ACP news - International Liaison Meeting of Pathology Presidents The Growth of Genomics Working in Singapore The Transition - Trainee to Consultant
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The Association of Clinical Pathologists Winter 2019
ACP news
International Liaison Meeting of Pathology Presidents
The Growth of Genomics
Working in Singapore
The Transition – Trainee to Consultant
Association of Clinical Calendar of Forthcoming Meetings & Courses
Pathologists
DIARY DATES FOR 2020
Officers
President Date Title Venue Contact Details
Dr C Gray
Past President Friday 27 Introduction to The Dome 01273 775700
Dr W Simpson March 2020 Leadership & Hotel du Vin info@pathologists.org.uk
Management in Brighton www.pathologists.org.uk
Chairman of Council NHS Pathology
Dr J L Burton & Hot Topics
Secretary Tuesday 9 National Leadership Royal Society of 01273 775700
Dr K Skordilis June 2020 Skills Meeting Chemistry info@pathologists.org.uk
www.pathologists.org.uk
Treasurer
Prof P Twomey Wednesday Thoracic Pathology Royal Society of 01273 775700
10 June 2020 Update Day Chemistry info@pathologists.org.uk
Editor www.pathologists.org.uk
Dr E Watts
9-11 September Advanced Leadership Chilworth Manor 01273 775700
Assistant Editors 2020 & Management Southampton office@pathologists.org.uk
Dr M Clarke Course www.pathologists.org.uk
Dr G Watson
Dr T Bracey
External Events
Dr S Elcombe
Education Secretary 5-6 March Liver Biopsy Royal College of UKLPG
Dr A Pugh 2020 UKLPG Pathologists, 6 Alie St www.virtualpathology.
London leeds
Management Course
Organiser
Dr B Wilkins
Secretariat
The Association of Clinical
Pathologists
189 Dyke Road
Hove, East Sussex, BN3 1TL
Tel: 01273 775700
Fax: 01273 773303
email: info@pathologists.org.uk
The ACP accepts no liability for errors or omissions in this calendar of meetings.
http://www.pathologists.org.uk
Readers are reminded that advertised meetings may be cancelled. Those intending
Administrator to attend are obliged to check the details on booking with the organiser in every
Mrs R Eustace instance. There will be a £25 administration fee per issue for entries in this table.
Correspondence should be addressed to:
The Editor,
Association of Clinical Pathologists,
189 Dyke Road, Hove,
East Sussex, BN3 1TL
Email: acpnews@pathologists.org.uk
©acpnews 2019 all rights reserved.
No part of this publication may be reproduced
in any way whatsoever without the permission
of the Association of Clinical Pathologists.
Charity registration number: 209455
ACP news
Winter 2019
Contents
P4 Invitation to contributors
P5 Editorial
ACP BUSINESS
P7 International Liaison of Pathology Presidents’ Meeting, Colleges of Medicine of South Africa (CMSA) – Julian Burton
ARTICLES
P11 Sicily, Florence and Lake Garda: corpus and corporeality – Carl Gray
P16 On the value and quality of case reports – Julian Burton
P18 Publish, but don’t be damned. How to spot predatory and fake journals – Julian Burton
P20 The life and work of Paola Domizio – Eric Watts
P23 The onward march of the genome – Eric Watts
P27 The public image of genomics: from the dizzy heights of high science to the depths of general ignorance – Eric Watts
P28 How to inspire histopathology trainees in autopsy practice – Dr Esther Youd
P30 Trainee to consultant: making the transition – Dr Elza Tjio
P32 Are we counting what really counts? – Eric Watts
P34 The lighter side of counting what counts – Eric Watts
P37 Apple, peach, pear, plum? – Eric Watts
P38 My three-year Singapore sojourn – Ian Chandler
P42 The travelling trainee; a Leonardo da Vinci painting, a salt mine, and the pathologist of Auschwitz – Dr Matthew Clarke
P46 Immunoglobulin problems – matching supply and demand – Eric Watts
P47 Switching immunoglobulin products, what are the implications? – Claire Bethune and Richard Herriot
P49 Haematology Christmas Quiz
P50 Letter from America – Eric Watts
P50 Seeing the patient behind the slide – E. Blair Holladay
P51 Pleasures and perils of working in the old lab – Eric Watts
P53 Paracetamoxyfrusebendroneomycin – Adam Kay and Suman Biswas
P54 A special Christmas surprise – Prof Humphrey Kay
CASE REPORT
P55 “Lobular” linitis plastica – Tim Bracey
ACP GRANTS AND REPORTS
P56 ACP Education Awards 2019
P57 Travel fund award report – Dr Sabina Kaur Mistry
P59 ACP Student Research Fund 2019 – Elinor M Roderick
LIFE OUTSIDE WORK
P60 Creating a world in miniature – G Watson
P63 Scotland: Skye and Hebrides SUP venture – Tim Bracey
BOOK REVIEW
P70 Diagnostic Cutaneous Pathology: Clinicopathological Correlation of Inflammatory and Other Non-Neoplastic Skin Diseases – a
Textbook and Atlas – Dr Charles Keen
ACP news - Winter 2019 3
Cover Picture
Alyn Cratchley, from Leeds came across this beautiful example of Rudolph in a
fibroadenoma in August.
Maybe Christmas comes early in Yorkshire?
Invitation to Contributors
In addition to the constant flow of material from ACP Council, the UK libel laws!
ACP committees and ACP branches, ACP news needs new Trainees: Trainees are especially encouraged to submit
material from you, the members of the ACP. material in any and all of the above categories. These will
normally be placed in the trainees’ section. Appointments
Pathology news items (1200-1500 words): Any items committees in particular value publications in ACP news.
related to the ACP or the College, pathologists in general, or
medical and management matters that may have an impact on Editorial Policy: The editor would particularly encourage
pathologists. overseas contributors, material from trainees, material from
non-histopathologists, commentary on current affairs in
Articles (1500-2000 words): These can be papers, reviews, pathology, occasional columnists, innovations in pathology,
essays, commentaries, critiques or polemics. Submitted articles humorous writing on pathology-related topics, and anything
are always very welcome, as well as suggestions for articles and/ downright cantankerous.
or details of people whom the editor may approach.
Format: The ACP news style guide is now available on
Reports (1000 words): These may be personal views and line via the ACP website in PDF format at: http://www.
reports on interesting meetings, travel or anything else of pathologists.org.uk/allpagestuff/publications_frameset2.htm.
interest to the readership. Travel reports are specifically for The publication is a magazine, not an academic journal, and
holders of ACP travel fellowships; however, other reports from long lists of references are generally considered unnecessary.
abroad are welcomed. Where given, references should be in the Vancouver style and
should be kept to a maximum of around six per article, unless
Columns (600 words): Regular and irregular columnists absolutely necessary. Alternatively, authors may prefer to give
exercise their thoughts. Please feel free to rant. a recommended reading list, or a list of relevant internet links.
The editor prefers these as they take up less space.
Pathological creative writing: All literary forms, including
short stories, serials, surrealism and even poetry. All suggestions are welcome; however, the editor’s decision
is final.
Appreciations (1000-1500 words): We prefer appreciations
on retirement, rather than obituaries. Please discuss these with ACP news is published quarterly. Regular publication dates are:
the editor before submission.
Issue Publication month Copy date
Photo-journalism: Favoured subjects include pathologists SPRING February 5 December
doing something interesting, or College and ACP officers SUMMER May 5 March
doing anything at all. Interesting or artistic photographs are AUTUMN August 5 June
welcomed. WINTER November 5 September
Cartoons: Suggestions are welcomed. Copy is best submitted by email, in any version of Microsoft
Word, although it should be possible to accommodate other
Curettings: Jokes and humorous titbits are always needed. formats. Submissions on paper by snail mail will also be
accepted. Illustrations should be sent as JPEG digital images
Debate: Letters to the editor are welcomed, but may be or hard copy prints. Please do not embed images in your text.
shortened for publication, or even converted into articles. Send them as separate files.
Please try to refrain from writing unless you are prepared to be
published. All criticisms of organisations or named individuals Please send email submissions direct to the editor at
will entitle the parties to a right of reply. Please bear in mind acpnews@pathologists.org.uk
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 - Winter 2019
Editorial
Winter brings a pot pourri of the pleasures and perils of
the pathologist’s life
One, if not the greatest, of all pleasures has to be
working with inspiring colleagues; following the article
on the life of Sidney Dyke I have discovered interesting
accounts of great works by other pathologists whose
contributions can too easily be taken for granted by later
generations.
One pathologist who made a substantial impact,
particularly in the field of pathology education, was
Paola Domizio, who also made great strides in paediatric
pathology. She took the bold step of showing children
with gut diseases their resection specimens. This radical
departure from the conventional pathologist role was a
great help to those children who had to cope with long- Your editor
term conditions.
Julian’s report from the International Liaison meeting the number of publications, I well remember searching
of Pathology Presidents helps to show that the UK is a for suitable journals. Not everything I wrote got into
major player in international pathology and that many of the major publications but eventually my first piece of
the issues that affect us are worldwide. We certainly have research came out in print and colleagues noted that I
problems with workforce but not on the scale of some have been forced to start with a periodical known to be a
other countries, and we are making progress in respect refuge for desperate authors.
of education. The progress of artificial intelligence is Predatory journals are increasing in number and
certainly an exciting area but with the possibility of major sophistication. I no longer publish any original research,
problems unless there is careful scrutiny and rigourous but I do write occasional commentaries and I was flattered
evaluation. to receive invitations to write for journals with impressive
We have accounts of travel to foreign lands, fascinating titles. Following Jules’ advice, I looked at the editorial
collections of experiences, work in Singapore, classical board to find not a single name I recognised, even some
history in Sicily, and the genuinely horrifying history of of the job titles were strange. The journal title was very
World War II to be found in Poland. Matt Clarke’s account close to the Journal of Internal Medicine, the front cover
of the visit to concentration camps is made all the more and layout looked authoritative but I noted that the
chilling by the knowledge that doctors had collaborated. editor-in-chief had, as his main qualification , Doctor of
This article was written at the same time as the annual Osteopathic Medicine, which made me cautious and then
Festival of Remembrance, reminding us of the moral I received an invitation to join them as lead guest editor,
purpose of that particular war. so I realised their standards needed to be improved. And
Pathology is largely about measurement and counting yet it all looked so plausible; once again, the devil is in
is a necessary component of much of the work in blood the detail.
sciences, but I look at whether we are counting what We also have excellent reports of grants and bursaries,
really counts and as always I welcome the views of showing how well members’ monies are being spent.
readers, especially any who have experience of measuring One long established tradition in the ACP news has
consumer satisfaction. been travelogues of adventure in mountainous regions
Thanks as always to the assistant editors for excellent but for this issue Tim Bracey has combined travel in the
and varied contributions and a special welcome to new Scottish Highlands with paddle-boarding on the coast and
contributors with a timely update from Elza Tjio on in lochs – an impressive adventure. I would have loved
the transition from trainee to consultant; it is notable to to have joined him if only I could keep up the pace and
compare this with Ed Carling’s description from eight as a fellow water-sports lover I would take my canoeing
years ago. Some aspects of the work have changed, much helmet off in salute, were it not firmly attached with a
remains the same. chinstrap!
Julian also warns us about predatory and fake journals
– an easy trap for those keen to get published. As a Eric Watts
trainee, well aware that promotion depended in part on Email: eric.watts4@btinternet.com
ACP news - Winter 2019 5
Editorial
NEXT ISSUE
The welcome return of Spring - the picture
was taken in faraway lands celebrated for its
beautiful blossoms.
No prize for guessing where it is! There will
be plenty of information and travel tips in the
spring and subsequent issues.
www.pathologists.org.uk
ISSN No. 0260-065X
6 ACP news - Winter 2019
ACP Business
International Liaison of Pathology Presidents’ Meeting, Colleges of Medicine of
South Africa (CMSA), Cape Town, South Africa, 3-4 October 2019 – Julian Burton
Dr Julian Burton is the ACP Chair of Council The lack of pathology research may well be a function
Email: j.l.burton@sheffield.ac.uk
of a lack of pathologists. When pathologist numbers are
The International Liaison of Pathology Presidents (ILPP) low, pathologists become swamped by the clinical work,
was started in the 1960s by the College of American leaving little or no time for research.
Pathologists as a way to bring together the English- The WHO has launched a global initiative for childhood
speaking pathology societies around the world, with an cancer, with two aims: increased prioritisation of childhood
aim of sharing expertise. The 2019 meeting was hosted cancer through awareness-raising at global and national
by the Colleges of Medicine of South Africa and took levels, and expanding the capacity of countries to deliver best
place in Cape Town in the shadow of Table Mountain. practice in childhood cancer care. IARC will be producing a
The meeting was opened by Professor Johnny Mahlangu, WHO book for paediatric tumours in the next year.
President of the College of Pathologists of South Africa. The World Health Organization has made a declaration
After a round table series of introductions and declarations to reduce cervical cancer to a very low level within
of conflicts of interest and confidentiality, we got down to populations (four cases per 100,000 population). The
the business of the day. It was evident even as the meeting incidence cannot be reduced to zero with current
began that some of the main challenges faced by the learned interventions, but this elimination threshold is considered
pathology societies present are a global lack of pathologists, attainable in all countries in the 21st century. Models
difficulties maintaining standards when teaching and demonstrate that vaccination alone will be insufficient,
examining students and trainees, and a general lack of visibility and screening will still be needed.
of pathology amongst the rest of the medical profession and The fifth series of the WHO Classification of Tumours is
the general public. South Africa, for example, has a population in development. The fourth series of the blue books took 12
of 58 million, served by only 1,000 pathologists. Despite this, years to develop and was not in the hands of pathologists.
South Africa is a net exporter of pathologists. Having been With the fifth series, the process is being managed by a
well-trained in South Africa, pathologists then move overseas pathologist (Dr Cree), who has appointed an editorial board
to practice, resulting in a shortage. of pathologists nominated by learned societies around the
world. The expertise and geographical spread of these
Professional practice individuals was reviewed to set up a standing board. For
Our discussions began with a consideration of the theme each subject area, experts chosen by bibliometrics have
of professional practice. How can we gain new evidence been invited to participate. This encourages younger
to support advances in cancer care? The World Health active academics to participate. The editors corral up to
Organization representative reported that overall there 200 authors per book to produce these texts. The books
remains very little pathology research. Globally, very few on breast tumours (currently only available online) and
systematic reviews are being undertaken. Pathology is digestive tract tumours have already been published online.
seen to have been slow to adopt evidence-based practice, Work is now beginning on female genital tract tumours
with a tendency to the publication of case reports and and thoracic tumours. The online texts include whole-slide
small series rather than large studies. There is a need images and work on mobile phones on 3G networks and on
to educate pathologists in research methodologies, and iPads. At present we do not know how many pathologists
move to evidence-based pathology and away from there are in the world but with bulk discounts it is hoped
eminence-based practice. WHO pathology is trying to that people will sign up and we will begin to know the
move towards evidence and away from eminence. The numbers. The aim will be 160 euros for all books available
meeting considered it desirable to move away from ‘high online as an annual fee.
power fields’ to standard international units, and to a more The International Collaboration on Cancer Reporting
scientifically rigorous classification of tumours. There are (ICCR) and the IARC work in sync but there is no overlap
opportunities to stimulate residents to undertake research between these two organisations.
as part of training. The International Agency for Research
on Cancer (IARC) is hoping to produce online tools to Cervical screening in Ireland
assist pathologists in developing these skills. Systematic At the ILPP meeting in 2018, concerns were raised
reviews are counted as primary research. regarding the future of cervical screening in the Republic
ACP news - Winter 2019 7
ACP Business
of Ireland. These followed a court case regarding an part of the histopathology report but this has not yet been
interval cervical cancer that was allegedly missed by attained in all EU countries.
screening. The patient had not been told the results of her In Canada, most molecular testing is done in laboratories
audit. The case was settled in the patient’s favour (for a run by scientists with variable oversight from pathologists.
multi-million Euro sum) and has been very damaging to Integration of molecular data into histopathology reports
the public perception of pathology. is becoming difficult in some laboratories.
Subsequently there have been two more court cases In Malaysia, laboratory supervision is strongly protected
(again resulting in large settlements). Judgments have by legislation but regulations are still in development.
stated that there should be absolute confidence (100%) University hospital laboratories are under supervision by
by a cytoscreener before a slide is called negative, and pathologists, but private laboratories that are overseen by
otherwise the case should be passed to a cytopathologist. clinical scientists are emerging.
The wider issue is that this might extend into diagnostic In the US, practice is mixed. There doesn’t have to
practice outside of screening programmes (where 100% be a pathologist or physician overseeing laboratories
accuracy cannot be attained in diagnostic histopathology, for accreditation. Some laboratories are overseen by
although many users of a pathology service likely do not pathologists but some are overseen by PhD clinical
recognise this). Appeals are in progress, but this issue scientists. Practice may be split across numerous
may reverberate internationally. laboratories in an institution.
Work is ongoing into the definition of interval cancers
and how they should be disclosed to patients. The area Genomic testing
of practice is becoming very litigious and this threatens About 15 years ago, England had very patchy access to
future viability. The meeting noted that the screening genomic testing, but this has now improved. In England,
programme had been working with a year-on-year there are plans to move to hubs with a separate computer
reduction in incidence of cervical cancer, and patient system (which is not yet ready) and with a more limited
advocates being used to promote the importance of range of testing than was previously available. Hubs of
screening. There is a need to tackle this issue at all levels. testing are not seen to be the best answer now that nearer
Pathology must be taught by pathologists in universities, patient testing is available. There are increasing concerns
and we must educate our clinical colleagues regarding the regarding turnaround times in some centres.
shades of grey in pathology. The UK/England model of centralised delivery is not
seen as optimal by other countries as it delays results.
Laboratory supervision Near-patient testing is considered more appropriate and
Australian pathology has undergone major changes desirable. There is not always good linkage between
in regulation, resulting in laboratories having to be funding for a new drug and funding for the genomic
supervised by pathologists with scope and recent practice testing that is needed to support its use. At present we do
in that area. This has particularly been an issue for not know the molecular differences in tumours between
chemical pathology where laboratories were supervised different countries and patient populations.
by clinical scientists. Genetic pathology is a strand that
runs through all laboratories but there has been difficulty Artificial intelligence in pathology
identifying people who can supervise them with a trained We keep hearing that artificial intelligence (AI) will
scope of practice. All supervisors have had to be scoped. replace morphologists, but will it really? Progress in the
There has been a change from a compliance model to a development of AI seems to be slow as engineers realise
risk management approach of laboratory management. that diagnostics is more complex than they think. A
In Europe, molecular pathology is not a stand-alone mistake by a machine would knock back the discipline
specialty. The ILPP agreed that laboratory supervision is decades. Complexity and shades of grey in diagnosis may
not something that can be done by any clinician – it needs be insurmountable in training AI.
pathologists with certified expertise. There is currently There is support for supervised AI assistance in
not always a requirement that there has to be a pathologist counting, but not for unsupervised machine practice. AI
supervising the laboratory – laboratories may be led by is likely to become a useful tool to support morphologists
clinical scientists. This may further highlight that there is and augment practice, for example, by pre-screening for
a lack of sufficient pathologists and a recruitment issue. abnormalities to allow pathologists to target their time
Molecular pathology should remain in the hands of the and attention to anomalies. AI will need very careful
pathologists and be interpreted alongside morphology, validation and regulatory approval, but some work on
as without this it is easy for molecular testing to be this is already happening. Pathologists should and must
misinterpreted. Reports of molecular testing should be be central to this process.
8 ACP news - Winter 2019
ACP Business
Given its advantages, why has the advent of digital equivalent to them working eight-hour shifts 365 days/year.
pathology been so slow? We still have to produce and As yet, there is no national workload standard in Canada,
store the slides, so digital pathology is an added financial no mandatory retirement age, and pathologists in Canada
expense, and this seems to be limiting digital pathology commonly like to work until they are 75 years old. However,
expansion in USA. Digital pathology is seen as a useful there is still likely to be a workforce issue in the future.
adjunct to training. FDA approval is limited currently to In South Africa, only those working in the state sector
two specific systems, and microscopy to sign out cases is can train pathologists, but the majority of pathologists are
still considered the necessary standard of care. working in the private sector.
In the US, a huge shortage of pathologists persists and is
Workforce modelling expected to peak in 2022. A retirement cliff is looming. It is
Workforce modelling in Australia has demonstrated that hard to know how many pathologists are actually working
the country faces an imminent shortage of pathologists in the US but it is recognised that there is a need for greater
if training numbers are not increased. Currently they are recruitment to pathology. The shortage is sometimes
surviving by importing pathologists from other countries linked to low visibility of pathology within medical school
such as South Africa. They have some pathologists curricula, and scholarships are being given to medical
working well into their 80s, but equally some are seeking students to encourage them to attend meetings.
retirement in their early 50s. Across Europe there is no systematic data regarding
In Canada there are workload guidelines, which have different countries, but there is a lack of pathologists across
recently been updated. These are available to the general the EU. There has been a brain drain, and pathologists
public. Canadian pathologist workload is now very heavy – trained in Poland, the Czech Republic, etc. are recruited
Front row, l-r: Prof L Burke (Dean, Faculty of Pathology, Royal College of Physicians of Ireland), Dr R Liebmann
(Vice-President, Royal College of Pathologists UK), Dr C Ross (President, Canadian Association of Pathologists),
Mrs L Hayes (CEO, The Colleges of Medicine of SA), Prof J Mahlangu (President, College of Pathologists,
CMSA), Ms E Propper (Secretariat, LLPP), Prof T Pillay (College of Pathologists, CMSA)
Middle row, l-r: Dr J Burton (Chairman of Council, Association of Clinical Pathologists UK), Prof A Ryska
(President-Elect, European Society for Pathology), Prof B Latham (President, Royal College of Pathologists of
Australasia), Mr S Myers (CEO, College of American Pathologists), Dr G Siegal (President, American Society
for Clinical Pathology), Dr D Graves (CEO, Royal College of Pathologists of Australasia), Dr I Cree (WHO
Representative Pathology), Ms S Ziemnik (Vice-President, CPD, American Society for Clinical Pathology)
Back row, l-r: Dr P Godbey (President, College of American Pathologists), Dr M Dray (Vice-President, Royal
College of Pathologists of Australasia), Prof SK Cheong (President, College of Pathologists Academy of
Medicine of Malaysia), Mr G Nel (Financial Director, CMSA), Ms H Dow (Executive Director, Canadian Association
of Pathologists), Prof L Martin (College of Forensic Pathologists, CMSA)
ACP news - Winter 2019 9
ACP Business
to Germany, Ireland, UK, etc. The brain drain may just Education
be an unavoidable economic reality – people follow the The advent of competency-based medical education
money. It raises the question of standards of practice in Canadian residency programs (the Royal College’s
across countries, which are known at present to be Competence by Design initiative) seems an opportune
unequal. Some EU countries have no board certification time to standardise the more robust training in molecular
and there is no uniform curriculum or minimum length pathology and bioinformatics that is crucial to the future of
of training. Some countries are introducing progress tests all the pathology specialties. Some initiatives have already
for pathologists in training but these have no minimum been taken by the Royal College, in cooperation with other
threshold and are voluntary. bodies, such as the Ontario Molecular Pathology Research
Are qualifications internationally portable? Generally, Network (OMPRN), to address gaps in molecular
the answer is no! There is a lack of global standardisation pathology training. In Australasia this is already included
and harmonisation in pathology training; there may be in core curricula. The USA has a specialist curriculum
scope for content standardisation. committee with comprehensive content outlines. Some
EU countries have included specific modules on molecular
Doctors vs clinical scientists pathology in their curriculum.
Clinical scientists are increasingly occupying roles The number of Malaysian pathologists is small, with
traditionally held by medically-qualified pathologists about 500 in the national registry. Every year, there are 60
in toxicology and genomics. Is this a good thing, or training positions available, with more than 150 applicants.
are we losing critical expertise as a result? What added The Ministry of Health is encouraging private pathology
value does a medical qualification bring in these fields? laboratories to provide such training. In Australasia, most
In South Africa these roles can be held by scientists training is conducted in public laboratories, but private
or pathologists, and the scientists can be held just as laboratories may be partially accredited for training for
accountable as pathologists. They have had to consider one to two years. (The private sector has a different
clinical scientists where there is a lack of suitably trained case mix.) No single institution can be the sole training
doctors. placement. In the UK, almost all training is done in the
In research, scientists and their laboratories are NHS. However, hybrid joint venture laboratories are
not accredited. It is very difficult to tackle concerns emerging, and are involved in training.
regarding quality of research. Doctors can be struck off Many countries are adopting new teaching modalities
whereas scientists cannot – there is an extra element of in their undergraduate pathology teaching. Curricula are
accountability for doctors in research practice. being updated in the light of precision medicine. There
In Australia, there is no registration body for scientists! is a greater focus on online learning with quick 10-15-
Pathologists carry the ultimate accountability. The medical minute packets of instruction/learning. Pathology in the
degree is seen to add value when people move from employing park sessions (work very hard in mornings and relax in
scientists to doctors – “we didn’t know what we didn’t know”. afternoon) have been popular.
Flipped classroom sessions are being used by some. It
Skills beyond skills is recognised that physical teaching sessions now need to
How can we ensure that pathologists have sufficient have something that is not available by on demand online
“skills beyond skills”? Are we paying enough attention to materials. Moving instructional materials online is very
the necessity of learning interpersonal, behavioural and labour intensive and is often done using instructional
quality improvement (aka leadership) skills? designers working with content experts.
In Australia most people need top-up training
under supervision and these things are included in the Quality and accreditation
curriculum. Clearly there is a recognised need for such In the UK, pathologists are being strongly encouraged to
training. In the US the role of the pathologist in the MDT merge into ever-larger laboratories. Now we live in the
is often to be the leader of the team, and so pathologists world of cyber attack and terrorist attack but we don’t
need leadership skills and skills in managing conflict. really have plans to deal with such issues. Disaster plans
“The Leadership Institute” has a discrete programme for tend to focus on what the hospital can provide to the
pathologists. Coaching is provided as needed. Boards do community, but generally do not consider whether the
not evaluate leadership skills. pathology laboratories will still be able to run. Accreditors
Learned societies in Australasia run management are supposed to be looking at this. In the US, standards
courses and, at conferences, non-scientific development exist and such disaster management plans are required.
sessions are hosted on topics such as bullying, resilience, Overall, this was an interesting and wide-ranging
unconscious bias, etc. meeting. The 2020 meeting of the ILPP will be hosted by
the Hong Kong College of Pathologists.
10 ACP news - Winter 2019Articles
Sicily, Florence and Lake Garda: corpus and corporeality – Carl Gray
splendid example in Rome under the church Santa
Maria della Concezione, but this in Palermo is the larger
installation. In Rome, the bones of Capuchins from 1500-
1870 are placed in an ossuary and employed as decorative
features in an underground crypt. In Palermo, in a large
underground institution, extensive gloomy corridors and
chambers are lined by real dead bodies, about 8,000,
dating from the 17th to 19th centuries. These are placed
in racks and upon shelves; some recumbent in coffins,
others strapped upright in groups. Most are in their
original clothes and are mummified – dried and hardened
– but inevitable deterioration has exposed some skull
bones and teeth and so on. Extremities are degrading to
dust. One wonders about dead and dusty fomites: could
1. ‘Him outdoors’ by Damien Hirst, on exhibition in there be bacilli, spores or pox viruses in the dust? There is
Briggate, Leeds no particular smell; the chambers are naturally ventilated
by air currents from grills. The best preserved clients
Shoppers in the central street of commercial Leeds are retain recognisable facial features.
presently over-awed by a version of Damien Hirst’s The dead ones are sorted by the social tenets of the time
Hymn (1999-2005) (Figure 1). Him Outdoors is about six according to age and gender, professions and status: old
metres tall and portrays a male figure partly dissected. before young; religious before others; male before female;
(Hirst has since admitted that the piece was based on the occupations in order of importance. There are numerous
Young Scientist Anatomy Set and a breach of copyright monks and priests first. The doctors are a bit lower down;
action was settled with the toy-maker.) He has another a chamber of dead doctors tells it all. There is a room
one – The Anatomy of an Angel – in an adjacent arcade of women who sadly died recorded as ‘virgins’; being a
(Figure 2). There is now a permanent ‘Bodyworlds’ virgin in those days was possibly a respectable full-time
exhibition at Piccadilly Circus in London. The public occupation in itself. Some babies and small children are
interest in the human body continues undiminished. This represented. Each cadaver has a number and the name
essay explores how this is nothing new. noted in hand-written script on a label; somewhere there
Good representations of the human form started in Italy must be large hand-written register of all the names.
in the Renaissance. The Uffizi Gallery in Florence, Italy,
has some of the finest, with numbers of Adams and Eves
and many other nudes and statues. Of course the principal
interest has always been with Adam, but Eve caught up
later. Eve’s breasts are the difficult bit for the artist:
depending on his artistic experience of actual women, he
has to get the details of the axillary tail right or end up
with another Adam with stuck on appendages.
Italy is full of strange old museums and I previously
wrote about three of these in Turin (1). Here I discover
another two old ones and have found a new one continuing
the traditional Italian interest in the human body.
Catacombe dei Cappuccini, Palermo, Sicily
Catacombs are underground caves filled with mummified
corpses. The Capuchin Friars were very keen on death
2. ‘Her indoors’ by Damien Hirst, on exhibition in
and keeping bodies of the dead on show. There is a
the Victoria Quarter, Leeds
ACP news - Winter 2019 11Articles
There is no explanation as to what statistical sample of own father told me he had seen them in his travels in the
all Palermians the chosen dead may represent or their merchant navy in about 1950. The throngs of visitors
causes of death; they are simply there. One imagines that are interested, attentive and respectful. Photography
infectious diseases must have loomed large and that Death is forbidden but the website shows pictures (Figure 3).
often called at a young age. The cadavers are very small Nowhere else in the world can you see over 8,000 corpses
but shrinkage is to be expected in their situation. The all at once: 8,000 insistent iterations of the Roman
friars at first mummified their own dead but then began salutation, Carpe Diem, ‘Seize the day’. After a spell in
accepting outsiders by request. In time, to be preserved the Underworld with the dead chaps, visitors are very
and displayed in the Capuchin Cemetery gained a high glad to climb the final steps back into the open air and
social value and people paid for the privilege. The friars Sicilian sunshine. And once out they are determined very
charged rent for the maintenance of the subjects. If the much to continue enjoying the living state for a while
family did not pay, the body was relegated to a less visible, longer. Sicily has much to offer in the land of the living,
higher shelf. The friars themselves presumably joined particularly its excellent food and drink.
their institution for life and knew what was coming. The
others paid for the service or were unclaimed after death. La Specola, Firenze, Italy
The Order of Friars Minor Capuchin, founded 1525, Anatomical teaching for medical students has been difficult
is still with us. They are an off-shoot of the Franciscan at times, with sometimes limited access to actual human
Order of the Roman Catholic Church. Their catacombs cadavers. Substitution for real tissues has traditionally
in Palermo live on as a sort of macabre museum and a been by wax models, the 18th century fore-runners of von
popular tourist attraction. Hagens’s plastinated tissues. There is a fine collection
Their display of preserved corpses, which could of obstetric waxes – portraying the gravid woman and
otherwise have been decently buried, was intended to foetus in good and bad positions for delivery and various
promote moral messages about living a good life and so obstructed labours – in the excellent science museum
on. Perhaps it maintains some strange continuity between at Florence (now named Museo di Galileo). An older
the living and the dead states. In a real sense, these collection is in La Specola, also at Florence (Figure 4). La
dead ones are still with us. Old Italians were fatalistic, Specola is named for the astronomical mirror that used to
expecting at any time to pop down into Dante’s Inferno. A be in the observatory atop the tower of the building. This is
plaque in the Rome church states: ‘What you are now, we an ancient block of the Università degli studi Firenze and
used to be. What we are now, you will be.’ As shown by incorporates various branches of their museums, including
the painting, Trionfo della Morte (in the nearby Galleria a large natural history museum with stuffed animals and
Regionale della Sicilia, Palazzo Abatellis, Palermo), the a mineralogical exhibition. The museum inherited the
figure of Death will get us all in the end: princes and extensive personal collections of the Medici family and
priests, doctors, babies and full-time virgins. in its earliest form opened in 1775, making it the oldest
The Catacombes are a popular visitor attraction despite science or natural history museum in Europe (and therefore
being about two kilometres south of the city centre. My the world). Members of the public were allowed in provided
3. Cadavers in the Catacombe, Palermo 4. La Specola
12 ACP news - Winter 2019Articles
exhibits are traditional in wax modelling and were said to
have been favourites of the Marquis de Sade. Strangely
there is no chap correspondingly undone; the gentlemen
present are more completely dissected. Perhaps the
modellers feared that the exhibits would come to life each
evening in the Museum after hours. There is only one real
specimen: a human skull augmented by wax soft tissues.
The provenance is not stated.
The wax models gracefully document in permanent
and largely tasteful form the 18th century view of our
insides, which was structural rather than physiological or
pathological. There are some lurid examples of memento
mori; one is a series of five florid theatrical tableaux
exploring the themes of ‘corruption’ and human suffering
5. Inside the wax museum owing to the plague, the cause of which was not at that
time understood. Otherwise no disease processes are
that they ‘Looked clean’. The exhibition was visited by all shown: all is perfection with some silk ribbons.
on the Grand Tour, including Goethe. The anatomical wax museum at La Specola is well
The Anatomical Wax Museum is open only by worth a visit whilst in Florence on your Grand Tour.
appointment and guided tour. I had the good fortune to join Unfortunately, the museum complex has recently closed
a tour by chance, arriving just as it was starting. Looking for refurbishment for about 18 months from 1 September
clean enough, they let me in. The museum comprises 2019. The German publishing house Taschen has published
several large chambers with numerous anatomical an excellent picture book from the museum collection (2).
etchings on the walls and vast numbers of wax models
of parts of the body in the dissected state (Figure 5). The Museo di Salò, Salò, Italy
waxes are very realistic and highly accurate, having been Salò is nowadays an elegant and expensive lakeside resort
modelled from real-life specimens by Giuseppe Ferrini on Lake Garda in Lombardia. It has the ideal position in
(18th century, Gaetano Giulio Zumbo (1656-1701) and its own bay on the western side of the lake surrounded
Clemente Michelangelo Susini (1754-1814), who were the by mountains and, facing the morning and afternoon
acknowledged masters of the craft. The latter eventually sun with pleasant onshore and offshore breezes, it has a
presided over a large workshop sending models around perfect microclimate reminiscent of the south of France.
Europe. There is strong emphasis on skeletal musculature, Salò has a dark episode in its history as the seat of
tendons and joints; all done in marvellous detail. The the Italian Socialist Republic, the Nazi puppet state
modellers were keen on the lymphatic system, which is which existed from September 1943 to June 1945. Its
of course very difficult to see in real dissected tissue, and leader, Benito Mussolini, Il Duce, formerly the dictator
the students were offered a full depiction of lymphatics of all Italy, took up residence at the Villa Feltrinelli at
in the body and their deeper connections. Viscera are also Gargnano up the coast, and departments of state were
nicely done, and where a tubular organ is necessarily seated in various lakeside towns. Our own familiar
interrupted in its course, the cut end is daintily tied with holiday resort, Desenzano, was disgracefully the seat
a silk ribbon. Brains, eyes and ears are demonstrated in of the state’s ‘Inspectorate of Race’. Deportation and
accurately enlarged models. Genital organs are explored extermination of Italian citizens were directed from a
but modestly and without ribbons. But, inevitably, for the pleasant villa, for many years later a branch of Benetton
benefit of those gentlemen students with least experience and lately an Outlet. The victims were Jews, Roma,
of real goddesses, perhaps clerks in Holy orders, monastic Jehovah’s Witnesses, the disabled, homosexuals, and
novices or Capuchin Friars, and the younger Grand political prisoners. A meagre plaque placed outside the
Tourists, there are dissected females. These are termed house in 2005 belatedly acknowledges the dismal past of
‘Venuses’; one of which is the reasonably-complete the building and quotes Primo Levi (Figure 6). We cannot
‘woman eviscerated on the couch’ exhibit. She is partly of course blame the present Desenzanini for their distant
draped, and has realistic hair. The modern viewer finds past but we must annually read the plaque and think. Il
this a bit uncomfortable, like a post mortem examination Duce himself was, at the end of the war, rounded up with
undertaken in the drawing room. These semi-voyeuristic his lover Clara and both were shot dead at Mazzegra on
ACP news - Winter 2019 13Articles
are offered suggestive worlds full of alchemy, mysticism,
research, interest in the fantastic and the beyond. These echoes
welcome the observer between wonder and expressiveness,
with a fascinating contemporary language and sometimes
volcanic. We are to expect curious multidisciplinary
masterpieces rich in symbolism. This returns us firmly to our
theme of the Italian view of the human body.
The Dead Class by Cesare Inzerillo is a corridor of peep
holes – you do feel naughty looking in – and behind each is
a form of puppet. These are distorted people, animals and
so on, often with deformations of face and genitals, and
dressed in old clothes and doing things. The artist says that
he intends to remind us of the mummified people in the
Capuchin Cemetery in Palermo! The puppets’ associations
with any number of slashed figs and objects longer than they
6. Commemorative plaque in Desenzano del Garda
are broad bring our minds to what he might be on about.
Lake Como. Their bodies were famously strung up on a Luigi Serafini gives us a modern ‘woman on the couch’
petrol station in the Piazzale Loreto, Milano. exhibit (Figure 7). This is a life-size mermaid-like figure,
The Commune di Salò with commendable transparency female in detail with her upper body undraped but her lower
reports the history of those times with informative plaques body morphed into a carrot. Recumbent on barky soil in
on buildings. The Museum of Salò – MuSa: Museo di Salò a raised garden bed, she holds further carrots in her hands
– was rebuilt in 2015 and is a lively cultural centre. In the and is surrounded by other vegetable produce and flowers.
Italian way, it stylishly combines hopelessly incongruous I had named this carroty person ‘Carrot Girl’ and was
materials. There is a traditional display of the regional delighted to find that her actual title is Persephone C (Carrot
contribution to World War I: worthy but dull. World War II Woman). Perhaps this is an advertisement for Gardeners’
issues are covered in a splendid exhibition of propaganda Question Time. (I’d like to ask the panel how to grow carrots
posters from the era. These mainly tell the Italians that with a very barky soil? Should I obtain and bury a young
the Germans are their friends and to jolly well join in woman?) Maybe this is a warning about the risk of over-
the war. A further room has the surviving busts of Benito doing vegetable juices in popular diets? Perhaps this is
Mussolini, the late dictator. (There is one more on his about fertility: soil and woman alike? Is it a joke about giant
tomb in his home town.) This appears to be a legacy of the vegetables: I’ve never seen one as big as that before?
exhibition Il Culto del Duce, which ran from May 2016 to But the best thing in the gallery is a permanent exhibit:
May 2017. Perhaps the museum owns them and they have a wall-sized version of Vetruvian Woman (Figure 8). The
to be put somewhere or no-one collected them after the reader is familiar with the Vitruvian Man, the drawing by
exhibition. Victors in warfare usually engage in vigorous Leonardo da Vinci of a man with his arms and legs out-
iconoclasm of the fallen enemy. Outside Budapest there is
a splendid scrap yard of enormous fallen Lenins, workers
of the world uniting and mothers Russia. We remember
the statue of Saddam being torn down by the allied forces
in the Iraqi war. But in Salò about 20 busts of Benito
Mussolini survive. Some are very stylish artistically. There
is no official celebration of Fascism and no-one is paying
neo-fascist homage but there they are and they are very
strange. Napoleon has many paintings, all preserved. There
are numerous busts and paintings of Hitler in existence but
not on public exhibition all together. We should take an
interest in dictators and how they come about. But how do
you solve a problem like Benito?
The museum’s modern art department has a vigorous
programme. We saw the current exhibition Contemplazione,
curated by Vittorio Sgarbi. Contemplating the brochure, we 7. ‘Carrot Girl’
14 ACP news - Winter 2019Articles
Corpus and corporeality
These three exhibitions, in their different forms and
presenting images over several centuries, show the abiding
Italian pre-occupation with the human body and its
representation. The Cappuccini kept your corpse and put
it on show in perpetuity. The 18th century wax modellers
recreated human anatomy in a permanent medium and
were not averse to a bat’s squeak of eroticism. Modern
artists continue to joke about the human form, pay homage
to the Cappuccini, and lay the vegetables on with a trowel.
Italy has no human tissue act. Churches are full of saintly
relics and even the Museo di Galileo has several fingers of
the great man’s hand. These were purloined when the body
was between tombs. The science museum has excellent
displays of Galileo’s work, including the actual telescopes
and lenses which he used to discover the Jovian moons.
But do we really need his fingers on display?
Italian arts and sciences have been the most intense in
Europe for several centuries and they are still going on.
8. Vitruvian Woman Even they have not yet solved the Cartesian mind-body
problem. Perhaps they never will?
stretched in two positions and placed within congruent
circular and square outlines. The umbilicus is placed at Visitor details
the centre of the circle but the penis is placed at the centre Catacombe dei Cappuccini, Piazza Cappuccini, 1, Palermo,
of the square. The original drawing is fragile, kept in the Sicilia, Italy. palermocatacombs.com
Accademia in Venice and rarely taken out for a look. But
the image is very widely employed. Leonardo and his La Specola, Università degli studi Firenze, Museo di Storia
contemporaries were worried about the ideal human form Naturale, Via Romana, 17, Firenze, Italy. msa.unifi.it/ls-13-
for painting and statuary. His drawing is surely only a natural-history-museum-html. [The university website has lately
suggestion; his notebooks are full of speculative images. announced that the whole museum complex will be closed for
Obviously, real men vary between tall and wide: shirt- refurbishment for about 18 months from 1 September 2019.]
makers will tell you that men with a given collar size may
have different arm lengths. [We are all lovable.] Da Vinci MuSa: Museo di Salò, Via Brunati, 9, Salò, Italy.
was most interested in the male form, although he did do info@museodisalo.it
Mona Lisa and the Lady with an Ermine very nicely with
their clothes on (and an ermine with its clothes off). References
The artist of Vetruvian Woman has drawn a splendid 1. Gray, C. Black and white magic in Turin: anatomy, criminal
female figure recapitulating the iconic Vitruvian Man. anthropology and fruit. ACP News 2011; Autumn: 12-14.
The fingers and toes again reach the outline of the square 2. Von Düring, M; Poggesi, M. Museo La Specola, Florence.
and the circle. The umbilicus is in the centre of the circle Encyclopaedia Anatomica: A collection of anatomical
and the centre of the square is again appropriately placed. waxes. Koln: Biblioteca Universalis, Taschen, 2014.
The picture is a delight: feminist and witty. It makes the ISBN: 9783836549318.
argument for diversity: of course women have different
proportions to men, but the artist is saying, ‘So what?’ Carl Gray is a Consultant in Histopathology and
The ideal human form can be female whatever Leonardo Forensic Pathology, Harrogate District Hospital,
may say, and what is ideal anyway? Alas, on returning Harrogate, North Yorkshire HG2 7SX
carl.gray@hdft.nhs.uk
home, I find on the Internet that there have been so many
variants of Vitruvian Woman published over the last two Dr Gray is the President of the Association of Clinical
decades that it is not possible to identify the original artist. Pathologists. This essay represents his own views in
Your author is at least two decades behind the Zeitgeist; his personal capacity only and not the policy of the
something often commented on at home. Association.
ACP news - Winter 2019 15Articles
On the value and quality of case reports – Julian Burton
Dr Julian Burton is the ACP Chair of Council conditions that we might see only rarely. Likelihood of
Email: j.l.burton@sheffield.ac.uk
the submission being accepted will likely be increased
At the outset I shall declare that I have mixed views if the report draws new insights or re-contextualises the
about case reports. This is reflected in my own academic condition.
output. Whilst I have written 17 original research papers,
23 review articles and a number of books/book chapters, I Pitfalls and how to avoid them
have written only two case reports, and both of these were When submitting any piece of work to a journal for
some time ago. However, I do spend considerable time publication the aim should be for it to be accepted with
each year reading case reports and reviewing submitted only minimal corrections or, the Holy Grail, with no
reports for journals. Over the years I have realised that corrections to be made at all. I am generally asked to
whilst some are very good – others are most definitely review around 10-15 case reports a year. There are pitfalls
not good. The aim of this article is to first consider the that many authors seem to fall in to. I cannot promise
value of case reports and then to consider the pitfalls, so that avoiding the ones suggested below will satisfy every
that you don’t spend time producing one that is not good. reviewer, but doing so is likely to encourage me to click
that “Accept” button when I submit my review.
The value of case reports
It is axiomatic in medicine that one should rarely say Wrong journal
“Always” and rarely say “Never”. The scope of diseases Before submitting a case report to a journal it is worth
covered by textbooks and journal articles largely deal considering two factors. First, does the journal publish
with the common variants of a condition, perhaps with case reports? Not all journals do, and there is no point
some unusual or uncommon exceptions. Writers of review submitting your manuscript to a journal that will have no
articles and textbooks will likely find well-written case interest at all in publishing it. Second, is the focus of the
reports to be extremely valuable – these are the source journal and your manuscript congruent? It makes sense
of information about the rare examples and unusual to submit a report of a rare liver lesion to a hepatology
presentations. They present the penumbra of what we journal. It makes little sense to present a report of a rare
currently know, and allow us to begin to appreciate these lesion in the organ of Zuckerkandl to that journal. Of
rarities when the numbers of cases is still too small to journals that are congruent with your manuscript it is
permit more detailed research. sensible to first submit to the one with the best metrics
Writing a case report can involve a considerable amount (for example, impact factor), but metrics alone should not
of effort. Depending on where you are in your career they guide journal choice.
will have a variable impact on your curriculum vitae.
If you are at an early stage in your academic writing Poor writing
career they provide a useful opportunity to develop your One of the commonest problems that case reviews suffer
academic writing skills. If you are at a more advanced from is poor writing. By their nature, they are typically
stage they may help you demonstrate that you are aware short publications. Therefore the author(s) will need to be
of where the edges of our understanding lie. You need an both precise and concise if they are to provide sufficient
awareness of this boundary to know that what you have information to explain the case within the word limit.
seen is indeed rare and therefore of interest. Careful proof-reading for spelling and grammar is needed
A less commonly encountered variant of the case report and I suggest that you do not rely on your computer’s
is the one that presents the exemplar of a condition. An spelling and grammar check alone because it is very easy
example of such a report might be one that demonstrates for you to teach it to allow mistakes. Your reviewer is
clearly the presentation of a condition that is common in not there to act as your proof-reader, and the journal may
some parts of the world but now uncommon in others. The or may not be prepared to copy edit out your mistakes.
pathology of septic emboli arising as a consequence of Numerous typographic and grammatical errors can
infective endocarditis is, for example, very well described readily amount to “major revisions”. In extreme cases,
but now rarely seen. It may be harder to get such case they may make your submission unintelligible, resulting
reports published but they have value in reminding us of in a “reject” decision. This all means that you must
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