to her job and skilled in managing the complex emotions that arise – undoubtedly something many doctors will understand with such conversations, she admits struggling when she first-hand. had a conversation with her parents on the subject. She Although this book will strike a chord with any medical wanted to know what their advanced directives were, professional who has been at the ‘coalface’ and had to and found herself fighting with the intense feelings have difficult conversations with patients about death and the conversation inevitably stirred. Nevertheless, she dying, it is probably a worthy read for anyone who has acknowledges the importance of having discussed this experienced (or will experience) loss. That means it is, by with family members, especially when individuals are definition, a book for everyone. well, because too many people put off the discomfort of In this age of modern medicine, many of us are living this discussion until it is far too late. into increasingly old age. Yet this does not seem to make I’ve taken the first step to recommend this book to my us any more prepared when death and incapacity signal family – my hope is that this will be the impetus for frank their arrival. It is this reluctance to recognise death, and conversation. Puri is unpretentious and humorous and so the lack of understanding that planning for a good death this is not a preachy treatise about advanced directives. I is integral to good medical care, that Puri grapples with enjoyed it immensely. every day in her work with terminally ill patients. My parting message would be we need to talk about As a pathologist who undertakes coronial autopsies (a death, especially when it seems so unlikely – because dying breed, pun quite intended), I feel I have regular it is not; it is inevitable. And you’d know that I am opportunity to reflect on mortality. It is not morose in deadly serious. the slightest. Rather, I am of the firm opinion that, it is when being fully aware that life is transient, we choose Reference to truly live. Imagine if it was your last day alive today 1. Puri, Sunita. That Good Night: Life and Medicine in the – what would you do? Would you lose your temper Eleventh Hour. Viking, 2019. ISBN-13: 978-0735223318
ACP news - Spring 2020 69 Addendum - written 14/03/2020
Newspaper headlines mid-March
No sooner had the ink dried on the previous piece be made available through GP surgeries. when another news conference was held with the Prime The non-interventionists counsel against panic stating Minister, the Chief Medical Officer of Health Prof Chris that we must be seen to be acting proportionately, and Whitty, and the Chief Scientific Officer Sir Patrick that early overreactions would result in a loss of public Vallance. The global and national situation regarding this confidence in expert advice, with less cooperation should pandemic is evolving rapidly and the situation is fluid. On the epidemic worsen. 12 March 2020 it was reported that there were almost 600 Boris Johnson’s statement was stark, even by the confirmed infections within the UK, and that it was likely standards of someone often criticised for his lack of that there were in actuality at least 5,000-10,000 cases. sensitivity, he boldly asserted that “many more loved It was also noted that the spread of infection in the UK ones will die”. A more measured statement would have is following a similar trajectory to, and is approximately been to the effect that the epidemic is progressing. That four weeks behind, Italy. will inevitably involve more deaths; why he chose to There have been widespread discussions on the speak of loved ones rather than people in general puzzles most effective course of action, with politicians of all me. It could be seen as a mark of a certain kind of shades joining in with the camps separating into the politician who wishes to make a drama out of a crisis. interventionists and non-interventionists. Jeremy Hunt, One of his aides suggested this much with the story about currently the chair of the all-party health committee Mr Johnston’s love of the film Jaws, and that he most advocating rapid action cited the success of the lockdown admired the sheriff who refused to close the beach whilst measures in China, where new cases are currently rare. the shark was in the area attacking swimmers. His point was that the countries that took control quickly Sir Patrick Vallance explained the strategy now was to such as Singapore and Thailand have had fewer cases. let the virus spread, stating that it could become endemic South Korea has shown how it is possible to turn the and recur on an annual basis. Containment no longer situation around and one of their key weapons in this possible, the expected countermeasures are to delay fight has been extensive testing of suspected cases. the spread leading to a flatter peak, i.e. a slower spread. Current, English policy is against this, and is only testing This would mean that hospitals were less likely to be selectively, but I understand that in Scotland testing is to overloaded by a sudden peak and therefore more patients
70 ACP news - Spring 2020 Addendum - written 14/03/2020 would be treated and over a longer period of time. no infection control measures should be allowed in Kent Questioned on why there were no plans to cancel large and the vulnerable move to the north of Scotland for their gatherings, a crowd of 75,000 expected to watch the own protection. rugby at Cardiff on Saturday 14 March, his reply was that There is confusion between self-isolation – he did not expect much spread to take place at stadium. recommended for those who have the virus – and reduced He went on to say that cancelling the game would lead social contact for other categories of people. to people congregating in pubs, and the spread was The public are advised to use NHS 111; having more likely to take place there. He gave no evidence a niece with a cough we did this. There were two simple to substantiate his views. Personally, I would question questions: their validity because stadium seats are close together and people squash together both on the way in and out, up and down the stairs, through the tunnels and narrow 1) Is this a new and persistent cough? entrances. Most people get there well before the match 2) Is there a fever? to enjoy the atmosphere and entertainment. Supporters of the winning side often staying on for celebrations, such As the answer to those two was no, we were advised as a victory lap. Therefore, people are in close contact that we did not need to take further action. More for probably three hours or more and may well be close information is available from other sites, but the official together travelling to the match. source of information was insufficient to help people with A decision to ban the match would be a clear public the natural concerns they would have if they ever needed statement that they take the risk of infection seriously, guidance on how likely they are to be exposed to the virus and I expect that would send a signal to all people to or infected. avoid crowded places, including crowded pubs, and What is clear is that we have not learned enough about I would expect more people to enjoy the match played how to handle an epidemic to get the best information behind closed doors in the benefit of comfort and privacy to help us in the future; we need to make the most the of their own homes. information we can acquire now. That means widescale We do not know how many people would choose to go testing to assess the prevalence of infection, now and to a pub nor how crowded pubs would be but certainly less travelling would be involved and there are many over the next few weeks and months. A busy time for our spacious pubs where there would be less person-to-person colleagues in virology. contact. Should the pub get too busy then people can As we go to press, the situation is changing rapidly, pop home without losing out on having paid an entrance public health professionals have criticised the official fee. This area clearly needs to be researched properly approach as WHO guidelines recommend widespread before authoritative statements can be made. Unguarded testing. Some have stated that the reconfigured public comments can only weaken the credibility of experts health system has left insufficient capacity in the labs to at a time when many people are wondering who they do this work on time. can trust. In Scotland, gatherings of more than 500 people are The press conference was not well received, as shown to be banned. Governments are in conversation with the by the newspaper headlines the next day. On Friday motor industry with a view to diverting some work from afternoon there had been a complete U-turn, the rugby crop production to making ventilators. Europe is now the cancelled, major football games suspended for six weeks, epicentre, with Italy, Spain and France the worst affected, and many other gatherings cancelled or postponed. and they are banning mass gatherings. Air travel from Experts were lined up by the media and the UK advice Europe to the USA has been banned. The Federal reserve was that the correct approach was to allow the virus to has reduced interest rate to 0.25% in an effort to stimulate spread so that herd immunity could be developed, the better to protect us in future years. That would mean the economy. In New York and Los Angeles entertainment accepting more deaths of vulnerable people with tabloid venues such as theatres and nightclubs are to close. headlines announcing that the proposed rationing of care In the UK, in response to mounting criticism of a poorly would mean that the elderly will not be treated on ITUs. coordinated communications strategy with contradictory One epidemiologist suggested, whilst recognising the advice, Downing Street is to launch a series of impracticality, that the elderly could survive if they are daily briefings. geographically isolated. He went as far as to suggest that The situation changes by the day.
ACP news - Spring 2020 71 Association of Clinical Pathologists
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ACP
NOTICE OF ANNUAL GENERAL MEETING
Notice is hereby given that the 2020 Annual General Meeting of the Association will be held by telephone on Saturday 6 June 2020 at 1pm
Please dial UK: 0808 100 5145 Participant code: 82780226#
AGENDA
1) Minutes of the last Annual General Meeting held at The Royal Society of Chemistry, Burlington House, Piccadilly, London on 11 June 2019.
2) Business arising therefrom.
3) To announce the re-election of the Honorary Officers.
4) To announce the election of Ordinary members of Council.
5) To appoint Parkers, Chartered Accountants of Brighton, East Sussex to hold office as accountants of the Association for the ensuing year.
6) To authorise the Council to fix the remuneration of the accountants for the year ended 31 December 2020.
7) To announce the election of the President elect.
8) Any other business (of which statutory notice of 21 days shall have been received).
J Burton Chair of Council
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