Pathway Winter 2007 - Blood Feuds
Transcription
Pathway Winter 2007 - Blood Feuds
Winter 2007 | Issue #12 Blood Feuds: MASSIVE CHANGES TO NZ PATHOLOGY SERVICESTEACHING STANDARDS: UP TO THE MARK? SPOTLIGHT ON NEW ZEALAND Blood Feuds MASSIVE CHANGES CREATE WAVES IN NZ NEVER HEARD OF ORAL PATHOLOGY? YOU'RE NOT ALONE MOUNTAIN HIGH: THE BEST OF NZ SKIING PRINTPOST APPROVED PP60630100114 $7.50 (inc. gst) PathWay #12 - Text 23/5/07 2:06 PM Page 1 ADVISORY BOARD Contents Dr Debra Graves (Chairman) Chief Executive, RCPA Dr Bev Rowbotham Vice President, RCPA Professor Jane Dahlstrom Representative, Committee of Deans of Australian Medical Schools Dr Tamsin Waterhouse Deputy CEO, RCPA PATHWAY Winter 2007 Issue #12 Wayne Tregaskis S2i Communications PUBLISHER Wayne Tregaskis EXECUTIVE EDITOR Dr Debra Graves EDITOR Kellie Bisset COVER STORY ART DIRECTOR Jodi Webster Blood feuds: ADVERTISING SALES DIRECTOR Bronwyn Sartori PUBLISHING CO-ORDINATOR Andrea Plawutsky Massive changes to New Zealand pathology services have unsettled the profession 8 FEATURES Movers and shakers Scalpel please: keeping forensic pathologists in regional Australia is tough, but entirely possible 14 In profile A floating asset: Dr Tony Barker’s nautical skills have helped him navigate a rewarding career 17 Disciplines in depth Teething troubles: never heard of oral pathology? You’re not alone 21 Spotlight on disease Silent assassin: spotting patients at risk of kidney disease is a medical challenge 26 Foreign correspondence People power: Dr Richard Williams has developed some rewarding links with China 30 Practice portrait Seeds of Change: Symbion Laverty is about to celebrate 25 years in specialist gynaecological pathology 32 Teaching Notes Pathology Training: PathWay special report 34 FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF Pathology Update 2007 40 IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE A round up of research presented at the RCPA annual conference Testing, testing 46 PathWay is published quarterly for the Royal College of Pathologists of Australasia (ABN 52 000 173 231) by S2i Communications, Suite 1201, Level 12, 4 O’Connell St Sydney 2000 Tel (02) 9235 2555 Fax (02) 9235 2455 PrintPOST approved PP60630100114 The Royal College of Pathologists of Australasia Tel: (02) 8356 5858 Email: [email protected] S2i Communications Pty Ltd Tel: (02) 9235 2555 Email: [email protected] PathWay Email: [email protected] http://pathway.rcpa.edu.au PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES www.rcpa.edu.au New horizons: thyroid testing is almost too good PATHWAY_1 PathWay #12 - Text 23/5/07 2:06 PM Page 3 PATHOLOGY UPDATE 2007 PAGE 40 REGULARS From the CEO Welcome from RCPA CEO Dr Debra Graves 4 Under the microscope 6 News + views Conference calendar 65 Postscript 68 Nutmeg liver and sago spleen: pathology serves up abundant culinary adjectives SNOW BUSINESS PAGE 50 LIFESTYLE Travel Snow business: Choice is not lacking on the NZ ski fields 50 Private passions Keeping the faith: Dr John Bothman gives his beloved racehorses a run for their money 54 Travel doc Southern exposure: Julia Potter and Peter Hickman are seduced by Antarctica 56 Recipe for success Make it a double: the Doyle brothers share a love of food and good waves 58 Dining out A yen for Japanese: PathWay’s search for sushi uncovers so much more 61 The good grape Hello mellow yellow: Ben Canaider welcomes the arrival of a more demure Aussie chardonnay 64 Rearview 66 Dark side of Venus: who’s to blame for foisting syphilis onto the modern world? PATHWAY_3 PathWay #12 - Text 23/5/07 2:06 PM Page 4 from the CEO Welcome to the 12th Edition of PathWay n this edition our cover story explores I the major and controversial changes to New Zealand pathology. There has been much activity across the country with the 21 district health boards tendering out community pathology services for periods ranging from 18 months to 10 years. We explore the implications of all this for pathologists and pathology, particularly the lack of a national overarching framework to address workforce and training needs. L-R: Visiting speaker Lord Carter of Coles; Debra Graves; chair of Update's overseeing committee Jeanne Tomlinson; RCPA president Dr Stewart Bryant We also profile Dr Tony Barker, Clinical Director of Auckland’s LabPLUS. Tony has had an interesting career, including a board role at IANZ, the New Zealand Laboratory Accreditation organisation. But he also has a passion for sailing. What better place to indulge this pastime than Auckland, with its beautiful harbour? Well I do live in Sydney, so maybe I can think of just one… Continuing our New Zealand theme, we check out what’s hot on the ski slopes in both the North and South Islands. If We now have a total of 63 new funded positions, so we’re getting there slowly Nicolaides laboratories in Brisbane, is but are still far short of the 400 we need employing part-time medical students in to address our workforce shortage. pathology as a career. College to attain her Fellowship via the Private Practice Training Scheme is featured in this issue. Dr Alash is an Iraqitrained pathologist who only required several years top-up training while There are many other interesting stories in this edition, including an update from the RCPA annual conference, an in-depth look at the little-known discipline of oral pathology and a review of kidney disease. I hope you enjoy this edition of PathWay. preparing for the RCPA exams. She did this at Symbion Health in Melbourne and and getting into the ski spirit this winter, attained her Fellowship earlier this year. Workforce issues remain vital in the laboratory so they can learn about Dr Aman Alash, the first Fellow of the you’re planning on building up those quads New Zealand is a great travel option. Another initiative, from Sullivan We also look at a number of initiatives the College and laboratories are pathology. We look at the federal undertaking to attract medical students Dr Debra Graves government’s support for private-sector into pathology. While we currently have CEO, RCPA training, including the good news that more medical students wanting to do 10 extra places have just been funded pathology than we have training places, it via the Expanded Settings for Specialist is important we maintain this interest. Training Scheme. This now brings the number of Commonwealth-funded Initiatives such as the RCPA and ACT positions to 20 – the highest number of Pathology medical school scholarships any government, closely followed by are designed to provide financial support Queensland with 18 positions, and for medical students to do an elective in a Western Australia with 11. pathology laboratory. 4_PATHWAY PathWay #12 - Text 23/5/07 2:06 PM Page 5 At Symbion Pathology we recognise that our primary responsibility is to the patients, medical practitioners and communities we serve. Remaining at the forefront of laboratory testing, Symbion Pathology constantly strives to innovate and improve accuracy and efficiency within pathology practice. With a national network of distinguished pathology providers, we remain committed to delivering a service based on superior quality and customer satisfaction. A National Network of Pathology Providers 03 9244 0444 03 5174 0800 02 9005 7000 08 9317 0999 07 3121 4444 PathWay #12 - Text 23/5/07 2:06 PM Page 6 under the microscope: news + views Government funds 10 new private pathology training spots he federal government has announced T funding for another 10 pathology training positions in the private sector. The RCPA has welcomed the move, with CEO Debra Graves describing it as “further evidence that the Commonwealth, in contrast to many state governments, has recognised the seriousness of the workforce crisis in pathology”. The positions will be offered under the Expanded Settings for Specialist Training program, and are based largely on the existing Private Practice Training Scheme (PPTS), which is currently training 10 new pathologists. The RCPA has called for applications for funding under the program, which offers $75,000 per position per year. It says at least two years of the training must be provided within the public sector and that there should be an appropriate mix of pathology trainees at different stages of training at any one time. It’s envisaged that an appropriate balance of trainees will also be allocated across the states and territories, with respect to the priority disciplines, location of providers and satisfactory applications received. For more on pathology training, see our special report, page 34 Melbourne researchers developing Parkinson’s blood test new screening test being developed for Parkinson’s disease (PD) may also be able to monitor treatment and measure the effectiveness of drug therapy, researchers say. A The diagnostic blood test, which measures the levels of the brain-secreted protein alpha-synuclein, was developed by researchers from the Howard Florey Institute, The University of Melbourne and the Mental Health Research Institute of Victoria. They found Parkinson’s patients had low blood levels of the protein while those without the disease had high blood levels. “Currently there is no specific PD diagnostic test, so doctors rely on their observations to make a diagnosis – which means some patients may not be prescribed the most suitable medication, and around 15% of those diagnosed may actually be suffering from something else,” said Professor Malcolm Horne, from the Howard Florey Insititute. 6_PATHWAY “Further studies are required to Dr Peter Garcia-Webb awarded AMA fellowship ong-time RCPA fellow Dr Peter L Garcia-Webb has been inducted as an AMA fellow for his outstanding service to the association. Dr Garcia-Webb, the chief pathologist and general manager of establish whether this test can distinguish Symbion Pathology, was one of a between people who are responsive to handful of AMA members awarded treatment and those who are not.” fellowships at the association’s national The research team is now conducting conference in late May. The list of his a large-scale study to determine the test’s contributions is long, but includes his effectiveness and is seeking funding for role in helping position the AMA as a further development. leader in e-health and his skills in “If the results of our large-scale study financial management – he is currently are encouraging, this test could be director of AMA Commercial and has available for clinical use within two years,” served as a member of the association’s Professor Horne said. finance committee and as a director of The team still needs to establish whether the test is applicable to all types of PD and whether it can measure disease severity and rate of progression. But the test’s availability will ensure AMPCo, the Australasian Medical Publishing Company, which publishes The Medical Journal of Australia. An RCPA fellow since 1971, Dr Garcia-Webb has previously been drug trial participants actually have the awarded the AMA President’s Award for disease so research outcomes will be his ongoing commitment to addressing more statistically valid. the medical indemnity crisis. PathWay #12 - Text 23/5/07 2:06 PM Page 7 he Australian and New Zealand And in Australia, a lack of clarity T over whether Rh(D) antibodies were just released revised guidelines for red due to prophylaxis or active blood cell antibody testing in pregnant alloimmunisation has caused problems Society of Blood Transfusion has women following recent cases of adverse foetal outcomes after routine anti-D prophylaxis. Rh(D) immunoglobulin (anti-D) is currently used to prevent the effects of Rh blood group incompatibility in another two cases. In both cases Rh(D) was given before the blood samples were collected and complicated the laboratory results. The guidelines were reviewed in between a woman and her baby. conjunction with the Joint Rh(D) Existing guidelines recommend all Consultative Committee, made up of Rh(D)-negative women should be professional representatives including screened for red cell antibodies at the the RCPA. initial antenatal visit and at least once between 28 and 36 weeks’ gestation. However, adverse events reported in Australia and the UK have The new guidelines recommend that when antenatal red cell antibody testing is indicated, blood samples highlighted the need for the correct be taken before administering Rh(D) timing and interpretation of screening. immunoglobulin. However, if In the UK, misinterpretation of PHOTO CREDIT: EAMON GALLAGHER Revised guidelines for antenatal red cell antibody testing administration has already occurred, antenatal antibody investigations in the test should still be performed two cases resulted in severe and the situation noted on the lab haemolytic disease of the foetus. request form. Correction story published in our Summer 2006 edition (‘STDs on the rise’) suggested there could be an additional role for pathologists in screening women who were sexually active and not found to be exposed to HPV types 16, 18, 6 and 11, who might still be suitable for vaccination. A However, at present the National Centre for Immunisation Research and Surveillance says pre-vaccination testing is not warranted. Serological testing is too poorly sensitive to be clinically useful and is only used in epidemiological studies. Testing for the detection of HPV DNA identifies only current, not past, infections. PathWay apologises for any confusion caused. PATHWAY_7 PathWay #12 - Text 23/5/07 2:24 PM Page 8 cover story Blood feuds NEW ZEALAND PATHOLOGY SERVICES HAVE BEEN GIVEN A MASSIVE OVERHAUL, BUT NOT EVERYONE IS HAPPY WITH THE RESULT, AS MARILYN HEAD REPORTS. n Aotearoa, the Land of the Long White Cloud, things are looking particularly cloudy when it comes to the delivery of pathology services. I Over the past three years, the pathology scene in New Zealand has seen massive change as services have moved away from central government control. Pathology will now be provided by regional contractors, who will tender for the work from each of the country’s 21 autonomous district health boards (DHBs) and be paid on a bulk-funding basis. This is a move predicted to save millions – but at what cost? There are fears the change might see a drop in service quality – and that patients will lose out. Some regions have opened their services for tender, and others have retained the status quo, but the regime change has been far from seamless. The transition has been overcast with vociferous criticism from unions and professional associations, intervention by business watchdog the Commerce Commission and a high-profile court case. Added to the melee is the Ministry of Health’s steady refusal to intercede, and an information void from the health boards’ representative body, the DHBNZ – all of which has enshrouded the process in unwarranted mystery. It seems the bunfight has resulted in diverting public attention from a crucial question: can restructuring the funding 8_PATHWAY and delivery of New Zealand’s pathology services result in better healthcare delivery? New Zealand’s population of 4.25 million is getting older, more urban and Auckland-centred. These major demographic changes, combined with new technologies that could deliver superior diagnostic testing, are behind the moves to look at pathology resources differently. Automation has reduced costs (and increased volumes) for specific schedule tests, but an ever-expanding list of new ones – including genetic and ‘wellness’ testing – has sent costs spiralling. diabetes and other recognised risk factors – which should be funded.” Despite this view Dr Beer can see the flip side of change. “The tendering process is fairly brutal,” he says. “It’s a bit disasterous for the industry in that somebody has to lose and some lab has to go under, fold up, or go away.” Another problem with the old system however, was the ad hoc distribution of pathology services. In Auckland, for example, there are not enough services – and they’re often not situated where the population is. And despite all the news-column centimetres devoted to the changes, the debate about how far the public purse should be stretched has never emerged. Now it’s estimated there will be a 50% reduction in the number of laboratory collection centres, where testing is free, in favour of GP collection, which is usually not. Necessity for change But those collection centres that do remain will be located more appropriately. As pathologist Dr Ian Beer points out, preserving free testing for ill patients in the face of uncapped costs was a major motivation for reform. “The risk was really that if testing kept growing at the same rate, the system might have fallen over,” says the director of Pathology Associates Ltd, a private lab that has won extra contracts under the new system. “There’s a whole range of testing for symptom-free patients like ferritin tests for athletes, which could be paid for by patients, and others – such as monitoring And then there’s the issue of over- and under-testing. Under the centralised regime, pathology providers were paid on a fee-for-service basis, so there was no incentive to monitor what level of schedule tests were necessary. While there have been some concerns about over-testing, Canterbury DHB in fact felt pathology services were being under-utilised, with people ending up in hospital as acute cases when they should have been treated earlier. Providers will now be paid on a bulkfunding basis, putting the onus on labs to > PathWay #12 - Text 23/5/07 2:06 PM Page 9 Providers will now be paid on a bulk-funding basis, putting the onus on labs to manage their volumes adequately, analyse ordering patterns, and rationalise equipment and personnel PATHWAY_9 PathWay #12 - Text 23/5/07 2:31 PM Page 10 “The risk was really that if testing kept growing at the same rate, the system might have fallen over.” – Dr Ian Beer manage their volumes adequately, analyse ordering patterns, and rationalise equipment and personnel. “[Bulk funding] means the lab is going to become responsible for managing the volumes because the bureaucrats believe that the pathologists should be sorting out what is more appropriate testing,” Dr Beer says. “That’s probably a fair call. The gatekeeper responsibility has changed from GPs to pathologists. There’s a real incentive to discuss things with doctors. We haven’t got the time to review every doctor’s decision, but we can review ordering patterns using ICT, and look for people who are being over-tested.” It’s also envisaged DHBs will be able to better control costs. They’ll know upfront what their costs will be, as providers will sign contracts on the basis of an agreed price. Models galore Some believe that in the variety of cooperative and competitive tendering models that have emerged, there is a wonderful opportunity to assess what works and why. But this variety of models has also caused a few raised eyebrows – and each DHB has approached the new system in its own way (see page 12). And while this might be a way of tailoring local services to the local community, there is no central control authority for pathology services to deal PHOTO CREDIT: NICOLA TOPPING with national areas of concern such as 10_PATHWAY training and workforce retention. RCPA chief executive Dr Debra Graves says this is a major concern. The college wants a national framework developed for laboratory services but is getting nowhere fast. PathWay #12 - Text 23/5/07 2:06 PM Page 11 “Our fundamental concern is about having a national framework of quality, especially around issues such as training,” she says. “We would have liked the Minister to set the ground rules of a national policy within which the DHBs had to operate. The workforce is already so thinly stretched that if the numbers fall, they will not have the capacity to train new pathologists under the accepted apprenticeship model or to develop new tests, so the quality goes into a ‘death spiral’.” The other concern is the destabilisation that has occurred in some DHBs as a result of the changes. “I have never seen pathologists so distressed,” Dr Graves says. “New Zealand is an integral part of the Australasian region, so it affects everyone if the quality of their service falls behind – and we are concerned that within their policy framework they’re losing the ability to monitor how pathology is being delivered in the community.” As for the government’s view, while the DHBs are autonomous, they must still work within “Operational Policy and National Service Frameworks”, according to Ministry of Health spokesperson Julie Rodgers. people who use it and maintaining as ‘flat’ a bureaucratic structure as possible, others say it has led to inconsistency and unnecessary duplication. “Twenty-one DHBs equals 21 bureaucracies” is a frequent observation, though Otago DHB’s Brian Rousseau argues “we’re not advocates for a single model, because each region is quite different”. Concerns over fragmentation have been exacerbated by the somewhat invidious position of DHBNZ, the incorporated society formed by the DHBs in 2000 to support and coordinate This structure was first introduced in 2001, when the Ministry contracted the 21 DHBs to deliver all health services to their respective regions. activities. While it does operate nationally Planning and funding are carried out under the auspices of the Deputy Director-General, DHB Funding and Performance, which also monitors the boards’ performance against agreed indicators. DHB, nor is it accountable in the same But while the government sees selfdetermination as critical to keeping healthcare in the hands of the local being restructured nationwide, there were on selected issues where there is agreement among all the DHBs to do so, DHBNZ has no mandate to direct any way as a government body, since it can, and does, operate behind closed doors. So the peculiar and frustrating situation arose that, while the provision and funding of pathology services was no national guidelines: the government had devolved responsibility and DHBNZ couldn’t speak on behalf of individual DHBs. This left representative bodies such as the RCPA, the New Zealand Medical Association and health workers’ unions out in the cold. For those concerned about the long-term implications, the only mechanisms available for challenge or discussion were the law and the lengthy process of policy change. The fallout So what has been the result of all this in terms of service provision? As you’d expect, a mixed bag. While West Coast DHB opted to maintain the status quo, Southland and Otago sought economies of scale, firstly by linking together, and secondly by selecting a single provider to cover both hospital and community services. Some private companies merged; others were forbidden to do so by the Commerce Commission. Several boards opted to keep hospital and community services separate, while others negotiated cooperative contracts between the two. The duration of contracts, which strongly impacts on the level of PATHWAY_11 > PathWay #12 - Text 23/5/07 2:06 PM Page 12 THE CHANGES: region by region NORTHLAND: separate providers for hospital and community services, the latter provided by Northland Pathology Laboratory (18-month contract). Review of services currently underway. AUCKLAND, COUNTIES-MANUKAU AND WAITEMATA: have negotiated an 18-month contract for transitional services with Diagnostic Medlab following a High Court decision to overturn the contract to newcomer Labtests as sole provider for the greater Auckland Region. Contract exclusive for first 12 months only. Both companies intend retendering for sole provision of services. WAIKATO: selected Pathology Associates over the incumbent Medlab Hamilton for community services. Hospital laboratories remain with the DHB. BAY OF PLENTY: opted for a sole provider, NZ-owned Pathology Associates trading as Medlab Bay of Plenty. LAKES (ROTORUA): a proposal for a joint venture between a private provider and the hospital laboratory likely to be signed off later this year. HAWKES BAY: has a single provider – a partnership between the hospital laboratory and Southern Community Laboratories (SCL). Hospital lab covers hospital services, all histology and non-gynaecytology and certain automated biochemical and haematology tests. SCL responsible for all sample collections, microbiology and the remainder of tests. TAIRAWHITI (GISBORNE): will have a sole provider (joint venture between hospital laboratories and Medlab Central) for hospital and community services, to start in September. TARANAKI: has retained its hospital services and contracted Taranaki Medlab for community work (three-year+ contract). WHANGANUI: announced the first preferred tender for all services to Medlab Central last October. Contract is yet to be signed. WAIRARAPA: selected Medlab Central as the sole provider from 1 March. MIDCENTRAL DHB (PALMERSTON NORTH): tender evaluation process complete and preferred single supplier selected, but contract not yet signed off. CAPITAL AND COAST (WELLINGTON) AND HUTT VALLEY: will maintain their respective hospital laboratories and jointly tender out community work. Contract awarded to Aotea Laboratories Limited, a merger between private providers Hutt Valley Diagnostics and Medlab Wellington. NELSON MARLBOROUGH: five-year contract to single provider, Medlab South. CANTERBURY: has kept hospital laboratory, and opted to keep both private providers Medlab South and Southern Community Labs for community schedule work with capped agreements. SOUTH CANTERBURY: the first DHB to tender services three years ago, it selected the incumbent Medlab South. It says it has made significant savings without compromising service. WEST COAST: smallest DHB has opted to maintain the status quo – hospital services provided by the hospital lab, and community services from Medlab South and the hospital lab. OTAGO AND SOUTHLAND: joint call for a sole provider of hospital and community services was won by Southern Community Laboratories, after the Commerce Commission forbade the merger of the private providers. 12_PATHWAY PathWay #12 - Text 23/5/07 2:06 PM Page 13 “New Zealand is an integral part of the Australasian region, so it affects everyone if the quality of their service falls behind.” SOURCE: NZ MINISTRY OF HEALTH – Dr Debra Graves District Health Boards Since the legal wrangle, the company investment, ranges from short 18-month ‘rollovers’ to up to 10 years. fact that Labtests had no existing laboratories raised alarm bells with many has been forced to make the 180 staff With thousands of jobs, millions of dollars, and a critical component of the health system at stake, change was never going to be easy. in the profession. members it recruited redundant, though But when NZ Medical Association president Dr Ross Boswell notes that “we’re so far steeped in the river of blood it’s too late to turn back”, one contract dispute has made it all the way to the High Court, and strong dissatisfaction has been expressed by a workforce that has lived with job insecurity for years, it’s clear the process has been massively disruptive. Nowhere is that more obvious than in the Auckland region. Last year, the Auckland, Waitemata and CountiesManukau DHBs jointly awarded their $560 million contract to newcomer Labtests Limited – a company part-owned by Auckland DHB member Dr Tony Bierre and Australian company Healthscope. While it promised to deliver an annual $15 million saving to the community, the This, and the ousting of the incumbent many of them have taken up the provider Diagnostic Medlab, sparked a company’s offer to relocate to Australia highly public and vituperative debate, and other parts of New Zealand. Labtests which ended in a $2 million High Court is currently working on placing the case where the contract was invalidated. remaining 18 staff in other jobs, though Justice Asher noted the DHBs had failed to properly consult GPs and the community as required, said Dr Bierre’s conflict of interest “amounted to an Ms Moss says it would want to re-instate all former staff if it won the contract further down the track. “We’re committed to re-tendering attempt to further his own interests”, and because we have some very innovative also criticised DHB chairman Wayne ideas about improving the delivery of Brown for allowing Dr Bierre’s pathology services, especially to low “impermissible” involvement. Since then, socio-economic groups who are not an interim 18-month agreement has been getting the testing they need,” Ms Moss negotiated with Diagnostic Medlab to says. ensure continuity of services beyond 1 July, when the contract was due to begin. Meanwhile, Healthscope has since There is still a long way to go to see whether the grass on the other side of the “river of blood” will be greener, but it’s bought out Dr Bierre’s share in the worth remembering that New Zealand company, and Labtests’ Chief Operating derives from Zeeland, whose coat of arms Officer Grainne Moss says the company bears the text luctor et emergo – “I will retender. struggle and I emerge”. PATHWAY_13 PathWay #12 - Text 23/5/07 2:06 PM Page 14 movers and shakers Scalpel, please… KEEPING FORENSIC PATHOLOGISTS IN REGIONAL AUSTRALIA IS A TOUGH ASK, BUT SOME STATES ARE MAKING HEADWAY. KATE WOODS REPORTS. he deceased man was Mr Maxwell T Marshall, found dead at his home in December 2003. The autopsy was performed by Dr John Scott, an experienced GP who had been working as a government medical officer (GMO) in Queensland for nearly three decades. Dr Scott concluded the cause of death was drug toxicity due to oxycodone. But the Queensland Coroner decided it was impossible to determine the cause of death, labelling the autopsy “inadequate”. Dr Scott’s report was too brief, the Coroner said. It omitted too many basic details; the GP was misled by inaccurate information in the police report; and he had decided on cause of death before seeing the toxicology analysis and before making “adequate” inquiries about the deceased’s medical history. But the coroner also concluded that these problems were due to Dr Scott’s lack of training, not a lack of professional application or commitment. This case was followed by media reports in NSW about the shortage of GPs prepared to conduct autopsies. Both the AMA and the Rural Doctors Association called for ongoing training to be offered to GPs doing this work. 14_PATHWAY But the media debate seemed to overlook an obvious question: what about the forensic pathologists? The GMO’s role in autopsies has long been a source of debate and discussion in Queensland and NSW. Both states – due to their size and the fact their populations are spread over large areas – need more pathologists in regional areas than other jurisdictions. But with the workforce shortage, they have been forced to rely on GMOs. This coroner’s case – among other things – has spurred Queensland into finding a way to increase the profile of forensic pathology in regional areas, although little progress has been made in NSW. And while the issue is not currently an urgent one in other states, the pathology workforce shortage could change that. The threat that coronial autopsies carried out in regional areas could be significantly reduced in future looms large. Sunny side up Queensland, in a bid to boost forensic pathology in the state, is now leading the way in establishing and filling trainee posts for young doctors. “In my view, this is absolutely the fundamental issue,” says Associate Professor Charles Naylor, chief forensic pathologist with the Queensland Health Scientific Services (QHSS). “You can speculate about putting forensic pathologists in regional centres all you like, but it is never going to happen unless you have the doctors to put in there.” He says Queensland has three trainee posts: two permanent, and one that may soon become permanent. Two of the trainees filling these positions are due to complete their final exams in forensic pathology this year. The hope is that if their roots are planted in Queensland, they will stay on after completing their specialist training. Professor Naylor says one of the reasons Queensland has been able to attract young doctors is its facilities. As well as pathology, the QHSS contains biology (including DNA PCR), chemistry and toxicology facilities, allowing young doctors to be exposed to a full range of cases at the one centre. The QHSS is also linked to a network of major pathology labs at hospitals around the state. “This means that during their training, registrars can, for example, rotate to the anatomical pathology labs at some of the big teaching hospitals like the Royal Brisbane and the Princess Alexandra Hospitals,” he says. PathWay #12 - Text 23/5/07 2:06 PM Page 15 “You can speculate about putting forensic pathologists in regional centres all you like, but it is never going to happen unless you have the doctors to put in there.” PHOTO CREDIT: ROBERT SHAKESPEARE – Associate Professor Charles Naylor “And while we might not be unique in this, we are probably better placed than most to offer this kind of well-rounded training to young doctors, and that is probably why we have had success in attracting and recruiting trainee forensic pathologists in Brisbane.” In Queensland, forensic trainees are attached to forensic laboratories from their first year of training and any time spent on rotation to other laboratories is paid for by the forensic lab. Keeping connected In other states, trainees are attached to an anatomical pathology laboratory for the first three years of training to obtain the basic surgical pathology they requre to be a forensic pathologist. As a result, they often get disconnected from forensics and lose interest. The Queensland model overcomes this problem and the RCPA is trying to encourage other states to adopt a similar model. With the ability to train and maintain forensic pathologists, the state is now working on an innovative way to promote the service in regional and remote areas. The initiative came about after a ministerial taskforce was established in 2005 to look at forensic services and the challenges it was facing, Professor Naylor explains. Of the 70 recommendations made by the taskforce, more than 90% were endorsed by Cabinet, including one that outlined the need to develop standard procedures for autopsies and running mortuaries across the state. As part of this drive, Queensland Health decided to establish facilities at seven regional centres, with enough trained mortuary staff and pathologists to service the local area. Dr Peter Ellis is the first forensic pathologist to be placed in a regional area under this scheme. Although he has only been in the job for four months or so, he says he is “delighted” with the situation. He says there are many benefits to working in a regional area over a big capital city like Sydney, where he worked for 19 years before taking up this post. “I have a reasonable workload, interesting case material and have been able to develop good, close relationships with the police, Coroner and other professional colleagues, which makes for better and more efficient working conditions.” Dr Ellis says while the downside to working in a regional area can be professional isolation, countering this was at the “top of the list” when he and Queensland Health were designing his post. The solution? He travels back to the QHSS one day a fortnight. “Maintaining professional contact with your peers is important in maintaining your standards. You need to be able to exchange ideas, bounce ideas off them, and if you are 500 km away from the nearest significant centre this becomes difficult. “If you can counter that or make provisions, then you are more likely to attract people to rural areas, including places as distant as Cairns or Rockhampton.” Dr Ellis adds there are also limitations with the type of cases that can be performed at his mortuary, because the facilities are not as large or as well equipped as they are at the larger centres. “It’s a bit of an experiment, but very exciting to be part of,” he says. “There are also a number of specialist trainees in the pipeline, which bodes quite well for the future. The hope is we will be able to spread this kind of regional service elsewhere in the state very soon.” PATHWAY_15 > PathWay #12 - Text 23/5/07 2:06 PM Page 16 In the shadows In NSW however, things aren’t looking up, though it’s not for want of trying on the part of forensic pathologists. Associate Professor Johan Duflou says there are a number of reasons for the shortage, including the low profile pathology has in the medical curriculum, and the low profile forensic pathology has among other medical practitioners – despite the popularity of crime television programs such as CSI. Very few medical schools have a formal series of lectures in forensic pathology, so students are not exposed to the topic and therefore don’t consider it when deciding their future, explains the chief forensic pathologist at the Department of Forensic Medicine, Glebe. And then there is the job itself. The work is “smelly”, night call-outs are not uncommon, and court appearances frequent. “On top of that, there is an income differential between forensic and anatomical pathology in NSW which is not insignificant; about $1000 a week,” Professor Duflou says. “Frankly, if you are starting out and get offered two jobs, one gets paid 50 grand more than the other, what would you do?” of Forensic Medicine, this system actually The institute – responsible for forensic pathology and clinical forensic medicine services throughout the state – has five or have been able to develop good, close relationships with undertake coronial autopsies on its behalf. the police, Coroner and other There are no GMOs because under Victorian law, autopsies must be carried professional colleagues” out by a pathologist or a medical – Dr Peter Ellis practitioner under the direct supervision of a pathologist. “Certain cases do automatically come to Melbourne – for example sudden infant death syndrome cases, all homicides, multiple fatalities and any other deaths the pathologists in regional areas are not happy to do,” Professor Cordner says. Shrinking numbers But he predicts this may not last long, with the continuous decline in pathologists expected to make it increasingly difficult to maintain the service in the future. “In the middle 1990s, about 800 or 900 deaths were autopsied in country Victoria every year; now the number is more like 400.” Professor Cordner says the main reason for this decrease is because some country centres now have their pathology “Over the decades, there have been multiple working parties and committees looking at the structure of forensic pathology services in NSW, and not surprisingly, they consistently come up with the same ideas – it’s just that these ideas keep being rejected.” inclination to engage with this work, and services provided remotely, and therefore autopsies have had to be transferred to Melbourne. It is also because some pathologists, for a range of reasons, don’t have a strong historically the pay has not been commensurate with the responsibility. While this second issue is being addressed with assistance from the state government, Professor Cordner says Victoria may have to consider other options, such as the feasibility of having forensic pathologists travel from the city to regional centres for certain cases. “The numbers do show an absolutely continuous downward trend in autopsies carried out in country areas due to the “It was a government policy decision, I suspect because they didn’t see the value in committing extra resources and funding in it.” unavailability of pathologists. But according to Professor Stephen Cordner, director of the Victorian Institute ones whisked hundreds of miles away to 16_PATHWAY interesting case material and six regional centres with pathologists who Professor Duflou is a member of the NSW Department of Health’s Forensic Pathology Services Committee, which is looking at service delivery throughout the state, but he says the solutions they are coming up with aren’t new. He says there was a plan to develop a NSW Forensic Medicine and Pathology Authority, which would operate in a similar way to the Victorian Institute of Forensic Medicine – “a statutory body with an independent board” – but this too was scrapped. “I have a reasonable workload, works “very well” in his state. “We are trying to maintain country services for as long as possible because we know families don’t want their loved the capital cities.” PathWay #12 - Text 23/5/07 2:06 PM Page 17 PHOTO CREDIT: BRENDON O’HAGAN in profile Floating asset DR TONY BARKER HAS FOUND THE PERFECT BALANCE BETWEEN HIS PASSION FOR QUALITY PATHOLOGY AND LIFE OUTSIDE MEDICINE, WRITES REBECCA GREATREX . uality assurance in medical testing has come a long way since Dr Antony Barker first began work as a chemical pathologist in the late 1970s. Q “It was very crude in the early days,” he recalls. “We made up our own control material from cow’s blood. The freezing workers would fill several buckets in exchange for a dozen bottles of beer, then we’d put this through a cream separator to produce a bright-pink serum control for use with the Technicon AutoAnalyzer. It was a huge breakthrough when uncontaminated commercial material became available in New Zealand.” Today, Dr Barker is Clinical Director of LabPLUS, the pathology service for Auckland City Hospital and the wider Auckland region that employs about 380 staff and has an annual budget of NZ$47 million. He sees his role as “being there to help other people achieve their aims. If you do that, and encourage people, it becomes a good place to work. People enjoy working where they feel their ideas are being valued. I try and be fair to people and I think people appreciate that.” Long-term colleague and fellow pathologist Kitty Croxson certainly does. “It’s very nice to work with someone so calm that you can rely on, and who always gives you a fair deal,” she says. And Don Mikkelsen, National Manager (Operations) of the NZ Blood Service, who has known Dr Barker for many years, describes him thus: “meticulous, honest, very considerate – and always thinks things through”. Dr Barker’s office overlooks the emergency helicopter landing pad on top of the Starship Children’s Hospital. On the wall is a photograph of his boat and an attractive print showing a view across the Hauraki Gulf – an area that he sailed frequently as a child. The work space encapsulates the balance between his professional and personal life. And this balance is a philosophy that he strongly believes in. “It’s the contrast between the challenges of a professional life and the pleasures of family life that make you appreciate both more fully,” he says. > PATHWAY_17 PathWay #12 - Text 23/5/07 2:06 PM Page 18 “I do think there’s a balance between work and the things you do outside of work that adds to both and makes them both more enjoyable.” Spirit of adventure Born in England in 1944, Dr Barker emigrated to New Zealand at the age of six. His architect father was an attractive proposition to the New Zealand government back then: it paid for the family’s passage on the Ruahine to alleviate the country’s architect shortage. The boat trip demonstrated that the young Tony’s sense of adventure was already well developed, though it included a heart-stopping incident for his parents. “There was a fancy-dress ball one night for all the children – and then I went missing. “They searched the ship for me, but there was no point in turning the ship round in the middle of the night. I was discovered the next day asleep in one of the life boats – so all was well.” The Barker family encountered another stroke of luck on that trip. They met a New Zealand judge by the name of Stanton who owned a house at Torbay. He invited his new acquaintances to live in the house, and they readily agreed. “You can imagine the contrast of going from the industrial north of England to staying in a beach house right on the sand, surrounded by paddocks,” Dr Barker says. The two families became firm friends and one of Judge Stanton’s daughters, Aileen O’Dell, had a major influence on Dr Barker’s life. Not only did he meet his future wife, Chree, during a sailing trip on Aileen’s boat during one university vacation, but Aileen was also his chemistry teacher at Takapuna Grammar School. “I was one of the lab boys, setting up the experiments for the next class, so we used to get into all sorts of mischief, as you can imagine, with a storeroom of chemicals to experiment with. We learnt a lot of chemistry, most of it outside the normal curriculum,” he laughs. CV in brief DR ANTONY (TONY) BARKER 1966 BSc 1974 MSc (Pathology) 1970 1977 1982– MB ChB MAACB, FRCPA Medical Testing Professional Advisory Committee, International Accreditation New Zealand 1983–89 Board of Education, Royal College of Pathologists of Australasia Education Committee member, Australasian Association of Clinical Biochemists 1990–96 NZ Councillor, Royal College of Pathologists of Australasia Member, Council of Medical Colleges in New Zealand 1989–96 Director of Laboratory Services, Auckland Hospital 2002– 2005– 18_PATHWAY Clinical Director, LabPLUS, Auckland District Health Board Council Member, International Accreditation New Zealand It was that interest in chemistry, though, that led him to consider a career on plant disease research, until he was advised that medical research had better funding. He studied organic chemistry and biochemistry at the University of Otago – despite being told by one of his teachers that he was “not suitable material” for university. He attributes this unlikely comment to the fact that so much of his time was devoted to sailing and athletics throughout his school years. Although the athletics has now morphed into strolls around the islands of the Hauraki Gulf, he and his wife still enjoy sailing and try to spend every other weekend on their (third) boat. “I’ve always been interested in boating,” he says, estimating that the family sails over 1000 miles each year. “It bought us close together, especially when conditions were bad.” After graduation, a short interval in the (then) very small medical laboratory at Auckland Hospital convinced him that he needed a medical degree to get an appointment as a medical researcher with a secure salary. So back he went to Otago. “As I went through medical school, I had chemical pathology in mind as my main interest. A lot of my fellow students used to tease me and say I was only choosing pathology so that I could have the weekends off to go sailing, and of course I would irritate them by agreeing with them because there was some truth in that! “I do think there’s a balance between work and the things you do outside of work that adds to both and makes them both more enjoyable.” He worked as a house surgeon in Auckland before starting an MSc in pathology in parallel with his pathology registrar training, but his thesis work convinced him that pure medical research was not for him. “I like a problem that can be solved practically within a fairly short period of time. I had to recognise that that was my personality and there was no point in pretending otherwise. My present job involves a lot of troubleshooting and sorting out issues on a day-to-day basis – I really enjoy that.” PathWay #12 - Text 23/5/07 2:06 PM Page 19 “I like a problem that can be solved practically within a fairly short period of time. I had to recognise that that was my personality and there was no point in pretending otherwise.” Enjoying family life; Right: Dr Barker and wife Chree on their first date; Opposite page: Boating trip 1984 Dr Barker is often invited to speak publicly and toured Australia last year as one of the Australasian Association of Clinical Biochemists (AACB) Current Concept Lecturers, promoting the need for reference interval standardisation, which enables laboratory results to be accurately compared. Dr Barker joined the Medical Testing Professional Advisory Committee of International Accreditation New Zealand (IANZ) soon after it was established, helping to write the laboratory accreditation-specific criteria. It was a subject that he had first presented at the AACB Conference in 1978, but back then his lecture had no impact whatsoever. Program Manager of Medical Testing at IANZ Graham Walker describes him as “highly skilled and highly capable”, and pays tribute to him as “one of the few pathologists that has dedicated his career to the less lucrative public health sector”. “People couldn’t understand how a group of competing laboratories could cooperate so closely, sharing problems and helping each other out,” he explains. But since then there has been a complete change of attitude in the profession, so it was “a pleasurable experience” to receive a very different, enthusiastic response from the audience last year. Another marked change that has occurred since the 1970s is the development of the RCPA/AACB Quality Assurance program, which Dr Barker describes as “amongst the best in the world today”. The Auckland Regional Quality Assurance Group that Dr Barker and like-minded colleagues were instrumental in setting up in 1977 to standardise reference intervals is still going strong. It now includes most laboratories in the upper North Island. “We’ve been meeting once a month for over 30 years. There has to be something of value for everybody there to keep it going, especially when people travel from as far away as New Plymouth, Whangarei and Tauranga.” Major contribution Dr Barker’s involvement with the RCPA began around the same time, when he became the chemical pathology representative on the college’s Board of Education And as if this wasn’t enough work, he was also appointed to the AACB Education Committee and helped organise and contributed to the annual RCPA/AACB chemical pathology course for six years. (His contribution to the college also includes a six-year stint as New Zealand councillor – from 1990 to 1996). By the early eighties, he and his wife had three young children, and he describes a “slightly mad” idea that saw them purchase 40 acres of land to develop into a forestry plantation. It was covered by gorse, however, and Dr Barker admits that “the family spent more time clearing this gorse – by hand – over the next 10 years than anything else put together”. It doesn’t sound relaxing, but he explains the attraction. “When you’re working in the health system there are lots of things that you cannot change so it can be very frustrating. “Some years, you feel you haven’t made a lot of advances, but the forestry block is something where you can literally see the difference that you’re creating. In retrospect though, it was a mind-boggling undertaking.” Today, the 18,000 trees that the family painstakingly planted are maturing and it’s “a lovely spot to be in”. There is still a way to go with quality assurance, though, so it’s fortunate he is not thinking of retirement just yet. One future goal is to “work with my colleagues to standardise the reference intervals used by laboratories across the whole of Australasia”, he says. “A network of regional qualityassurance groups needs to be developed to work together and share ideas and proposals for standardisation.” Given the huge amount Dr Barker has managed to achieve so far, it seems likely this is another of his goals that will become reality. PATHWAY_19 PathWay #12 - Text QAP ad 14/11/05 23/5/07 5:45 PM 2:06 PM Page 1 Page 20 Not just Quality Assurance! A resource for the Pathology community RCPA Quality Assurance Programs— RCPA Quality Assurance more than just broad range, world class, Programs are offered in the accredited external quality assurance following disciplines: programs. RCPA QAP offer educational support for Anatomical Pathology your quality initiatives: Benchmarking in Pathology z Seminars Chemical Pathology z Workshops Cytopathology z Forums Haematology z Educational supplements library Immunology Microbiology z Educational exercises Serology z Virtual Images library Synovial Fluid z Case study exercises Transfusion Quality Systems Certification Organisation No: 9013 NATA Accredited Proficiency Testing Scheme Provider Number: 14863 www.rcpaqap.com.au PathWay #12 - Text 23/5/07 2:06 PM Page 21 This radiolucency around the crown of an unerupted wisdom tooth was diagnosed radiographically as a dentigerous cyst Teething troubles PHOTO CREDIT: SUPPLIED BY DR MICHAEL ALDRED disciplines in depth ORAL PATHOLOGY IS BOTH A MEDICAL AND DENTAL SPECIALTY, BUT FEW PEOPLE ARE AWARE IT EVEN EXISTS. CATHY SAUNDERS REPORTS ON THIS UNHERALDED DISCIPLINE. ral pathologists carry out sleuthing work every day for doctors, dentists and patients – and their work can be lifesaving. O But they do all this in relative obscurity: some have even dubbed their under-recognised and under-funded role ‘the Cinderella discipline’. As a result of this, oral pathologists are becoming an endangered species – there are only about 10 of them in Australia and New Zealand. These low numbers are partly explained by low remuneration compared with other dental specialties. And job opportunities are scarce. So while dentists are queuing to become orthodontists because ‘everyone wants their teeth straightened’, oral pathologists are struggling for survival. While patients certainly don’t register the term ‘oral pathology’, many doctors and dentists aren’t aware of its role either, despite the fact it is a discipline of both medicine and dentistry. Its practitioners deal with pathology of the soft and hard tissues of the mouth, jaws and salivary glands. Diagnoses include consideration of the clinical picture and radiographs as well as biopsies. “But no-one really knows what an oral pathologist is,” says Dr Anna Talacko, chair of the RCPA Faculty of Oral Pathology. And according to Dr Michael Aldred, secretary of the college’s oral pathology faculty committee, oral pathologists diagnose “lumps and bumps” in the mouth, which can range from benign conditions to serious malignancies. “As one example, a lot of tissue we deal with is from changes in the jaw associated with teeth or with cysts,” says “Many clinicians removing tissue from the head and neck do not even realise that oral pathologists, who are people with expertise in this area, exist. Dr Aldred, who shares the diagnostic oral “In addition, some anatomical pathologists are not familiar with the role of oral pathologists.” some of which are caused by a dead And yet their work is indispensable. Training in oral pathology has traditionally been combined with training in oral medicine – a discipline of dentistry – in Australia. Some work exclusively as oral pathologists, dealing with the microscopic diagnosis of oral and maxillofacial conditions, and some combine this with oral medicine. pathology reporting with Dr Talacko at Dorevitch Pathology in Melbourne. There is a bewildering variety of cysts, tooth that can be removed but some of which are likely to recur, and “that will be important for the long-term management of the patient, to intervene if there is going to be a recurrence to catch it early rather than late”. It’s also important to get a correct initial diagnosis: some samples diagnosed by the clinician as cysts can prove on examination to be tumours. PATHWAY_21 > PathWay #12 - Text 23/5/07 2:06 PM Page 22 Oral pathologists diagnose “lumps and bumps” in the mouth, which can range from benign conditions to serious malignancies. If teeth could talk While oral pathologists might often be asked by medically qualified pathologists to give their opinion on specimens from the oral cavity, they also deal with extracted teeth. Dr Aldred, who has a special interest in inherited diseases of the teeth, helps clinicians distinguish between amelogenesis imperfecta and dentinogenesis imperfecta in which the enamel or the dentine, respectively, is imperfectly formed. “Clinically, these can sometimes be confusing,” he says. “A correct diagnosis is important for patient management because if the dentine is affected, it can be associated with the medical problem Oral pathology – how to get there o become an oral pathologist, it is possible to qualify as a dentist and then complete a higher degree in oral pathology or a combined degree in oral medicine and oral pathology, depending on the university. T Alternatively, dental or medical graduates can train for the Fellowship of the Faculty of Oral Pathology (FFOP) through the RCPA, which sought to set standards of training and assessment in oral pathology with the establishment of the Faculty of Oral Pathology in 1996. Dental and medical graduates can enrol in accredited laboratories (two in Australia and one in New Zealand) to train for the FFOP, which requires five years of training with specific requirements for the number of cases reported, similar to the requirements in anatomical pathology. Oral pathologists who have done a Masters can apply for exemption from part of the FFOP training. The degree of exemption depends on the training undertaken, particularly with regard to diagnostic work. 22_PATHWAY osteogenesis imperfecta or ‘brittle bone disease’.” Dr David Booth, a retired WA oral and maxillofacial surgeon who works part-time as an oral pathologist, agrees that because the mouth is such a good litmus test for overall health, oral pathologists often diagnose serious diseases long before they manifest in other parts of the body. Some gastrointestinal disorders for example – such as Crohn’s disease and ulcerative colitis – can present with oral manifestations. Persistent ulcer of the lip Dr Nick Boyd, an oral pathologist who works for the WA pathology company PathWest and at the University of Western Australia’s Oral Health Centre of WA, has other pertinent examples. to do with the oral cavity and jaws – they have a gap in their education, which starts at the lips and ends at the tonsils.” When a woman with a history of cancer had a wobbly molar for no apparent dental reason, he examined the extracted tooth and found islands of carcinoma on the root. When he reported he did not think it was from an oral location, a CT scan was performed and her sinus was found to be cancer-ridden. Because the role of oral pathologists has largely been under-recognised, the work generated from pathology laboratories does not fill a week. A tight squeeze So most also teach, conduct research in universities, or work as oral medicine specialists, combining oral medicine with oral pathology. Another recent diagnosis of metastatic prostate cancer followed the biopsy of a patient who presented with a numb lower lip, and was found on x-ray to have a suspicious area of bone in his jaw. Dr Aldred says only about five oral pathologists report in commercial laboratories, and full-time posts in oral pathology do not exist. Despite valuable diagnoses such as these, Dr Boyd says patients with oral pathology are often referred inappropriately by their GPs to ear–nose–throat surgeons. Worse still, there are only two registrars in training, one unfunded in Victoria and one in a half-time funded training post at Westmead Hospital in NSW. “I often say I wonder which part of ENT stands for mouth,” he says. The Australian Medical Workforce Advisory committee recommended 400 extra pathology training posts over the past four years and only 53 (soon to be 63) have been funded. Similarly, GPs may see problems with the oral mucosa, think it is a skin problem and refer the patient inappropriately to a dermatologist. Dr Booth says the lack of understanding by GPs about oral pathology is due to little exposure during training. Medical students have no, or at most two, lectures on it in six years of training compared with a full year of training for dental students. None of these are for for oral pathology, Dr Aldred says. “A number of years ago we put our bid in for two oral pathology posts but have never had any success.” But there may yet be some hope. And he believes this “downgrades oral pathology in the eyes of the medical profession”. A federal health department spokesperson says the department is currently in discussions with the RCPA about pathology specialties in particular shortage. Dr Aldred agrees. “Most medical students have limited teaching of anything “Funding will take into consideration specialities and sub-specialities that are 23/5/07 2:06 PM Page 23 PHOTO CREDIT: EAMON GALLAGHER PathWay #12 - Text Drs Michael Aldred and Anna Talacko: indispensable but unheralded work experiencing severe shortfalls,” the spokesperson says. able to become an approved pathology practitioner, the spokesperson says. But training posts and recognition are not the only hurdles for oral pathology. The lack of patient rebates presents another difficulty. Despite this impasse, the college’s Faculty of Oral Pathology is hopeful of success soon in a different field: receiving accreditation from the Australian Dental Council (ADC). Because they traditionally have dental, not medical, training, oral pathologists are not eligible for a Medicare provider number and cannot access Medicare item numbers for pathology reports on microscope slides. Medicare claims for their work are therefore made by anatomical pathologists in the pathology companies they report for. The RCPA has been lobbying the federal government to have Medicare provider numbers instated for oral pathologists and discussions are still underway. But the federal health department spokesperson says that in general, Medicare benefits are available only for professional services provided by, or on behalf of, a medical practitioner. An oral pathologist with only dental and no medical qualifications would not be This is on the basis that the Australian Medical Council has recently carried out its accreditation review of the RCPA and is likely to have implications for registration of oral pathologists as specialists. To date, state dental boards have accepted that the three-year combined masters degree course (or equivalent) in oral medicine and oral pathology is sufficient for a specialisation in both disciplines. All state dental boards, except Victoria, have allowed oral pathologists with a Masters degree to register with them as specialists. (The WA Dental Board does not have a category for specialist registration in oral pathology.) In Victoria, the Dental Practice Board requires the Fellowship of the Faculty of Oral Pathology (FFOP), and so agrees with the RCPA that the five-year fellowship should be the basis of an oral “Most medical students... have a gap in their education which starts at the lips and ends at the tonsils.” – Dr Michael Aldred pathology specialisation before dentists can register. “Traditionally, the Masters degree has been the registrable specialist qualification, but we believe the College really has the benchmark standards… and there should be one exit – the College Fellowship,” Dr Talacko says. The Faculty is hopeful that once it has gained formal recognition by receiving accreditation from the ADC, the FFOP will be the only pathway to specialisation. While there is still some way to go in gaining better recognition for oral pathology, formal accreditation may well be a promising step towards a brighter future for this unsung speciality. PATHWAY_23 PathWay #12 - Text 23/5/07 2:07 PM Page 24 close up 24_PATHWAY 23/5/07 2:07 PM Page 25 Coloured scanning electron micrograph (SEM) of the mass of capillaries (red), known as glomeruli, which carry blood to be filtered in the kidney. PHOTO CREDIT: SUSUMU NISHINAGA / SCIENCE PHOTO LIBRARY PathWay #12 - Text PATHWAY_25 PathWay #12 - Text 23/5/07 2:07 PM Page 26 spotlight on disease Silent assassin HUGE GAINS ARE BEING MADE IN OUR ABILITY TO DETECT EARLY SIGNS OF CHRONIC KIDNEY DISEASE – BUT AS MATT JOHNSON REPORTS, SPOTTING THOSE AT RISK REMAINS HALF THE BATTLE. ou would certainly notice if half your heart had become so diseased it couldn’t function. And you wouldn’t feel well with just one lung, or one side of your brain. But lose up to 50% of your kidney function and you won’t notice much. Y Such is their efficiency that your kidneys can actually cope with losing nearly half the nephrons they use to filter your blood. By that stage though, the disease process could be so well entrenched that reversing it is next to impossible. Then, all that lies between you and catastrophic physiological collapse are two organs, each the size of your fist and weighing less than 2% of your body weight. For decades, the appearance of symptoms marked almost the end for patients with chronic kidney disease (CKD), which can be caused by diabetes, obesity, hypertension or smoking. But advances in pathology have shown that early detection is possible. We know that treatment can slow the disease – but ultimately, we may be able to prevent it developing at all. Every day, fleets of mini-buses collect patients with CKD for their dialysis treatment. The bus trip precedes four or five hours of sitting tethered to a machine as it filters and cleans their blood. By the time they arrive home these patients have lost another day to simply surviving. Most of them have to repeat this process every second day. Forever. But what is most disturbing is that until 90 days before they required dialysis, 26_PATHWAY more than a quarter of these patients had never seen a kidney specialist. For years they had unknowingly been developing a condition that would not clinically declare itself until it was too late. Appalling costs The economic costs of CKD are, quite simply, appalling. This year it will directly cost $700 million. That will rise by $1 million per week next year and continue to do so until 2010, when conservative estimates of the total health sector cost lie between $4.26 and $4.52 billion annually. nearly all solutes out through the capillary wall and into a series of tubules that run parallel to the capillaries. In an energy-sapping process, the kidneys then pump 99% of the filtrate and its dissolved components back into the bloodstream, leaving wastes, drugs and a small amount of water in the tubules to be excreted as urine. The glomerular filtration rate (GFR) for a healthy kidney is about 100 mL/minute, which means nearly 200 litres of filtrate is collected every day in the tubules: all from a blood volume of just six litres. Every day during that time will have seen five more Australians added to the list of patients requiring dialysis or a transplant. The effort of returning nearly all this filtrate requires almost as much energy as the heart, and about twice as much as the brain. But these figures pale against the human cost. The burden of regular dialysis and the general disability associated with CKD are so severe and interminable that many – such as Australia’s then richest man, Kerry Packer – chose to decline the treatment and succumb to the disease. But the process of filtration and reabsorption allows the kidney tubules to delicately control blood volume and pressure, nitrogenous wastes, pH (acidity/alkalinity), haematocrit (percentage of red blood cells) and even bone density. The million or so nephrons that lie near the outer edge of your kidneys receive 25% of the blood pumped by your heart every minute. It’s a totally disproportionate amount for organs their size, but as the blood flows through the capillary beds, it’s not just supplying the kidney with oxygen and nutrients. Those delicate glomerular capillary beds are much more porous than normal capillaries and they act like sieves, allowing the passage of plasma and Nephrons severely damaged by disease or trauma cannot be replaced – but the surviving nephrons can, to a point, take on an increased workload. Patients who have a kidney removed effectively lose half their nephrons, resulting in a 50% reduction in GFR at the time of surgery, but within several months their total GFR will have risen to 80% of the pre-operative value. But beyond a 50% nephron loss, the remaining nephrons are forced past their capacity, become irreversibly damaged, 23/5/07 2:07 PM Page 27 PHOTO CREDIT: CNRI / SCIENCE PHOTO LIBRARY PathWay #12 - Text Light micrograph of a section through kidney tissue in a case of diabetes. and the symptoms of uraemia (literally, urea in the blood) begin to emerge. The increased workload itself causes the relentless destruction of the remaining nephron pool – and at this point, even if the original disease process is halted, the degeneration can continue. Raising awareness Alerting GPs and the public to this long asymptomatic development period of CKD has become the focus for groups such as Kidney Health Australia. “The emphasis in the past five years in CKD has swung to early detection of damage and impaired function rather than on diagnosis of explicit disease that is causing the damage,” explains Kidney Health Australia Medical Director Dr Tim Mathew. “A number of large studies across the world have led to the realisation the kidney function is significantly reduced in greater numbers in the community than we have previously realised. “Surveys of otherwise healthy people show up to 8% have reduced function – and there’s another 6.5% on top of that figure who show some signs of significant damage. That’s one in seven.” Standard tests There are several tests commonly used to assess kidney disease. A urine sample can be analysed for red and white blood cells or proteins that get into the urine through damaged nephrons. Or a blood sample can be analysed for waste products such as urea and electrolytes that start to accumulate in the blood as kidney function fails. An ESR (erythrocyte sedimentation rate) test used to measure inflammation can also be indicative of kidney disease, but most of these tests are non-specific, and it’s the presence of creatinine in the blood and its relationship to GFR that is considered the most reliable test. Pathologists and clinicians have known for decades that the onset of CKD symptoms would be preceded by a long period of steadily falling GFR, but the lack of an accurate test made it difficult to predict if a person was indeed on the path to CKD, or how far they had to go before the point of no return and becoming permanently dependent upon dialysis or transplantation. Under these conditions it was difficult to determine treatments and how aggressively they should be administered. The standard test was to use the link between GFR and creatinine – a product of muscle metabolism that is freely filtered at the nephrons but never reabsorbed in the tubules, so high creatinine levels in the blood reflect low GFR. However, the creatinine figure gained in testing could be affected by diet, weight loss, ethnicity, sex or age, making its clinical significance difficult to interpret. “There’s been more than 50 equations over the past 30 years that have tried to estimate GFR from a creatinine result,” explains Dr Graham Jones, SydPath’s staff specialist in chemical pathology at St Vincent’s Hospital in Sydney. “But for previous equations to be accurate they need detailed information about the patient, such as weight and body composition.” > PATHWAY_27 PathWay #12 - Text 23/5/07 2:07 PM Page 28 A new formula – the MDRD equation – has changed that and given pathologists the ability to accurately quantify renal function on lab tests alone. “There were a number of companies supplying assays for creatinine, but they were all slightly different,” Dr Jones explains. “The MDRD equation is robust and at least as accurate as any alternative. It’s been widely validated and doesn’t need any measurement of the patient – just age and sex,” Dr Jones says. “We weren’t able to compare the results gained with one assay with the same person tested by another assay. Lab to lab there would be differences.” The new formula has also been easy to integrate into the existing testing process. “It’s much easier to add a calculation to existing samples than if you were to bring [in] a new test, where there’s not only the cost of the test, but also the cost of educating GPs and pathologists about the test and what the results mean. “The cost of the new formula to Medicare has been zero.” Significantly, Kidney Health Australia has persuaded every lab to report the new eGFR value created by the MDRD equation with every creatinine test. Technically the eGFR test is quite simple: a chemical reaction changes light absorbency, depending on the volume of creatinine in the sample, but even with the new MDRD equation, problems remained with standardisation between laboratories and the testing products they used. Synergy and standardisation But unprecedented cooperation between clinicians, pathologists and the companies that develop the assays led to a breakthrough. “Most diagnostic companies have a very high level of expertise, but their ability to cooperate has not been great,” Dr Jones says. “In this case the doctors and scientists provided the diagnostic companies with what they needed to align their assays, and the companies agreed. It has been expensive for companies in the short term, but doctors and patients have benefited enormously.” The significance of uniform lab reporting cannot be overstated as it now allows expert groups to review the evidence and know if a treatment is effective, regardless of which lab the patient has attended. From there clinical TREATMENT APPROACHES reating CKD involves firstly treating the underlying causes, and secondly, slowing the progression. T The optimal time for treating the underlying cause is usually well before CKD is established, and effective control of blood pressure and blood glucose levels is often enough to stop the progression of the disease. Once the disease is established these remain just as important, but additional treatments such as restricting protein intake can help slow progression. Ultimately, most patients will require renal replacement therapy: either peritoneal or haemodialysis. Unfortunately, even optimal dialysis therapy is not a panacea, with some of the symptoms unlikely to respond fully, while others will continue to progress and some new problems may even arise. Haemodialysis currently costs the community $72,000 per person per annum, and has a significant impact on the lifestyle of those restricted to attending a dialysis centre every second day. Technological advances are allowing more patients to dialyse at home – and if taken to the optimum level this would, according to Kidney Health Australia, produce an annual saving of $88.2 million, as well as improving the freedom and lifestyle of these patients. Simply increasing the rate of peritoneal dialysis to an optimal level would produce a saving of $135.4 million. Virtually all abnormalities associated with CKD are completely reversed by successful renal transplantation, and increasing the number of kidney transplants by 10% to 50% would save $5.8 million to $25.9 million a year. 28_PATHWAY guidelines and policies can be implemented. This standardisation has ultimately extended beyond the researchers, clinicians, laboratories and diagnostic companies, to include a standardisation between countries. “The work on serum creatinine is hopefully the forerunner of many other tests that could become aligned. “It’s one of the most dramatic examples of cooperation between pathologists and clinicians – and it’s a paradigm for future collaboration, and the way healthcare should be coordinated and then delivered,” says Dr Jones, who sees this degree of accuracy as integral to pathology. “We should aim to deliver a message to the doctor with every result. We should be able to provide every doctor, every time, with information to assist with the diagnosis or management of the patient. This way pathology can essentially be an ‘effector organ’ for the guidelines.” The eGFR test has proved successful not only for its accuracy, but because it has made the test easy to understand. Normal GFR is 100, so any eGFR result is effectively a percentage which doctors say is simple for patients to understand. And long-term studies have accurately established the values at which treatments need to be implemented. As advantageous as the new eGFR test has proven, it remains only a screening test – and once it identifies kidney damage, doctors and pathologists must then try to identify what disease is causing the damage by a range of other blood and urine tests and interpretation of biopsy samples. But with the emphasis on early detection, are there other ways of identifying these patients? The presence of protein or albumin in urine may actually be an earlier marker than creatinine, but before it can be used as a screening test it too needs to be standardised. Reaching those at risk There also needs, according to Dr Tim Mathew, to be a shift towards conducting more urine tests on high-risk individuals. “We’ve already identified the high-risk groups for CKD: it’s those over the age of 50 years, with diabetes, hypertension, PathWay #12 - Text 23/5/07 2:07 PM Page 29 “It’s one of the most dramatic examples of cooperation between pathologists and PHOTO CREDIT: ELIZABETH ADAMS clinicians.” – Dr Graham Jones obesity, malnutrition, family history and those who smoke, and Aboriginal and Torres St Islander people,” he says. “And we know that early detection reduces the impact of the disease, but we have to take the message out to both doctors and patients that this is a silent condition, and unless you get a regular CHRONIC KIDNEY DISEASE: risk factors, stages and complications Risk factors are hypertension, obesity, diabetes, family history, smoking, and Aboriginal or Torres Strait Islander descent. CKD has been divided into five stages based on GFR. kidney check – that’s blood pressure, eGFR, and urine protein and blood sugar – you won’t know until it’s probably too late.” Dr Mathew has been encouraged by Stages 1–2 Patients usually remain symptom free, other than those symptoms associated with the original disease causing the damage. large cost-effectiveness studies that applied best care to high-risk groups and Stage 3 found the process more cost effective Anaemia; loss of energy and appetite. than the current screening processes for breast, cervical or bowel cancer. Abnormalities in sodium and water balance can lead to generalised oedema, congestive cardiac failure and shortness of breath. But he is dismayed by other studies that found of 1600 diabetics, 30% had not Stage 4 had a proteinuria test in the preceding Cardiovascular and gastrointestinal disturbances continue. year, despite their cycle of care requiring it Possibility of uriniferous odour to the breath (associated with metallic taste). annually. Gastritis, peptic disease and mucosal ulcerations can lead to abdominal pain, nausea, vomiting, blood loss. “Chronic kidney disease is simply not being thought about enough at a GP level – and if it’s not considered it can’t be diagnosed,” he says. “Once diagnosed, treatment is Skin affected with anaemia, bruising and yellow discolouration from the deposition of pigmented metabolites, or even urea itself forming in a ‘frost’ on the skin. Stage 5 remarkably effective.” Severe disturbance in activities of daily living, sense of well-being, nutritional status and electrolyte balance. GPs NOTE: This article is available for Survival without renal replacement therapy impossible. patients at http://pathway.rcpa.edu.au PATHWAY_29 PathWay #12 - Text 23/5/07 2:07 PM Page 30 foreign correspondence People power WHAT BEGAN AS A ONE-OFF TRIP TO SHANGHAI HAS TURNED INTO AN ONGOING CROSSCULTURAL PARTNERSHIP FOR PROFESSOR RICHARD WILLIAMS. KIM COTTON REPORTS. hen Professor Richard Williams first visited Shanghai, it wasn’t the cultural polarities between East and West that surprised him. W Instead, what intrigued him was the gleaming new medical equipment and the forward thinking of his Chinese peers’ approaches to pathology. “Their knowledge is just racing. They’re just really bowling into the 21st century – we’ll be playing catch-up within a few years time,” says Professor Williams, the director of anatomical pathology at Melbourne’s St Vincent’s Hospital. He first arrived in Shanghai two years ago on the back of a one-week symposium held at Peking University in China’s capital, Beijing. While there, he was invited to Shanghai’s Changhai Hospital Second Military Medical University – which boasts 30_PATHWAY more than 1500 beds and 3000 staff – by the hospital’s director of pathology, Professor Minghua Zhu. The intermediary was Chinese pathologist Dr WeiQiang Zheng, who had spent six months in Professor Williams’ department to investigate breast pathology research. “When Dr Zheng heard I was going to Beijing he contacted me and asked if I would accept an invitation from Professor Zhu to visit his department and talk about what we did in Australia,” Professor Williams says. “I think the [presentation to] medical students might have been so they got used to listening to lectures in English,” he laughs. “And I could do it on one of my interests – pathology of the appendix.” Quiet revolution Formerly known as the Paris of Asia, Shanghai is fast becoming the citadel of China’s modern economy. And like the racing pace of its fiscal expansion, Professor Williams believes the medical system is enjoying a similar transcendence. “I was shown the pathology department in the cancer hospital… they’ve got molecular pathology going on not only as diagnostic adjuncts but as research work, and they’ve got all this equipment spread round in what looks like very old buildings but with very up-to-date facilities,” he says. “I don’t know what I really expected… but every door they opened up [at Changhai Hospital] was full of the latest equipment you could buy internationally in PathWay #12 - Text 23/5/07 2:07 PM Page 31 “Every door they opened up was full of the latest equipment you could buy internationally in every part of the anatomical pathology department.” Above: Professor Williams with wife Julie and daughter Siobhan Left: Old Shanghai Town preserved in the middle of modern Shanghai every part of the anatomical pathology department.” Professor Williams says pathology appears to be enjoying a high profile in China as it keeps pace with modern Western science. “What they’re trying to do is make sure their people are keeping abreast of everything that’s going on everywhere,” he says. “They will put the resources into it [pathology], whereas the problem with Australia is there are too few of us around.” Professor Williams was invited to return to Shanghai in 2005 to discuss the e-learning tool InView. Developed by an associate, Professor Peter Hamilton at Queens University in Belfast and i-Path Diagnostics Ltd, the tool helps young pathologists make more reliable detections in cancer pathology based on analytical rather than intuitive diagnostic practices using virtual microscopy. The RCPA is closely involved in the development of the educational content and responsible for Australasian distribution. During the visit, Professor Williams was also asked to the annual symposium held between the professional pathology bodies in Shanghai and Osaka, Japan. And last year, he and three colleagues were asked to present keynote lectures at the symposium. The collaboration has since led to the formation of the Shanghai–Osaka–Melbourne meeting. Four things you didn’t know about China Professor Williams says the tri-city partnership will prove valuable for • China’s projected population for the year 2050 is 1.5 billion • During the 2008 Olympic Games, about 1890 professional medical staff will provide voluntary healthcare services to athletes and spectators • The leading cause of death in 2000 was cerebrovascular disease (17.7%), followed by chronic obstructive pulmonary disease (13.8%) and ischaemic heart disease (7.5%) • China accounts for almost one-third of all cigarettes smoked annually around the world – about 350 million smokers puffed on 1722 billion cigarettes in 2003 Australian pathologists because of the exposure it will give them to different groups of pathologies, such as China’s broad variations of liver disease and Japan’s string of gastric cancers. There is also the potential for professional training exchanges based on interest from China in developing a national assessment system for pathologists, with inquiries having been made about the RCPA’s assessment system. Contrary to the global trend, China’s pathology workforce is buoyant and competitive. However, the notion of China supplying Australia with much-needed consultant pathologists is unlikely in the foreseeable future, Professor Williams says. And even if it were, perhaps they wouldn’t want to come: “Some of the Chinese and Japanese pathologists thought the team in my Sources: department were actually doing a bit too China Population Information and Research Center – http://www.cpirc.org.cn/en/eindex.htm much service work and not enough World Bank research and development. World Health Organization “They thought our workload was pretty high – and ours isn’t as high as some of the private laboratories.” To purchase InView please log onto www.rcpa.edu.au PATHWAY_31 PathWay #12 - Text 23/5/07 2:07 PM Page 32 practice portrait Celebrating 25 years FROM LITTLE THINGS, BIG THINGS GROW. KATE WOODS PROFILES THE 25-YEAR RISE OF A SPECIALIST GYNAECOLOGY PATHOLOGY PRACTICE WITHIN SYMBION LAVERTY. TIMELINE: 25 years of change Late 1980s New sampling implements introduced to replace the spatula. Laverty Pathology trials and promotes the now widely used Cervex brush. 1991 The National Cervical Screening Program is introduced after a decades-old ad hoc approach. Dr Colin Laverty is a member of the steering group. 1992–6 The first automated equipment designed to prepare and/or read slides is introduced into Australia. Mid 1990s He watched it grow exponentially over 16 years, and by the time he sold the business in 1998, it was firmly placed at the cutting edge. The NSW Pap Test Register is launched. Laverty Pathology is a pilot lab. Commercial HPV testing becomes available in Australia. Laverty becomes one of the first labs to offer it as a regular service. ThinPrep Imaging system becomes available in Australia. Symbion Laverty conducts first Australian study looking at its efficacy. 2006 Revised NHMRC ‘Guidelines for the Management of Women with Screen-Detected Abnormalities’ introduced. Symbion Laverty Pathology a pilot lab for the required changes in NSW Pap Test Register. 32_PATHWAY As the practice, now known as Symbion Laverty Pathology, celebrates its 25th anniversary, it has much to be proud of. It’s now at the forefront of its field in Australia as a specialised gynaecological cytology service. It employs more than 60 people, processing more than 200,000 Pap smears each year. And while it doesn’t eschew its humble beginnings, life is now a little more comfortable – with facilities and staff housed in a spacious laboratory in North Ryde. Rapid re-screening is discussed as a quality assurance technique. Colin Laverty involved in development. 2005 The premise was sound: cervical cytology and histology results would be correlated, and pathologists would have the opportunity to develop a high degree of knowledge and skill in the area. Dr Colin Laverty and his wife began the lab as a private practice in 1982, a bold move considering he was the only one in private practice to become specialised in this area. National Pathology Accreditation Advisory Council (NPAAC) Performance Measures developed. 1998 The first of its kind in NSW, Dr Colin Laverty and Associates was a lab designed specifically for quality gynaecological pathology. Laverty Pathology performs and publishes trials of these new technologies, becoming the first lab to introduce ThinPrep into Australia. Laverty Pathology introduces rapid re-screening as a regular part of its quality assurance program. 1996 t started with a handful of staff in a small house in the western suburbs of Sydney. I “We were really lucky, although they say you make your own luck; all we ever tried to do is achieve the highest standards and success followed.” He says since this time, there have been numerous changes and achievements; "We were the first people in the world to prove and publish evidence that many more women than previously recognised contracted wart virus infection but that the great majority didn't ever get clinical recognisably warts; rather they got a sub-clinical infection which it was postulated might be pre-malignant. This was later confirmed and preventive vaccination is now being introduced worldwide”. But he believes the most interesting changes have been in improvements in the standards of Pap smear screening and detecting and managing cervical abnormalities. PathWay #12 - Text 23/5/07 2:07 PM Page 33 “We anticipate the landscape will evolve to include a predominance of liquid-based cytology, imagerassisted screening, HPV testing and use of molecular techniques.” – Dr Clare Biro PHOTO CREDIT: ELIZABETH ADAMS "In the 1960's when Pap smear screening was introduced into Australia standards really were pretty low. But subsequently, with increasing awareness among doctors about how to take a truly representative smear; awareness in laboratories of the quality controls needed to ensure the highest standard of reporting; new advances in automatic slide preparation and screening; and the advent of papillomavirus DNA testing, we now have enormously improved standards and have achieved a substantial reduction in cervical cancer”. Ron Bowditch has worked with Laverty, as it’s known, for most of its 25 years. The senior scientist and full-time training officer has had a number of roles, including monitoring cytologists’ performance and ensuring quality assurance measures are up to scratch. “While a number of laboratories carry out rapid re-screening as a quality assurance procedure, we actually insert disguised abnormal cases into the rapid re-screening so we can assess the quality of the quality assurance,” he says. “I believe this is unique to our laboratory.” The lab also provides Pap smear, ThinPrep, cervical biopsy and HPV testing services, and employs a statistician to collect data about the laboratory’s overall performance, and also to profile each cytologist – how many smears they are screening a month, how many are called high grade, negative and so forth. While this overall performance information is now required as part of National Pathology Accreditation Advisory Council performance measures, Laverty has been collating these statistics for most of its 25 years. Specialisation has led to several advantages. Dr Jennifer Roberts, one of the lab’s senior gynaecological pathologists, says L-R: Drs Suzanne Hyne, Clare Biro and Jennifer Roberts at the lab’s multi header microscope one advantage is that doctors can ring with questions, knowing they are “speaking to someone who is up-to-date and has a special interest in the subject”. “Because of our volume and because we monitor outcomes of our Pap reports, including rarer conditions, we are well placed to provide clinicians with statistical data to aid them in management of their patients. And this can be very useful when doctors have a worried patient sitting in front of them.” Specialisation and volume also mean the lab is able to easily trial new technologies. Its most recent trial looked at the effectiveness of the ThinPrep Imaging System – technology designed to enhance the ability of cytologists to assess abnormal slides. It was the first Australian study to be published on the topic (Diagn Cytopathol 2007;35:96–102). The laboratory is now concentrating on assessing the efficacy of the ThinPrep Imaging System in detecting rarer glandular lesions – “an area of controversy which will be important to elucidate if liquid-based cytology is ever to replace conventional cytology in Australia”, says chief gynaecological pathologist Dr Clare Biro. Looking ahead, Dr Biro predicts a bright future. While the HPV vaccine marks an exciting new development, she says cervical screening will remain an integral part of the health system for years to come. “We anticipate the landscape will evolve to include a predominance of liquid-based cytology, imager-assisted screening, HPV testing and use of molecular techniques,” she says. And while Dr Roberts says there’s no doubt technology has made great leaps in 25 years, rather than remove the need for human expertise, she says it has actually produced a need for enhanced human input. “Screening and interpreting Pap tests remains as challenging as it ever was.” PATHWAY_33 PathWay #12 - Text 23/5/07 2:07 PM Page 34 PathWay special feature Widening pupils GETTING MEDICAL STUDENTS AND YOUNG DOCTORS INTERESTED IN PATHOLOGY IS CRITICAL TO ADDRESSING THE WORKFORCE SHORTAGE. KIM COTTON UNCOVERS A RANGE OF STRATEGIES THAT ARE ENJOYING SUCCESS. “I began considering anatomical f you ask medical students what goes on inside a pathology lab, you might get a few blank stares. science students part-time is paying “The approach has got great benefits year of medical training. My time at SNP For many, pathology remains in the laboratory – out of sight, out of mind – as young students are lured to medical specialties that dominate the hospital wards. because for most people what goes on in gave me the necessary insight to make a labs is unknown to them – they are the well-informed choice,” Dr Khamu says. Downsizing of pathology subjects at medical schools over the past decade and the elevation of problem-based learning are deemed by some to be largely to blame. had five of our young scientists I And fewer qualified pathology lecturers at some universities has meant there are limited opportunities for student exposure to mentors who are passionate about the discipline. It’s feared that this, combined with a growing pathology workforce crisis, is becoming a toxic cocktail. So what’s the antidote? dividends. original black box,” says SNP chief executive officer Dr Michael Harrison. “This last year here in the main lab we successfully join the graduate medical pathology as a career path during my third “The knowledge and skills I gained made the transition to my registrar position smoother, while being integral now to my day-to-day work.” Dr Harrison says working in a lab course. Because of their experience in a gives all medical students valuable laboratory there is a good chance they will experience because they learn the rigours come back as pathologists.” of quality control and quality assurance, how to build systems and processes that Opening doors are safe and accurate, and how to Dr Tim Khamu is one of SNP’s success scientifically evaluate and assess the stories. value of what they’re doing. A science graduate, Dr Khamu began “Even if they don’t come back to working as an SNP laboratory assistant pathology as a career I think they will during his first year of medicine at the have achieved a basic understanding of University of Queensland in 2002. As a those principles, which will stand them in matter of course, he went on to do his a really good stead.” Like most complex problems, there’s no single answer, but the pathology profession has begun the process of changing mindsets by starting at the grassroots – with the students themselves. fourth-year MBBS elective at SNP’s Opening budding doctors’ eyes to the possibilities of pathology is taking several forms. year. And this has led to a place in the know of anybody who has worked here as Queensland Health pathology training a medical student who has not said program – he is now placed for his first they’ve gotten great benefit from it At Sullivan Nicolaides Pathology (SNP) in Queensland, employing medical and year as an anatomical pathology registrar personally – and of course the money at SNP’s main Taringa laboratory. doesn’t hurt either!” 34_PATHWAY The caveat to employing medical and histopathology department, where he other university students as lab assistants gained a deeper understanding of without formal qualifications is the need histology, histopathology and cut-up skills. for them to commit to the job for several He was subsequently offered a regular cut-up position at SNP during his intern years, Dr Harrison adds. “Once people commit to it I don’t PathWay #12 - Text 23/5/07 2:07 PM Page 35 “My time at SNP gave me the necessary insight to make a wellinformed choice.” PHOTO CREDIT: ROBERT SHAKESPEARE – Dr Tim Khamu RCPA scholarships popular Another approach to stimulating student interest in pathology is the scholarship route. The RCPA has offered its Scholarships in Pathology for Medical Schools for 10 years and by all accounts, inroads are being made. “The idea is to give $2000 to allow students to either go into a lab in their own city or travel to a lab somewhere else to work with a pathologist to see what’s actually involved,” says RCPA CEO Dr Debra Graves. used the funds to complete her elective in anatomical pathology at The Canberra Hospital under Professor Jane Dahlstrom, a pathologist and Professor at the ANU Medical School. part of her time in the lab and was required to produce a lecture on gastrointestinal pathology as well as a practical, which is now being used by second-year students at the ANU Medical School. “An elective allows you to appreciate the lifestyle and training area of medicine and whether that’s going to suit you. It was really valuable from that point of view,” says Ms Hunt, who now has a better feeling for the nuts and bolts of pathology. “[I got a] much better idea of what my job would be as a pathology registrar so I was able to come into it knowing what my day-to-day duties would be and [also gained] an interest in medical education – I didn’t expect that,” she says. Vacation scholarships “It’s fairly flexible in how they can use it. It’s an incentive to think about doing pathology.” Another avenue for medical students to road-test pathology is via hospital salaried specialists’ private practice funds, which make money available for various causes including pathology scholarships. The program of up to eight scholarships is made available annually to Australian and New Zealand universities that have a medical school or medical faculty. Two of these scholarships are offered to the Faculty of Medicine at the University of Papua New Guinea. The $2000 Private Practice Fund vacation scholarship offered at The Canberra Hospital is similar in structure to the RCPA scholarship, allowing six medical students each year to take on a supervised project during their elective across any department. Dr Graves says the funds support medical students’ participation in a pathology-related project under the supervision of an RCPA fellow during an elective term or for the duration of their medical degree. For Dr Andrea Rapmund, the opportunity to complete her elective in anatomical pathology under Professor Dahlstrom with the support of a vacation scholarship was the cornerstone in her decision to pursue pathology. Rosalyn Hunt, a fourth-year medical student at the Australian National University (ANU), became an RCPA scholarship recipient last summer. She Now an anatomical pathology registrar, Dr Rapmund was able to immerse herself in the program without having to worry about juggling part-time work. She spent The anatomical pathology elective program developed by Professor Dahlstrom has in itself become a promotional device for the profession. “The program is unique because it involves all aspects of pathology and it offers a medical education component,” she says. “Some of it is about the consolidation of knowledge, the other is to try and help a student understand that as a pathologist my job is so varied and interesting.” Despite the competition for vacation scholarships across The Canberra Hospital, Professor Dahlstrom says her students have always received hospital funding to participate in the program since its development in 2003. “I think the reason the program is successful and that students receive funding is that the scholarship committee knows from the student report how much they enjoy the program and what they have achieved,” she says. PATHWAY_35 > PathWay #12 - Text 23/5/07 2:07 PM Page 36 PathWay special feature Private schooling THE PRIVATE SECTOR HAS AN IMPORTANT ROLE TO PLAY IN TRAINING AUSTRALIA’S FUTURE PATHOLOGISTS. hree years ago, a commitment was made that would leave a significant imprint on pathology training in Australia. T The federal government’s $3.75 million in funding for the Private Practice Training Scheme (PPTS) saw the introduction of a unique training model that it is hoped will make a dent in the pathology workforce shortage. Under the scheme, the private sector is responsible for training 10 doctors to become pathologists. Each position is funded for $75,000 per year for five years (until 2009) with the provision that registrars spend two years training in public hospitals. RCPA CEO Dr Debra Graves says while the scheme has placed pathology further ahead of other medical specialties on private training, moving away from the traditional public hospital training model has been a matter of necessity. While the public sector has the capacity to take on registrars, there are not enough pathologists available in the labourintensive specialty to train all the new pathologists that are needed. “Opening up the private sector… has increased the pool of pathologists who can actually train the doctors to become pathologists,” she says. “It’s a good partnership between the public and private sector – it’s a model that gives the labs a lot of flexibility so it is not prescriptive to the [last] degree.” The government’s agreement to fund the program was part of the Pathology Quality and Outlays Memorandum of 36_PATHWAY “There used to be quite a significant difference between public pathology and private pathology and slowly as time goes by those differences are disappearing.” – Dr Michael Guerin Understanding 2004/05–2008/09, developed in consultation with the RCPA, Australian Association of Pathology Practices and National Coalition of Public Pathology. It came in response to the 2003 Australian Medical Workforce Advisory Committee report recommending an extra 100 pathology training positions annually for at least five years to sustain the profession. “There used to be quite a significant difference between public pathology and private pathology and slowly as time goes by those differences are disappearing,” he says. “It won’t be all that long before it will be difficult to pick if you’re with a private or a public organisation.” The scheme is also expanding the scope of opportunities for private sector Dr Graves says there should have been 400 new places established since the report’s release, and instead there have been just 53 (soon to be 63). pathologists. But she says the 10 positions generated by the PPTS have been a “big contributing factor” to the overall numbers of new training positions. Guerin says. “It’s very helpful and we’re very appreciative. It certainly recognised there was a need for this well before the state governments did anything about it.” $60 million plan to expand training in Meshing together further 10 positions created by the “Almost in every pathologist there is a latent teacher. What it does is bring satisfaction to those individuals,” Dr A spokeswoman for federal health minister Tony Abbott says the government is in consultation with the RCPA over a private settings across many different specialty areas. A very recent development has seen a Commonwealth, which will be managed Dr Michael Guerin, president of the Australian Association of Pathology Practices and chief medical officer at Symbion Health, says the new training model is strengthening and broadening the profession by merging the individual skill bases practised within each sector. by the PPTS. Dr Graves says any other additional funding that becomes available will be used to create up to another 30 positions in private laboratories based on their training capacity. PathWay #12 - Text 23/5/07 2:07 PM Page 37 First new RCPA Fellow: Dr Aman Alash “Opening up the private sector… has increased the pool of pathologists who can actually train the doctors to become pathologists.” – Dr Debra Graves While most of the registrars who joined the Private Pathology Training Scheme will complete their training in 2009, it has already been a long journey for Dr Aman Alash (above), an Iraqi-born pathologist who is the first federally funded trainee to successfully complete the RCPA fellowship. Previously a senior lecturer at Al-Mustansiriya University’s College of Medicine in Baghdad and in charge of the attached hospital’s histopathology and cytology departments, Dr Alash fled the war-torn country with her husband and children in 2001. She travelled with her family to Yemen and was employed as a consultant pathologist in one of the private hospitals before leaving for the United Arab Emirates, where she continued working. Dr Alash arrived in Australia in 2003 to establish a new life with her family She applied to the RCPA for assessment as an overseas-trained doctor when the PPTS was being rolled out and was offered a registrar position in anatomical pathology at the Victorian-based laboratory Symbion Health. Dr Alash passed her exams on the first sitting and in January this year attained her college fellowship. She says the support and encouragement she received from colleagues and family helped her complete the fellowship in such a short period of time. “It’s a big relief,” she says. “It’s a stepping stone to achieving a bigger dream of specialising in cytology or breast pathology.” PATHWAY_37 PathWay #12 - Text 23/5/07 2:07 PM Page 38 In situ Hybridization Reagents Helping pathologists with tools for a timely and accurate diagnosis Now offering ™ INFORM Chr17 Case 1 Case 2 Case 1 Chromosome 17, normal HD H&E™ Case 1 HER2 HER2 Breast carcinoma True Same Day Results • INFORM Chr17 6-hour time to diagnosis Fully Automated All steps are fully automated • Flexible integration into daily routine • Reagents are pre-formulated “ready to use” • Case 2 rpretation • • • • • • Chromosome 17, normal Advanced silver deposition technology maximizes signal precision Morphology is easily distinguished as the assay is visualized under bright microscopy Reported as a function of the HER2/Chr17 ratio Highly concordant with FISH Reproducible between pathologists Reproducible between laboratories Case 2 Archivable Staining • HD H&E™ Breast carcinoma Ability to discuss results and re-examine Experience Ventana 1300 139 070 (AUS) 0800 VENTANA (NZ) www.ventanamed.com www.HER2SISH.com PathWay #12 - Text 23/5/07 2:07 PM Page 39 PathWay special feature Thinking globally, acting locally INTERNATIONAL DIAGNOSTICS MANUFACTURER DADE BEHRING IS DOING ITS OWN BIT TO ADDRESS PATHOLOGY WORKFORCE ISSUES. PaLMS, he will rotate between the public year ago Dr Chris Farrell was contemplating his future career as an anaesthetist. The notion of landing a training position in his dream job as a chemical pathologist was just too remote. A and private laboratories – and the shared structure will give him enormous opportunities. “Chemical pathologists in the private “I didn’t think I had much of an opportunity to pursue chemical pathology because I knew there weren’t many training positions. I only had it in the back of my mind as a future career,” Dr Farrell says. labs have a much bigger exposure to the general practitioner market. That’s experience he wouldn’t have otherwise gotten without this opportunity,” Dr Chesher says. As part of the scholarship, Dr Farrell In a sweet twist of fate, he joined the ranks of chemical pathology registrars in January when he became the first Australian recipient of the Emil von Behring Scholarship, a US$1.25 million global initiative developed by diagnostic company Dade Behring to help address the worldwide pathology workforce shortage. Dr Farrell will complete his training via a unique collaboration between Dade Behring, Pacific Laboratory Medicine Services (PaLMS) and Symbion Health. Dade Behring Australia’s managing director Erica Flynn says the company will fund one-third of Dr Farrell’s position, which is worth nearly $500,000 over five years, with PaLMS and Symbion Health contributing equally to the remaining costs. “It’s a really innovative and exciting way to fund a pathology position,” she says. “This is the first time we’ve actually had a pathology trainee position that involves the interaction between a diagnostic supplier, a public teaching hospital and a private lab providing teaching support.” will also visit Dade Behring’s headquarters in the United States. Dr Michael Guerin, chemical pathologist and chief medical officer at Symbion Health, says learning how diagnostic companies operate is an advantage to all young pathologists. Dr Chris Farrell: realising his dream of chemical pathology One-off position – for now Internationally, the scholarship has been awarded to clinical laboratory science students, but the decision to support a pathology position in Australia was based on Ms Flynn’s observations of the industry workforce crisis and subsequent discussions with the RCPA. At this stage, the scholarship is a oneoff proposition in Australia, but based on the collaboration’s success, Ms Flynn says Dade Behring may award it again in future. Dr Douglas Chesher, PaLMS department head of clinical biochemistry, who is overseeing Dr Farrell’s training, says while Dr Farrell is employed by “They will one of these days become directors of departments and therefore have multimillion-dollar budgets. It would be handy for them to have to learn this stuff upfront rather than the way I did it, which was to learn it on the floor.” Dr Guerin says the scholarship’s structure is an example of the ingenuity needed to support the industry moving forward, particularly when private laboratories have relied so heavily on pathologists trained in the public system. “Neither of them currently has the capability on their own to be able to provide the numbers of positions we need,” he says. “The private sector therefore has got to understand that it can’t just keep feeding off the public sector trainees as has been the process in the past – it’s got to do its part in the future.” PATHWAY_39 PathWay #12 - Text 23/5/07 2:07 PM Page 40 update 2007 Pathology Update 2007 ANOTHER YEAR, ANOTHER SUCCESSFUL PATHOLOGY UPDATE. BIANCA NOGRADY REPORTS ON THE WIDE RANGE OF RESEARCH PRESENTED AT THE RCPA’S ANNUAL CONFERENCE. O n one side of Sydney, lycra and sequins were in, but at Darling Harbour, lab coats were definitely the order of the day. As Sydney’s gay and lesbian community celebrated Mardi Gras, the Royal College of Pathologists of Australasia held their annual Pathology Update conference on March 2–4, hosting nearly 1000 delegates from as far afield as Malaysia and London. The conference was a great success, according to RCPA Chief Executive Officer Dr Debra Graves, thanks to a combination of great venue, weekend Genes predict child leukaemia prognosis The future for children with acute lymphoblastic leukaemia is looking a little brighter now that Australian and The result is a group of genes that, group of genes that could help target form the basis of a diagnostic tool to more aggressive treatment to those who need it most. Using high through-put microarray technology (where the whole human genome can be monitored on a single DNA chip), researchers also identified two conference’s event manager. disease. The head of the Tumour Bank at The way to keep pathologists up to date with Children’s Hospital at Westmead, Dr the latest advances in pathology. It’s also Daniel Catchpoole, said the use of a chance to bring together pathologists microarrays provided a wealth of genetic from all disciplines to meet, network and information, but distilling useful ‘cross-fertilise’. knowledge from the mass of data was from within Australia and New Zealand, are likely to relapse. international researchers have identified a previously unknown genes linked to the While most of the delegates came that might distinguish those patients who once validated by further research, could timing and the tireless efforts of the Pathology Update is exactly that – a The challenge for researchers was to sift through microarray data for genes daunting. “Microarray is a way of looking at the single out patients who would benefit from more aggressive therapy. In the course of this research, Dr Catchpoole and colleagues also came across two genes that appeared to play a significant role in acute lymphoblastic leukaemia, but which had not previously been associated with the disease. “It’s highlighted new and interesting genes that we can follow through, and that can highlight new and interesting mechanisms of leukaemia,” he said. Assay points to subarachnoid haemorrhage A new approach to diagnosing subarachnoid haemorrhage offers a there were significant numbers of activity level of thousands of these genes robust screening alternative to the more attendees from Hong Kong, Singapore in one go,” Dr Catchpoole said. costly and difficult spectrophotometric and Malaysia, Dr Graves said. The conference’s social events were popular and gave delegates the chance to mingle over cocktails and dinner, with “In the past, we were looking for a needle in a haystack – whereas now we look at the whole haystack.” New patients with acute scanning, say New Zealand researchers. Using an assay to measure very low concentrations of bilirubin – a by-product of the haemoglobin released by a Sydney’s spectacular harbour scenery lymphoblastic leukaemia are classified as subarachnoid haemorrhage (SAH) – in the providing a wonderful backdrop. being either at standard or high risk of cerebrospinal fluid, researchers have disease relapse according to various correctly identified 100% of confirmed next year’s conference, and for the clinical characteristics. However, about cases of haemorrhage. combined Pathology Update and World 10–25% of standard-risk patients still fail Association of Societies of Pathology and to respond to therapy and therefore chosen cut-off point were accurately Laboratory Medicine conference in 2009. experience a relapse. ruled out for SAH, thus avoiding the need Preparations are now underway for 40_PATHWAY Patients with bilirubin levels below a > 23/5/07 2:07 PM Page 41 PHOTO CREDIT: FIREFLY PHOTGRAPHY PathWay #12 - Text PATHWAY_41 PathWay #12 - Text 23/5/07 2:07 PM Page 42 “If we’ve got 24,000 genes, it could be that there’s somewhere between 100 to 1000 mutations in each of those which cause disease.” – Professor Richard Cotton for samples to undergo further testing said in contrast to the Human Genome using spectrophotometric scanning. Project, which focuses on a single Associate Professor Christopher genome, the Human Variome Project will Florkowski, Consultant in Chemical be collecting genetic information from Pathology at Canterbury Health across the community. Laboratories in Christchurch, said in “If we’ve got 24,000 genes, it could Sweat-testing standards on notice Early detection and improved treatment have significantly increased life expectancy for children with cystic fibrosis, but an Australian expert has stressed the need for future, outlying hospitals and laboratories be that there’s somewhere between 100 increased vigilance and standardisation in may be able to use this approach to to 1000 mutations in each of those which testing for the disease. screen samples from suspected SAH cause disease,” Professor Cotton said. Dr John Coakley, a specialist in For example, cystic fibrosis can be paediatric chemical pathology, said cases and then send those that are above the cut-off point for scanning. “We’re confident that we’ve got a system that doesn’t replace scanning but is a robust initial screen, which means we the result of more than 1000 mutations in sweat testing for cystic fibrosis was an a single gene. involved test, and a false positive or false “That is a vast quantity of variation don’t have to scan about 90% of that’s going to come in that causes samples,” Professor Florkowski said. disease, and we better get ourselves In the past, many labs would simply organised,” he said. eyeball a sample to see if it looked yellow The Human Variome Project is a – an indicator of bilirubin – but Professor global initiative conceived in 1994, when Florkowski said this technique was a meeting of some of the world’s leading extremely crude and inadequate. geneticists decided experts in genes Spectrophotometric analysis has been advocated as the most reliable way to test for bilirubin in the cerebrospinal negative result could have extremely detrimental effects. “It’s not a simple test like putting a blood sample on a machine and getting a result,” said Dr Coakley, head of biochemistry at The Children’s Hospital at Westmead. “Sweat testing requires some expertise in doing it, so it’s important were the best curators of information people are well trained and that they are about those genes. doing the test regularly so they maintain Several mutation databases already their expertise.” fluid, but spectrophotometers are exist around the world, but the expensive and the results can be unclear. fragmented nature of work in the area working in the area do at least 10 sweat has meant these collections are tests a year to keep their skills up to date. “There is still some subjectivity and if you get blood in the cerebrospinal fluid incomplete and in some cases the from the lumbar puncture itself, you can information is incorrect. get peaks that can make it difficult to interpret,” he said. The assay could detect the low concentrations of bilirubin in the cerebrospinal fluid and was easier to perform. However Professor Florkowski said the results of the study needed to be carefully validated in other centres before the assay could be introduced into wider “One of the unique parts about this project is we want to have variations in each gene curated accurately by an expert then measuring chloride and sodium concentrations in the sweat. A chloride concentration above 60 mmol/L is a strong indication of cystic The mutation information will fibrosis, while a result of 30–60 mmol/L therefore be collected via a federation of ‘locus-specific database curators’ around the world, then fed into a central location requires follow-up and potentially further testing. Dr Coakley said the challenges of with mirror sites in other countries to sweat testing for cystic fibrosis included enable global access. getting a proper volume of sweat from a Professor Cotton said this information could be used by patients, clinicians, An Australian researcher is heading the diagnostic laboratories, genetic mammoth task of building a database of counsellors, researchers and diagnostic human genetic variation, which could companies. revolutionise genetic medicine. Sweat testing involves stimulating sweat production for up to 30 minutes, in that gene,” Professor Cotton said. practice. What mutation is that? He recommended pathologists “They are knocking on doors already, very young patient, handling children and babies for the test, and carefully explaining the test and its consequences to parents. “In terms of reporting sweat-test results, there’s not uniform reporting across Australia, so we’re working but it’s just that they don’t have a one- towards having uniform results, so when Cotton, also the director of Melbourne’s stop shop and they can’t be confident that GPs get the result they know what is Genomic Disorders Research Centre, it’s all there and it’s accurate,” he said. abnormal or borderline,” he said. Project convenor Professor Richard 42_PATHWAY > 23/5/07 2:07 PM Page 43 PHOTO CREDIT: FIREFLY PHOTGRAPHY PathWay #12 - Text South East Queensland Allied Practitioner Opportunity Located within the Caboolture Shire, The Village at Burpengary presents opportunity for members of the allied health and wellness fraternity to establish a complementary business alongside several general practitioners and a brand name pharmacy. The development is due for completion late-2007 and includes a supermarket, childcare centre, food outlets, retail and office accommodation. To register your interest for lease contact Ken Kramme | 0418 144 855 or [email protected] PATHWAY_43 PathWay #12 - Text 23/5/07 2:07 PM Page 44 MS 043 ABBOTT ADVERTISEMENT A4 14/5/07 4:41 PM Q: A: Page 1 What if you could detect Rheumatoid Arthritis early? Abbott Anti-CCP – A new blood test for RA. 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PathWay #12 - Text 23/5/07 2:07 PM Page 45 “Efficiency alone will not make professionals reconfigure a service if they are not confident quality will be safeguarded.” – Lord Carter of Coles Dr Coakley and colleagues have However, this procedure was not “For instance, would we create free- recently initiated a survey of laboratories without its own risks and could have long- standing pathology organisations into around Australia that perform sweat term consequences for quality of life. which employees who currently provide testing to identify any problem areas and Another option was regular ensure a high standard across all endoscopy or chromoendoscopy, where laboratories. stains or pigments are applied during the Genetic link discovered for gastric cancer A new group of genetic mutations has been identified that places carriers at a 70% lifetime risk of gastric cancer, and also significantly increases the risk of lobular breast cancer in female carriers. The hereditary mutations affect the Ecadherin gene, which is expressed in epithelial tissues. This gene is known to be involved pathology services in existing hospitals would be transferred?” Lord Carter said. “Would that organisation be endoscopy to aid diagnosis. However, responsible for providing and staffing researchers were uncertain if this process both hot and cold laboratories? Which would be able to detect gastric cancers labs would be shut? Where would new before they metastasised. ones be built?” Discovery of the mutations also raised The pilot projects were launched in the question of a possible screening January this year and are expected to be process for the mutation which may completed by September, with identify at-risk individuals and families implementation of the new system early. proposed for April 2008. Professor Huntsman proposed criteria One of the main aims of the pilot for mutation testing which included young projects is to gain a deeper age of onset (under 35 years) in a low- with tumour invasion and cancer understanding of the whole system of incidence population, and family history of progression, according to genetic costs of pathology, “to avoid privatising two or more cases of gastric cancer, with pathologist Associate Professor David at least one diffuse gastric cancer Huntsman from the BC Cancer Agency at diagnosed before age 50. the University of British Columbia, Canada. Research has shown these mutations underlie nearly one-third of families with hereditary diffuse gastric cancer, but have also been identified in patients without a family history of gastric cancer. First-degree relatives of patients with gastric cancer linked to E-cadherin mutations are themselves at more than double the relative risk of the cancer. The first E-cadherin mutations were detected in Maori families by two New Zealand researchers. Because patients with the mutations were at such increased risk of gastric cancer, a number of more aggressive management options could be considered to reduce their risk of the disease. Professor Huntsman said unaffected mutation-positive individuals could consider undergoing a prophylactic total gastrectomy. An earlier study had found 29 of 32 UK Pathology heads for a shake-up the obvious and putting up costs in the remainder, resulting in a total increase rather than decrease in expenditure”. “At its simplest level, we are trying to get our service to understand its costs Pathology services in the United Kingdom and make decisions based upon these,” are set to undergo a radical overhaul after Lord Carter said. an inquiry chaired by Lord Carter of Coles However, he highlighted the found fragmentation of service and a lack importance of maintaining quality in of centralised, standardised information pathology services. on pathology services. “What was clear was that there were “Efficiency alone will not make professionals reconfigure a service if they significant discrepancies in performance are not confident quality will be and standards throughout the country, safeguarded.” and many leading members of the profession believed it was time for reform,” Lord Carter told the conference. His report, released in August last year, highlighted issues such as wide variations in standards of equipment, processes and results, significant duplication between primary and secondary care, and a desire within pathology departments for independence. Lord Carter identified six main priorities for change and proposed a series of pilot projects in metropolitan, prophylactic gastrectomies in patients urban and rural areas to determine the with the E-cadherin mutation already bore best configuration for the new-look signs of early diffuse gastric cancer. pathology system. The Pathology Update 2007 Overseeing Committee thanks all the exhibitors and partners for their ongoing support of Pathology Update. Exhibitors: Olympus, Informa Health Care. QLab, Helena Laboratories, QAP, Department of Health and Ageing, Dictaphone, Vision Bio Systems, Tourism Tasmania, Ventana, Novartis, Bio- Rad, Millipore Aust Pty Ltd, Howden Medical Books Pty Lts, Abbott Diagnostics, Diagnostic Technology, Dako and Inview. Partners: Department of Health and Ageing, AACB, NATA, RCPA QAP Pty Ltd, Dade Behring, Roche Diagnostics, Symbion Health, Bayer Health Care Diagnostic Division, UBS, Deacons, PKF, Abbott Diagnostics, Lenton Brae Wines, What’s new in Lab Technology and Sonic Health Care PATHWAY_45 PathWay #12 - Text 23/5/07 2:07 PM Page 46 testing testing New horizons: thyroid dysfunction THE ACUTE SENSITIVITY OF PATHOLOGY TESTS FOR DIAGNOSING THYROID DYSFUNCTION IS RAISING INTERESTING QUESTIONS FOR CLINICIANS. MATT JOHNSON REPORTS. he principle is simple. Identify the symptoms that define the disease. Use the symptoms to determine the cause. Develop a test that identifies the causative factor or, at least, the physiological clues it leaves behind. Refine the test so it becomes increasingly accurate and treatments can be better targeted and managed. T It’s this principle that so effectively guides the interaction of scientists, pathologists and other doctors. But what happens when the tests become so accurate that the patient, despite a positive test, shows no symptoms? Do you change the ‘positive’ value and risk normalising the disease? Or do you commence treatment for something that may never cause a problem? Over the past decade the sensitivity of some of the tests for thyroid dysfunction have increased their accuracy by 100fold, and with rapid growth in the number of tests being conducted, an increasingly large number of patients are being captured in the ‘abnormal’ range. 46_PATHWAY Some have raised concerns that this has led to confusion – not clarity – for patients. But others argue that identifying subclinical thyroid dysfunction could prove highly beneficial in the long term. The thyroid and its hormones Weighing about 30 grams, the two connected lobes of the thyroid gland wrap around the sides of the larynx in the throat. The gland secretes two hormones directly into the bloodstream: tri-iodothyronine (T3) and thyroxine (T4), both of which regulate an enormous range of metabolic and growth functions. The two most common dysfunctions of the thyroid gland are hypothyroidism (decreased hormone output) and hyperthyroidism (increased hormone production), with one in 20 people estimated to experience some form of thyroid dysfunction in their lifetime. T3 and T4 are the active hormones released by the thyroid gland, but their production is controlled by the pituitary gland located in the base of the skull. The pituitary gland secretes thyroidstimulating hormone (TSH). Too little T3 or T4 in the blood prompts the pituitary to release more TSH, causing thyroid activity to increase. Too much T3 or T4 decreases the amount of TSH released by the pituitary. Because it controls the release of T3 and T4, measuring TSH is usually the first step in investigating thyroid function. In fact, the logarithmic relationship between T4 and TSH means small changes in T4 levels normally result in very large changes in TSH levels, making TSH a very sensitive indicator of thyroid gland dysfunction. Too good to be true? The TSH test currently used in Australia is a chemiluminescence immunoassay that is highly automated, extremely accurate and takes less than 20 minutes to complete. Blood in the collection tube is centrifuged to separate the plasma and the tube goes directly into a machine for analysis. Perry Giannopoulos, senior hospital scientist at SydPath, says the accuracy of PathWay #12 - Text 23/5/07 2:07 PM Page 47 “It may be that identifying these sub-clinical patients allows them to be treated and never develop more serious symptoms, but the outcome studies will take time to do.” PHOTO CREDIT: DR. E. WALKER / SCIENCE PHOTO LIBRARY – Dr Graham Jones Light micrograph of a section through a thyroid gland with the autoimmune disorder Hashimoto's disease the chemiluminescence method is now almost too good. “Over the past 30 years we’ve moved through different assays. The original radio-immunoassays measured down to a lower limit of about one. When we moved to enzyme-immunoassays, that limit improved to 0.1 – and now, these thirdgeneration chemiluminescence assays are 10 times better again,” she says. The improvements in accuracy with each generation of assays has been the key factor in allowing doctors to make the distinction between true hyperthyroidism and the non-specific changes in thyroid results in people with other illness. But the increased accuracy has raised concerns that the clinical aspects – the signs and symptoms – of hypo- and hyperthyroidism have been downgraded, with many patients now returning abnormal results but showing no symptoms. One article published in the BMJ (2000;320:1332–4) described this as having led to “chaos” in the diagnosis of hypothyroidism. And some have noted that the concept of “sub-clinical hypothyroidism” and using TSH concentrations above 2 mIU/L to suggest an increased risk of hypothyroidism mean half the population fall into this category. SYMPTOMS OF HYPOTHYROIDISM Too little T4 and T3 causes the But to Dr Graham Jones, SydPath’s staff specialist in chemical pathology at St Vincents Hospital in Sydney, the increased testing accuracy is a positive virtue. metabolism to slow down too much. • lethargy and fatigue He contends the significance of borderline values will only be borne out in longer-term studies that now, at least, can be based on very precise data. • sensitivity to cold • unusual weight gain • depression • confusion • hair loss • dry skin • constipation • goitre. “It may be that identifying these subclinical patients allows them to be treated and never develop more serious symptoms, but the outcome studies will take time to do,” he says. In the short term Dr Jones sees the accuracy as providing better answers for doctors and their patients. “The symptoms of hypothyroidism such as lethargy and weight gain are so common that TSH testing is often required to exclude thyroid disease, and with the current tests, you’ll arrive at the right answer nearly all the time.” Chemical pathologist and endocrinologist Professor Creswell The symptoms include: Eastman agrees it will take years to determine how many of these sub-clinical patients will develop clinical signs, but says the increased accuracy of the test is already allowing doctors to identify and treat high-risk patients. “Before we had a highly sensitive TSH test, there were a group of people who had normal T4 and T3 levels and were not PATHWAY_47 > PathWay #12 - Text 23/5/07 3:27 PM Page 48 “Over the past 30 years we’ve moved through different assays… now, these third-generation chemiluminescence assays are 10 times better again.” – Perry Giannopoulos evidence of subclinical hyperthroidism than wait for clinical signs. It’s a judgment at this stage, but you have to make a lot of judgments in clinical practice.” The increased accuracy has also seen a trend towards treating some patients identified with sub-clinical hypothyroidism. “There is certainly some conflicting data whether treating sub-clinical patients delays the development of clinical signs,” Professor Eastman says, “but it certainly shows improvements in cardiac function and lipid levels, and it means patients with elevated cholesterol are much more likely to be treated earlier rather than later.” “TMA and TGA tests are ‘old fashioned’; they’re manual, time consuming and only semi-quantitative,” says Ms McGill, comparing the tests to the more expensive TPO test. “Although it may be difficult to justify TPO on cost grounds, in every other way, TPO is the method of choice for thyroid antibody testing as part of a strategy for thyroid disease investigation.” In most circumstances, TSH is the only thyroid function test ordered for patients, but if the result is outside the normal range, a T4 level can also be requested. The thyroid gland requires iodine to produce T3 and T4, and how much of the substance the thyroid absorbs from the blood is an accurate measure of thyroid activity. Much of the T3 and T4 produced by the thyroid is bound to other molecules and is not available to act on its target cells, so Australian laboratories measure ‘free’ T3 and T4. That is, the active amount of the hormones. Injecting a small amount of radioactive iodine allows pathologists to scan the thyroid and measure the uptake to determine the cause and help plan treatment. Other thyroid tests identified as being at risk of developing hyperthyroidism because we were unable to measure subnormal TSH levels,” he says. “But if you become more selective and look at the high-risk patients in this group – those older patients with longstanding goitre and with cardiovascular disease – you are now much more likely to treat these people on their biochemical SYMPTOMS OF HYPERTHYROIDISM Too much T4 and T3 causes the metabolism to speed up too much, and ultimately damages the heart and liver and leads to death. Symptoms of an overactive thyroid include: • rapid pulse • tremor (shaking) of the hands • sweating • sensitivity to heat • weight loss (despite a high appetite) • agitation and anxiety • fatigue • diarrhoea • bulging eyes • goitre. 48_PATHWAY may easily be linked to other thyroid testing strategies; hence there is a worldwide trend towards TPO analysis, a trend which Kate McGill, senior operations manager of immunochemistry at St Vincent’s Hospital in Sydney, would also like to see adopted. Free T4 (FT4) is also commonly used to monitor the effectiveness of treatment and is typically measured every few weeks in the early stages. Thyroid antibody tests can be used to support the diagnosis for patients who have returned abnormal TSH or FT4 results, or who are displaying clinical signs of thyroid disease but have returned normal tests. Only 10% of healthy individuals will have positive thyroid antibodies, with a higher prevalence among the elderly. Thyroid peroxidase antibodies (TPOs) – the predominant thyroid microsomal antibody (TMA) component – and thyroglobulin antibodies (TGAs) are regularly produced in thyroid disease. The specific test for TPOs is quantitative, can be fully automated and The diagnosis of thyroid nodules, autoimmune hyperthyroidism and thyroid cancer can all be assisted by the scan, which uses a specialised nuclear imaging camera to take pictures of the thyroid gland from three different angles over 20 minutes. Associate Professor Judith Freund, director of nuclear medicine and bone densitometry at the St Vincent’s Clinic in Sydney, says the accuracy of other thyroid tests has improved so much that the thyroid uptake test is only really used now in Australia for diagnosing sub-acute thyroiditis and in therapy for thyrotoxicosis. “The test also helps us decide how much iodine therapy a patient requires, and if certain treatment will not be effective because their iodine uptake is too low,” she says. PathWay #12 - Text 23/5/07 2:07 PM Page 49 lP ia t hfWe s t y l e ay lifestyle travel 50 private passions 54 travel doc 56 recipe for success 58 dining out 61 the good grape 64 conference calendar 65 rearview 66 postscript 68 PATHWAY_49 PathWay #12 - Text 23/5/07 2:07 PM Page 50 travel Snow business VISITORS TO NEW ZEALAND’S SKI FIELDS HAVE A PROBLEM: WHICH ONE TO CHOOSE? DEANA HENN GIVES A SNAPSHOT. ith preparations for the southern hemisphere’s winter snow season underway, skiers and snowboarders are gearing up for another season of powder thrills. But figuring out where the heavens will open for the 2007 season will be anyone’s guess. W The numbers bear this out – almost 50,000 Australians skied or snowboarded in New Zealand last year. For many, the question isn’t whether to take advantage of the many snow packages that make skiing in New Zealand great value. It’s which of the country’s 11 commercial resorts (or increasingly popular club fields) will offer the experience you’re after. Kiwis looking to frolic in the white stuff this winter will face the same quandary. Many Aussie snow-goers will be tossing up whether to venture across the Tasman to play in the snow this winter. Fortunately, in this corner of the world, where winter is truly wonderland, everyone is catered for – adrenaline junkies wanting to carve fresh tracks through blackdiamond gullies, families looking to refine their form in ski school and cruise the corduroy, those wanting to get the heart racing with off-mountain adventure or even those just looking for retail therapy. And New Zealand’s variety of terrain, resort facilities and almost-mythical scenery along with the strong Aussie dollar are big drawcards for Australians looking for a snow jaunt. And to sweeten the deal, ski resorts across New Zealand will aim bigger and better in 2007 as they unveil improved ski terrain, upgraded mountain grooming and resort facilities. 50_PATHWAY Queenstown For an all-round ski holiday, it’s hard to look past Queenstown – long considered New Zealand’s adventure capital. Nestled on the shores of the stunning Lake Wakatipu on the South Island, with its picture-postcard snow-capped peaks, Queenstown has it all: great food, great bars, great shops and access to great adventure. The gateway to several of the South Island’s major ski resorts – Coronet Peak, The Remarkables and Cardrona – the town jumps throughout winter. Just a 25-minute shuttle ride away at Coronet Peak, skiers and boarders of all grades take pleasure in the wide and rolling terrain, and excellent facilities. And night skiing means diehards can stay on the slopes even longer. This year the resort has also doubled its beginner area and expanded its snowmaking facilities to ensure good coverage throughout the season. The Remarkables Ski Area, with its eponymous mountain range, overlooks PathWay #12 - Text 23/5/07 2:07 PM Page 51 PHOTO CREDIT: MARK WATSON Above and left: In the air and on the slopes at Treble Cone, Wanaka Lake Wakatipu and is a 45-minute shuttle ride from Queenstown. A new terrain park, new grooming facilities and snowmaking can only enhance the terrain, which includes gentle slopes as well as powder bowls and extreme runs. Snow tubing – riding a massive tyre tube down the slope as you would a toboggan – is also a family-friendly way to get to the bottom of the mountain. Heading north from Queenstown, an unforgettable drive puts you atop the magnificent Crown Range and the Cardrona Ski Area. Ideal for families, Cardrona has an abundance of runs geared at beginner and intermediate skiers and boarders (80% of its mountain), specialised kids’ lessons, and four childcare centres for the littlies. Cardrona also boasts on-mountain lodging – a rarity in the Southern Alps. Come sundown, skiers and boarders from all three resorts descend on Queenstown’s innumerable eateries and bars, looking to lubricate their muscles and steel themselves for another day on the slopes. Queenstown also offers a bevy of extracurricular activities, from bungy jumping and jet-boating through canyons to sky diving and mountain biking, which add yet another dimension to your holiday. The downside? Expect crowds and hefty price tags for any activity that looks remotely ‘extreme’. And if you’re looking for a ski-in, ski-out lodge experience, Queenstown is not for you. Wanaka Heading north from Queenstown brings you to Wanaka, renowned for its stunning mountains, glacier-carved lakes, alpine meadows and impressive snowfields. Treble Cone is one such snowfield and demands attention. With more skiable – and reputedly more advanced – terrain than any other resort on the South Island, Treble Cone is a mountain to be reckoned with. And it’s making no apologies. While the resort goes out of its way to cater to intermediate skiers and boarders like nearby Cardrona, the terrain and pitch at ‘TC’, as the locals call it, will always attract those who take their skiing seriously. Applying the ‘bigger is better’ theory, Treble Cone expanded its terrain last year with a multi-million-dollar investment. By adding 45 hectares to its terrain, the resort added some serious runs to its trail map. Treble Cone also claims the highest vertical drop on the South Island and enjoys plumes of powder thanks to its location. Striving to be all things to all people, TC guarantees your money back if you can’t comfortably ski or board the whole mountain after three days with the help of ski school. New this year, the resort will also offer on-mountain guided tours to assure everyone a great experience. And at Treble Cone, everyone will go home with that unforgettable view implanted in their minds; the majesty of Lake Wanaka overwhelms at every turn. While TC has no on-mountain accommodation, skiers will find no PATHWAY_51 > 23/5/07 2:07 PM Page 52 PHOTO CREDIT: MARK WATSON PathWay #12 - Text “New Zealand’s variety of terrain, resort facilities and almost-mythical scenery along with the strong Aussie dollar are big drawcards for Australians looking for a snow jaunt.” shortage of options at nearby Wanaka or can day-trip from Queenstown. If you don’t want Queenstown’s roundthe-clock activity, Wanaka’s charm ensures those wanting refuge, fine dining, and watering holes with live music are equally satisfied. It’s little wonder this town is dubbed the New Zealanders’ Queenstown. Canterbury Plains Not to be overlooked on the South Island is the Canterbury region, about an hour from Christchurch. It’s no match to the activity of Queenstown, but there’s plenty here for those who care more about carving up the mountain than après ski. Two worlds collide here: the patchwork quilt of the Canterbury Plains and the wild, majestic mountains that form the Southern Alps. Mount Hutt, the largest and most commercial resort in the area, offers excellent varied terrain and facilities, particularly after the reconfiguration of the 52_PATHWAY mountain in 2005. The resort is also considered the highest in the southern hemisphere, contributing to its consistent snow quality. Also popular in the Canterbury region are local ‘club fields’, which are gaining the South Island an international reputation. While the behemoth resorts with their slick facilities typically win over in the popularity stakes, the smaller fields run by private ski clubs are making their own mark and welcome day-trippers. Among those developing recognition are Ohau, Temple Basin and Craigieburn. The proximity of Christchurch makes it an ideal base for this region, though most choose to stay at local accommodation hub Methven. This is no Queenstown – but for many, that’s the point. At no other commercial ski area can you ski or snowboard a semi-active volcano or find natural half-pipes created by lava flows. The volcano is home to two ski resorts – Turoa and Whakapapa – and this year, all eyes will be on Mt Ruapehu’s massive $40 million injection including a new six-person express chairlift and snowmaking. Whakapapa, on the volcano’s northern face, is the country’s largest ski area and is popular with beginners for its dedicated ‘Happy Valley’. The resort is also known for its expansive views of Mount Ngauruhoe, otherwise known as Mount Doom in The Lord of the Rings films. Meanwhile, Turoa serves up big open basins, natural half-pipes, steep chutes, and fantastic off-piste glacial skiing. Mt Ruapehu The South Island is New Zealand’s attention-grabber when it comes to winter adventure, but the North Island deserves more than a passing mention. The downside to Mt Ruapehu? The weather. Blasting gales can close the whole mountain and you may have to contend with crowds from Auckland and Wellington. PathWay #12 - Text 23/5/07 2:07 PM Page 53 Getting there Air New Zealand and Qantas fly regularly to New Zealand from Sydney, Melbourne, Perth, Cairns and Adelaide. To Christchurch or Auckland, expect to pay about $580 return including taxes. • Air New Zealand and Qantas fly non-stop to Queenstown during winter from Sydney, Brisbane and Melbourne. Airfares start from $710 return including taxes. • South Island resorts are accessible from Wanaka, Queenstown and Christchurch airports. Mt Ruapehu is serviced by Hamilton, Auckland, Palmerston North and Wellington airports. PHOTO CREDIT: MARK WATSON • Above: Treble Cone’s, Base Lodge Left: Kiwi snowboarder Abby Lochart shows her style Package deals Air packages Available from most Australian capital cities. Departing Sydney, packages start from $AUD1065 per person including return airfares, five nights accommodation, car hire, and multi-day ski pass. Prices are based on twin share and include taxes. Conditions apply. But if you’re not too fussed about whether you ski every minute of your holiday, brunch at Chateau Tongariro comes highly recommended, as do the nearby geothermal hot pools. Whakapapa Village and Ohakune provide plenty of accommodation and après-ski options, with regular shuttles servicing the ski areas. For skiers and snowboarders thinking of heading to any one of New Zealand’s resorts this winter, one thing is certain: the Kiwis do adventure as well as anyone in the world. It’s simply a question of what flavour of adventure you’re after – there’s little risk of disappointment. Air New Zealand Holidays (1300 365 525; www.airnewzealand.com.au) Ski Express (1300 130 524; www.skiexpress.com.au) SKIMAX (1300 136 997; www.skimax.com.au) Value Tours (1300 361 322; www.valuetours.com.au) Land-only packages Start from $AUD520 depending on the resort and typically include 5–7 nights accommodation, car rental or shuttle, multi-day ski pass plus extras. Prices are per person, twin share and conditions apply. Ski Express New Zealand (0800 650 333; www.skiexpress.co.nz) SKIMAX (1300 136 997; www.skimax.com.au) Ski New Zealand (03 353 7354; www.skideals.co.nz) Ski New Zealand Online (03 379 1451; www.ski-newzealand.co.nz); Australian free-call number (1800 121 029). PATHWAY_53 PathWay #12 - Text 23/5/07 2:07 PM Page 54 private passions Keeping the faith A HEART ATTACK SLOWED HIM DOWN TEMPORARILY, BUT DR JOHN BOTHMAN IS BACK TO LIVING LIFE LIKE HIS BELOVED RACEHORSES – FAST PACED. KATRINA LOBLEY REPORTS. decade ago, general pathologist Dr John Bothman got a huge wake-up call. A The horse-racing fanatic was 48 when he went to the Melbourne Cup to watch the big race before heading to Tasmania for a well-earned fishing holiday. As it turned out, he never got to cast that line. “Just after [the Cup] finished – and, sure enough, the horse I backed was beaten in a photo finish – I had a massive heart attack and just collapsed to the ground,” Dr Bothman says. “I knew what was happening but I couldn’t speak, I couldn’t stand up. If it wasn’t for a couple of country blokes who came along and picked me up and took me to the ambulance, I don’t think I’d be here today.” Dr Bothman, who lives and practises on the NSW South Coast, was rushed to hospital but went into cardiac arrest on the way. chest. No-one wanted me to go – they thought the excitement might kill me.” Post-heart attack, he cut back to working two to three days a week. But his resolve to slow down didn’t last. These days he’s working full time at the Southern.IML Pathology practice in Nowra. He is also chief examiner in general pathology for the RCPA. But as a nod to his passion, he will take time off whenever his beloved racehorse, Keeping the Faith, is racing. The seven-year-old son of Leap of Faith has clocked up five wins and 17 second-placings, earning nearly $200,000 prize money for his owners. A pretty good return on investment, considering he cost Dr Bothman and another owner-breeder less than $2000. And Dr Bothman is hoping that Keeping the Faith’s full brother – twoyear-old gelding The Patriot – will be even more successful. “They had to put the paddles on and get me going in the ambulance,” he recalls. Before he knew it, he was being prepped for a triple arterial bypass. Doctors told him there was a 70% chance he wouldn’t survive it. Alpacas and other curiosities “I said, ‘You’ve already told me I’m going to die if I don’t do anything. I’m a punter – I don’t mind those sorts of odds. I’ll see you in about six hours.” “I cover all sorts of odd areas – even a bit of veterinary work,” he says. When he’s not following the fortunes of his racehorses or indulging in a spot of fly-fishing in Tasmania or New Zealand, Dr Bothman remains busy with work. The next month, while recovering, his low spirits were buoyed when his $500 brood mare Leap of Faith won the main race at Kembla Grange on Boxing Day. In fact, one of his strangest assignments came when his neighbour, a doctor who breeds alpacas, asked if he’d conduct a sperm count on a new $25,000 male alpaca that had failed to impregnate a single female alpaca. “I was driven to the race propped up in a friend’s car with pillows to protect my “I said, ‘I’ll have a look’,” Dr Bothman recalls. 54_PATHWAY “He said, ‘Oh no, I want you to come out and help me collect a sample. There’ll be a bottle of red wine in it for you.’ He’s a red wine connoisseur and I am, so I thought, ‘Oh, I’ll try anything once’.” He collected the sperm - “the way we collected the sample is probably not suitable for [publication]” – made a smear and examined it under a microscope he’d brought with him. Little viable sperm could be seen. “Being a true pathologist, I said I’ve never seen alpaca sperm before so we’ve got to get a positive control and compare it.” They repeated the exercise with a fertile male, found plenty of swimmers in that sample, and his neighbour got his money back. Dr Bothman is an enthusiastic advocate both for general pathology and rural life. He lives with wife Julie, a community health nurse, on an acreage at Cambewarra, a lush grape-growing region north of town. And he wants to encourage others to follow his footsteps. He opted for general pathology “because I wanted to keep my clinical skills up and that’s what my current day entails. Unlike a lot of pathologists, I actually do see quite a few patients.” The practice services a private hospital in Nowra that conducts a lot of orthopaedic and general surgery. As many older patients prefer to give blood preoperatively in case they need a postoperative transfusion, Dr Bothman assesses these patients before collecting their blood. He also carries out fine needle biopsies and the odd bone marrow PathWay #12 - Text 23/5/07 2:07 PM Page 55 “Unlike a lot of pathologists, I actually do PHOTO CREDIT: GREG TOTMAN see quite a few patients” biopsy, diagnoses more primary He tours Australia and New Zealand “It’s going to be a long, hard road – melanomas than most of his big-city spruiking the joys of general pathology but I can see we’re having some counterparts and sees malaria cases from because “we’re all going to be extinct in success.” the nearby naval base. He’s even come the next 10 years”. across a case of leprosy. And he’s encouraging the creation of As for his inability to follow doctor’s orders and take it easy, he says: “Life’s to training positions and has had some be enjoyed. They tell you all these things, to stimulate more interest in general success with both public and private like keep fit and don’t drink too much pathology as a career. pathology laboratories. wine – well, I totally ignore that.” Dr Bothman is also helping the RCPA PATHWAY_55 PathWay #12 - Text 23/5/07 2:07 PM Page 56 travel doc SOUTHERN EXPOSURE THE MAGNIFICENT ANTARCTIC WILDERNESS HAS SO ENCHANTED PROFESSOR JULIA POTTER AND ASSOCIATE PROFESSOR PETER HICKMAN THEY’RE ALREADY ANTICIPATING THEIR THIRD VISIT. s soon as we returned from our first trip to Antarctica we knew we wanted to go again. We love cold climates and have always had an interest in this continent. In fact, we even thought about working in Antarctica but never managed to do it, so actually taking that first trip was the realisation of a long-held ambition. A On our second trip we travelled with Aurora Expeditions on a route that took us to the Falkland Islands, South Georgia and the Antarctic Peninsula. The journey began in Ushuaia, Southern Argentina, and even at this point we felt like we had reached the end of the earth. Our ship was a Russian vessel, Polar Pioneer, and while no luxury cruise, it was certainly very comfortable and we were very well looked after by captain and crew. 56_PATHWAY The other passengers were mostly The island of South Georgia in the over 40 with some into their 60s and 70s, South Atlantic Ocean was one of the and although we all came from different expedition’s highlights. Observing the countries and had different backgrounds spectacular wildlife – penguins, seals, birds we were united in our amazement and and whales – was a special experience. wonder at what we saw. It was inspiring to see some of the We were also drawn to its isolation. A whole day could pass without seeing older passengers getting into the Zodiac another vessel and the sense of quiet and dinghies, helped by the burly Russian appreciation of nature was extremely crew, and then balancing on the edge with powerful. Prion Island was also a delight – their feet in the middle like the rest of us here we saw pairs of nesting, wandering as we took off across the water to explore albatrosses. With our guide we were the landscape. allowed to come within 20 metres of these It sounds a little wild but safety was taken seriously and the crew made sure everyone got on and off the dinghies in one piece. magnificent birds and no-one talked above a whisper the entire time. We felt so privileged – we still smile when we think of it. PathWay #12 - Text 23/5/07 2:07 PM Page 57 “It’s an overwhelming expression of nature and a life-changing experience” Photographs can’t do this region justice: the pure white of the snow and ice; the ever-changing colour of the sea; floating clouds of plankton in the ocean; huge boulders and glaciers; flocks of birds in the sky; whales close by and on the horizon; and dolphins frolicking near the ship. It’s an overwhelming expression of nature and a life-changing experience. A journey to Antarctica is challenging, even with the comforts of our ship and Julia Potter is the Executive Director of ACT Pathology and Professor of Pathology at the Australian National University Medical School. Peter Hickman is an Associate Professor in attentive crew, and so we often asked Chemical Pathology at the Australian National ourselves in wonder: just how did those University and is the past-Chief Examiner in original explorers survive? Chemical Pathology for the RCPA. PATHWAY_57 PathWay #12 - Text 23/5/07 2:07 PM Page 58 recipe for success Make it a double COOKING IS A FAMILY AFFAIR FOR TOP CHEFS GREG AND PETER DOYLE, WRITES BRONWYN MCNULTY. B mistake people make when cooking seafood is overdoing it. “It’s still sort of the basis of worldwide food these days,” Peter says. Greg Doyle was an apprentice chef who spent his mornings catching waves and his afternoons in the kitchen. “It’s very important when you are buying seafood to buy premium product,” he says. “Pay a little bit more and you get a much better product.” “When I was first cooking, there was just iceberg lettuce. It never occurred to me that there were other types... you used to go to Europe just to eat an oak leaf lettuce.” ack in the 70s, Peter Doyle envied his little brother. Twenty-year-old Peter, on the other hand, was holed up at a desk in the government’s land tax department valuing real estate, with only dreams of the green room to keep him going. “When I left school I didn’t know what I wanted to do,” says Peter, pictured left with Greg. “Greg was two years younger than me, and already a cook. He was surfing in the mornings and going to work in the afternoons. But I was going to work in the mornings...” It wasn’t long before Peter headed for the kitchen too. The brothers (no relation to the Doyles of the Doyles seafood chain) are now in good company as two of Australia’s most respected and admired chefs. “I always liked food, but I didn’t know that much about it,” says Peter, who, 30 years later, is variously described as “a founding father of modern Australian cuisine”, “a home-grown legend” and “an inspiration to the industry”. He runs the kitchen at Est. – an elegant fine-dining eatery at the trendy Establishment Hotel in Sydney’s CBD – where he specialises in produce-driven contemporary Australian cuisine. He says simplicity and restraint are vital ingredients in creating a perfect meal. Five kilometres east, at Rose Bay’s glass-encased Pier restaurant, Greg receives rave reviews for dishing up what this year’s The Sydney Morning Herald Good Food Guide describes as “arguably the country’s best seafood”. He likes to keep it simple, too, and says the biggest 58_PATHWAY Greg says his early interest in food was probably sparked by the fact that their mother cooked meals that were ahead of her time. “There’s never been an industry background for Pete and I, but mum was a good cook,” he says. “We always had fresh vegetables, lots of fruit... For our era I think she did a lot of interesting stuff like fish, fresh vegetables, pork and veal, lamb casseroles and things like that.” When their mum was crook, it was Greg who stepped up to the cooker to feed the family of five. “I don’t know why it was me,” he laughs. “It’s about time I asked Pete about that.” A revolution in cooking in the late 70s – the nouvelle cuisine movement – made it difficult for the brothers not to get carried along by a wave of excitement stirring up the industry. “When I first started my apprenticeship, the same 20 dishes were on all over town,” Peter says. (Think oysters kilpatrick, steak diane.) “It was known as ‘international cuisine’ and nearly all restaurants and hotel dining rooms around the world served food based on Hotel French cuisine that had become standardised through lack of interest, direction and experimentation.” Not surprisingly, after three decades of this, food had become boring. Then the emphasis gradually shifted away from heavy sauces masking flavours towards a lighter approach aimed at enhancing fresh produce. > Greg’s recipe SEARED TUNA STEAK WITH BALSAMIC-BRAISED RADICCHIO 2 baby fennel bulbs extra virgin olive oil 4 eschallots, sliced 4 baby radicchio 2 tablespoons baby capers aged balsamic vinegar cracked black pepper sea salt 4 x 180 g tuna steaks Wash the baby fennel and slice finely (on a mandolin is best). Bring a deep pan that has a lid to a medium heat. Add some olive oil and heat, and then add the thinly sliced fennel and eschalots. Sweat these over a low heat with the lid on. Add the radicchio leaves and capers and sweat again until half cooked. Deglaze with a good splash of balsamic vinegar. Season with salt and pepper and remove from the heat. Heat some olive oil in a frying pan until very hot (nearly smoking) and sear the tuna on each side for approximately 45 seconds. The tuna should be crisp on the outside and raw in the centre. Place the braised fennel and radicchio on the heat, and add a little more olive oil and balsamic vinegar. Place the radicchio and fennel onto one side of the plate and add the tuna. Dress with the pan juices. Serves 4 PathWay #12 - Text 23/5/07 2:07 PM Page 59 When they’re not in the kitchen, it’s a safe bet that one or both of these brothers are out in the surf. PHOTO CREDIT: MICHAEL AMENDOLIA PATHWAY_59 > PathWay #12 - Text 23/5/07 2:07 PM Page 60 SURF N TURF In 1978, an eight-month trip around parts of Asia and Europe in a campervan with wife Beverley and their nine-year-old daughter fuelled Peter’s passion for new cuisine. Greg and his wife Jenny joined them for about three months. Both brothers also worked in restaurants to see what was happening. Back then they thought that one day they might run something together. But so far a variety of other ventures has prevented that from happening. Peter has run a number of restaurants since 1980, including Turrets in the city, Reflections at Palm Beach, Le Trianon and Cicada at Potts Point and Celsius in the Radisson Plaza Hotel, Pitt Street. He moved to Est. in 2003. Greg was the chef and had a business interest in hip 90s Darlinghurst nightclub Rogues, then had a place called Puligny’s in Neutral Bay, followed by Eastside Bar and Grill in Kings Cross. He took over at what is now Pier in 1994. “This restaurant had been doing seafood since the late fifties and early sixties,” he says. “It was Dories, then Doyles... quite a coincidence.” PHOTO CREDIT: MICHAEL AMENDOLIA “We just travelled around, went to the markets every day and went surfing,” Greg says. Ironically, Greg is not keen on fishing, so dinner was caught and cooked by the boys running the boat. “We were surfing six to eight hours a day,” he says. “The last thing I want to do on holidays is go into the kitchen.” At home Greg says he will cook if they are entertaining. Otherwise it’s up to his wife Jenny. “A favourite meal of ours that is really nice and easy is stuffing some corn-fed chickens with lemons, rosemary and garlic, and cooking them in a bag,” Greg says. “Then just wilt some spinach in the juices and serve with a nice big salad.” Peter is partial to a good dessert but also loves slow-cooked, stewy meals, like beef cheeks. “Because there are so many opportunities to eat lightly it’s nice to have something like a slow-cooked, braised meal. And then you have an opportunity to enjoy that nice bottle of big red you put down.” Today both Greg and Peter find themselves battling challenges because of the drought and seafood shortage. “The longer the drought goes on, the more impact it has on fruit and veg,” Peter says. “And fish is looking hard to source. We are changing our menu not because we want to but because we can’t guarantee that we will get the same fish each week.” LOCUM DOCTORS The fish shortage is also a considerable problem for Greg. When they’re not in the kitchen, it’s a safe bet that one or both of these brothers are out in the surf – although they don’t get out together as often as they did when they both lived in Whale Beach. Greg is still there, but Peter now lives in Balgowlah. When PathWay spoke to them they were preparing to head off on a surfing safari to the Maldives. “And a couple of years ago we went to the Mentawis, in Sumatra, on a surfing safari on a boat,” Greg says. “We were surfing reef breaks out in the middle of the ocean.” 60_PATHWAY 50_PATHWAY We have doctors available for short term, long term and permanent placements to meet your requirements. Our team of recruitment consultants are dedicated to offering you flexible staffing solutions whatever your requirements in the following areas: • General Practices • Hospitals – Private & Public • Mental Health, Aboriginal Health & Correctional Health Services • Department of Defence • After Hours doctors • DWS & AON GPs for permanent placements Fantastic Employment Opportunities. Work available for GPS, RMOs, SMOs, Registrars & Consultants throughout Australia. If you have any time available for locum work, we would love to hear from you. Great rates! Travel and accommodation included in most country areas and some hospitals. 1300 666 420 Email : [email protected] Web : www.australianmedicalplacements.com.au PathWay #12 - Text 23/5/07 2:08 PM Page 61 diningout A YEN for Japanese BLENDING ELEGANCE AND SIMPLICITY WITH INGENUITY AND QUIRKINESS, JAPANESE CUISINE HAS WON LEGIONS OF FANS. PATHWAY TRACKS DOWN SOME OF THE BEST JAPANESE JOINTS ACROSS AUSTRALIA. Toko Sydneysiders are quick to embrace a new restaurant, especially when the diners have a view of those not enjoying the new, hip place, and can be seen in return. Toko, located in the old MG Garage/XO site in Surry Hills, will not disappoint restaurant voyeurs. Brothers Al, Daniel and Matthew Yasbek have opened their second eatery among the hub of restaurants in Crown and Burke Streets. In Japanese, Toko means “room within a house to relax”, and this chic, informal style of eating is quintessentially Sydney. With an open kitchen, low-rise communal tables and a bar area, Toko offers several vantage points. You can see the chefs at work and there is a large emphasis on fresh local fish – the menu has 22 sushi options alone. The menu is extensive but not overwhelming and you will probably want to try everything. For an entrée we tried the nigri sushi salmon ($5.20) which is what I would expect of any good Japanese restaurant, and my tastebuds also appreciated the sashimi tuna ($18.50). Presented on a bed of crushed ice with wasabi sauce, the tuna was cut very fine and melted in the mouth. It was followed by a most interesting vegetarian option for a nori roll, the toko yasai makai nori ($8.20) with asparagus, zuchinni, capsicum, shitake mushroom, avocado and miso sauce. It was a smooth taste explosion. Mains are served themed on the traditional lunchbox idea with salad, miso soup and rice. We tried the tempura donburi ($23.80) – assorted tempura with sweet soy sauce and the beef steak donburi ($28.80) – chargrilled beef fillet steak with sweet sesame soy sauce. The latter dissolved deliciously in the mouth and was so tender we almost forgot it was red meat. The kotori ni miso zuke ($26.50) – miso-marinated baby chicken oven-baked with bok choy - was a stunning fusion of tastes, with hints of peanut sauce and ginger - and the chicken, like the beef, was beautifully tender. There is no better wine to match Japanese cuisine than an elegant rosé. We chose Fonty’s Pool Rosé 2006 from Margaret River ($11.00 per glass). It had a subtle strawberry aroma and delicate salmon colour and perfectly brought out all the flavours of the meal. It was delicate enough to enhance, not overwhelm, the food. To finish we took the waiter’s recommendation with a choice of 3 sorbets ($11.20) – lemongrass, lime and coconut, and shiso (a Japanese herb). The traditional lemongrass, lime and coconut was divine but the shiso, well, it created much conversation. Something for you to try. Toko is a welcome addition to the Crown St restaurant strip. - Eve Propper PHOTO CREDIT: NICKY RYAN All images from Toko Toko 490 Crown St, Surry Hills 2010 NSW Ph: (02) 9357 6100 Web: www.toko.com.au Open for Dinner Mon- Sat 5.30pm -11.00pm Open for Lunch Thurs - Sat 12noon -3pm Bookings only available for lunch | private dining room available About $170 for 2 including drinks PATHWAY_61 > PathWay #12 - Text 23/5/07 2:08 PM Page 62 diningout PHOTO CREDIT: NICKY RYAN Toko sushi | Kenji Ito has just opened his first restaurant Seizan One of the hallmarks of a good restaurant – apart from the food and the ambience – is the way the staff handle nuisance customers. I fear we were unwittingly just that when four of us descended on Seizan restaurant and were ushered to sit at the raised seats around the large hotplate where the teppanyaki barbecue cooking is performed. We had inquired whether teppanyaki was available when booking but after one look at the extensive menu, we decided to go with sharing dishes. Our waitress looked fleetingly taken aback and then with consummate Japanese politeness led us to the sunken seating typical of authentic Japanese restaurants. We reckon we made the right decision. We shared four entrees, all of which proved to be delicate and tasty. The most popular was the deep-fried scallops coated with crisp rice ($10.80), which were delectable, followed by the cooked octopus with soya bean dressing ($6.50), which was suitably tender, and the chicken skewer with yakitori sauce ($6). Of our main meals, the bento box ($24) was a hit. Each of the four delicacies – sashimi, teriyaki chicken, simmered beef and tempura mix – was full of flavour and combined well. Another favourite was the Tempura Moriawase ($16.80), a combination of fresh prawn, fish and vegetable tempura served with Japanese radish and a gingered lime sauce, which proved an inspired choice. All the mains came with miso soup, rice and salad. The friendly and obliging service persisted throughout the evening. Iced water had appeared immediately on arrival and was topped up regularly, our courses were served at decent intervals and drinks orders were promptly filled. As the restaurant filled up – a good sign, especially on a Monday night – we were relieved to see a couple had ordered teppanyaki and were being entertained by the showmanship of the knife-clashing, pepper-grinder-tossing chef. 62_PATHWAY In fact, it appeared the customers had much of the menu covered when a nearby couple ordered the Yakiniku set ($22.50 p/p), in which a griddle is brought to the table and you cook your own tenderloin beef and vegetables. The wine list was not extensive but the prices were reasonable. The decor was modern and restful with several aquariums and framed Japanese fans, and the waitresses were clad in beautiful yukata, a summery version of the kimono. For those of us who, after a couple of drinks, fancy imitating Joe Cocker or Aretha Franklin, the Seizan karaoke bar is open upstairs on Fridays and Saturdays from 7pm and Wednesdays and Thursdays by request. - Cathy Saunders Seizan 566 Hay Street, Perth Ph: (08) 9325 5980 Web: www.seizan.com.au Open for lunch Mon–Fri 11.30am–2pm, dinner 7 nights from 5.30pm About $60 for two plus drinks Kenji What happens when a highly trained Japanese-born chef, versed in the Kyoto style of cooking, is exposed to the work of two of South Australia’s finest regional chefs? The answer is to be found at Kenji, on the eastern side of central Adelaide. Owner chef Kenji Ito is a fully trained kaiseke chef whose specialised skills have been influenced by stints cooking at leading regional restaurants such as the Salopian Inn and d’Arry’s Verandah in McLaren Vale. This is Kenji’s first restaurant of his own, opened last year in partnership with his wife, who runs the floor, and it is one of the more interesting restaurants to open in Adelaide in recent times. It is a reminder of the days when Adelaide was a leader in cross-cultural cooking, with chefs such as Cheong Liew, Le Tu Thai and Cedric Eu, except this time the underpinning influence is Japanese. Although this smart-looking restaurant is at the ‘difficult’ end of Hutt Street, in a location that hasn’t worked too well in the past, PathWay #12 - Text 23/5/07 2:08 PM Page 63 Cooking up a storm at Seizan's teppanyaki barbecue | Beautifully presented Seizan sushi unlike most of its predecessors Kenji is having no trouble attracting a stream of dedicated customers. That is, of course, until you taste acclaimed chef Hiro Nishikura’s Kenji says his restaurant is a reflection of everything he’s ever done, with a seasonally driven menu providing Japanese flavours and style, with a focus on regional produce. The large menu possibly places strains on the kitchen from time to time, but in general Kenji’s dishes are immaculate and often quite dramatic in presentation. lighting become irrelevant. Look for dishes such as slow-cooked Barossa pork belly with hakusai cabbage rolls, duck leg poached in orange with teasmoked duck breast and fragrant red rice, or wagyu beef with taro and ginger mash and a green chilli salsa. The plate of half-adozen mixed appetisers for two is a fine way to taste the scope of Kenji’s skills – or simply opt for the bento box, which is a very stylish presentation of tempura, sushi, sashimi and beef teriyaki. Desserts can be interesting – such as frozen green tea mousse on sweet potato purée with poached satsuma plum and white fungi. The wine list is small, but individual, interesting and well priced. exquisite sushi, and suddenly the trivial details of decor and Seated at the bar, with a bird’s eye view of Hiro at work, opt for Omakase, a piece-by-piece selection of the best sushi of the day. You might be offered edible wonders such as the oysters warmed and served in a nori wrapper with a dash of Japanese mayo and a touch of chilli, or the briefly grilled eye fillet wrapped around a firm oblong of sushi rice. Watch Hiro put together his extraordinary mackerel sushi, oily and sweet with miso or the simplicity of sushi with tuna – prime slices of melt-in-the-mouth fish with a touch of wasabi paste. Whatever you’re served you’ll see it being freshly made in front of you – the perfect way to whet the appetite for the next piece coming your way. It would be easy to just let the sushi and sashimi keep coming but it would be a shame to miss out on Shira Nui’s wonderful cooked dishes such as the Chirimushi, a delicate dish of steamed fish and cabbage in broth with a mild dipping sauce, or - Nigel Hopkins Kenji Shop 5, 242 Hutt Street, Adelaide Ph: (08) 8232 0944 Open Tues–Sat from 6pm Licensed & BYO About $120 for two, plus drinks Bookings recommended Shira Nui Located on the edge of a shopping centre in the heart of Melbourne suburbia, Shira Nui doesn’t look much different from other Japanese restaurants. With its decor of pale yellow walls matched with blond wood timber, a long sushi bar and a few ocean-themed decorations, the smallish restaurant (it only seats 35) is indistinguishable from many of the Japanese eateries to be found throughout the city and suburbs. the robust Nasuden, two wonderful grilled circles of eggplant, meltingly soft and glazed with miso paste and sesame seeds. Desserts won’t disappoint either. We couldn’t resist black sesame seed brulée, a wonderfully creamy custard the colour of licorice with a distinct nutty flavour. But there’s also a green tea version I’ll be coming back to try another time. With a handful of excellent reviews and inclusion in every significant guide to great food in Melbourne, you’ll need to book in advance to secure a table or a seat at the bar, but the wait will definitely be worth it. - Justine Costigan Shira Nui 247 Springvale Road, Glen Waverley Ph: (03) 9886 7755 Open for lunch Tues–Sat noon-2pm, dinner Tues–Sat 6-10pm About $140 for two including drinks PATHWAY_63 PathWay #12 - Text 23/5/07 2:08 PM Page 64 the good grape HELLO MELLOW YELLOW AUSTRALIAN WINEMAKERS ARE TURNING TO A MORE REFINED AND LESS BLOUZY BREED OF CHARDONNAY – AND JUST IN TIME, SAYS BEN CANAIDER. t is our most loved wine. Chardonnay. We drink more of it than any other single grape variety – white or red. I Its popularity stretches from viticulturalists, who find it friendly and forgiving to grow, to winemakers, who love the tricks and artefact they can conjure with it, and to the vast majority of drinkers who find chardonnay’s fruit-salad flavour reliable and reassuring. over two decades to move on from that As one Hardys winemaker says, unavoidable and awful sunshine-in-a- “altitude and latitude equal attitude”. The bottle chardonnay flavour profile. further south you go, or the higher up you But finally there’s some real go, you get grapes with one very sophistication starting to creep in. We are important quality – higher levels of natural not making great Chablis or white acidity. And acidity is the key to elegance, burgundy yet, but that’s not really the freshness, balance and – more point or goal. We are now, as a importantly, potential longevity – in wine. winemaking nation, starting to make balanced, elegant and very gently, subtly But $53 is still $53. Pay that sort of Australian chardonnay’s smell and flavour is pleasantly – almost banally – memorable. stylish chardonnay. In other words, white money and you should rightly expect to wines that observe wine’s first and most get a good wine – and a wine you should important rule: it has to be a beverage, be able to easily drink. But what about Unlike riesling it is not too piercing; unlike sauvignon blanc it is not too strident; unlike viognier – the latest new kid on the block – it is not too viscous or alcoholic. Yet if these statistics and general comments are true, then why is there an ABC – Anything But Chardonnay – Club? not a statement – no matter how many under $20? Trends, fickle and sometimes fathomless, come and go in the wine game, as much as they do in the fashion industry. But this can be good news, too, because it encourages rethinking and refinement. And that’s something the great majority of Australian chardonnay has needed for some time. best wine of the show – from all classes, 2005 Gulf Station Chardonnay is around red and white – went to Hardys Eileen $19, and is often discounted further. Going back nearly 30 years now, chardonnay burst onto the local bottled wine-drinking scene like Dolly Parton in a hot-pink, rhinestone-encrusted rodeo outfit – buxom, loud and very cock-ahoop. It was a style of white wine that was unmissable. Its flavour was big. Because of this a newly wine-sophisticated Australia took to it – it was a drink and a taste that was easy to remember. We liked that because it made us all feel like instant wine connoisseurs. The trouble was the long hangover – in gustatory terms, that is. It has taken us 64_PATHWAY meaningless wine trophies and medals such ‘statement’ wines might win. And maybe the wine show system is even changing, too. At the 2007 Sydney Royal Wine Show more chardonnays with more elegance and breeding took out more gold medals. Indeed, the award for Hardy 2004 Chardonnay ($53). This is still a wine with all the Chardonnay has been fine-tuning itself at this price point, too. Leading the way with such elegance, refinement and very drinkable – and affordable – subtlety is the Yarra Valley’s Steve Webber. The De Bortoli winemaker’s It is chardonnay that is more citric and grapefruity than tropical fruits and winemaking bells and whistles, but the peaches and cream. There’s some decibel knob has been well and truly roundness and richness from some good, turned down. This is a new style of unobtrusive barrel ferment, but nothing Australian chardonnay that demures too fancy-pants gets in the way of the rather than bullies. clean, pure fruit flavours. Part of the reason for this is the fruit. Eileen Hardy chardies of days gone by were made from ripe, rich, heady grapes from such places as Padthaway and McLaren Vale. The wine was given a fair This is a wine you can drink, and drink. And it is a wine Webber is proud of. Not letting the grapes get too ripe; sourcing fruit from south-facing slopes, whack of barrel ferment in very osmotic, away from full sun; sorting the fruit to toasty French and American barrels. In guarantee the best quality; and not relying other words, Dolly Parton. on too much new and loud oak has The 2004 Eileen is a different lady altogether. The fruit comes from Tasmania, the enabled him to build a wine that’s seemingly simple, yet all so satisfying. This is the future for Australian Yarra Valley, and from Tumbarumba, near chardonnay. As Dolly might have said, the Snowy Mountains. here chardonnay comes again... PathWay #12 - Text 23/5/07 2:08 PM Page 65 2007 Conference Calendar JUNE 2007 3 11th Greek Australian International Legal & Medical Conference 14 The Adelaide Small Biopsy Course 14 - 15 July 2007 Adelaide, Australia [email protected] 3 - 9 June 2007 Crete, Greece [email protected] AUGUST 2007 16 First World Congress on Pathology Informatics (WCPI) 16 - 17 August 2007 15 AACC Annual Meeting Brisbane, Australia www.pathologyinformatics.org/ 15 - 19 July 2007 3 17th IFCC – FESCC European Congress of Clinical Chemistry and Laboratory Medicine 3 - 7 June 2007 The Netherlands 5 Dermatopathy 5 - 8 June 2007 Las Vegas, USA 18 The Virology Master Class 18 - 29 June 2007 Adelaide, Australia www.sapmea.asn.au/virology2007 23 Microbal Genomics and Secondary Metabolites 23 June - 1 July 2007 Split, Croatia www.jic.ac.uk/science/molmicro/ summerschool2007 JULY 2007 1 23rd International Conference on Yeast Genetics and Molecula 1 - 6 July 2007 Melbourne, Australia www.yeast2007.org San Diego, USA http://www.aacc.org/AACC/events/ann_meet/ annual2007/ 20 24th World Congress of Pathology and Laboratory Medicine 20 - 24 August 2007 16 Techniques and Application of Molecular Biology: A Course for Practitioners 16 - 19 July 2007 Coventry, UK www.warwick.ac.uk/go/bioscienceshortcourses 20 Basic Pathological Sciences Seminar 2007 Program 20 - 21 July 2007 Sydney, Australia 22 4th IAS Conference on HIV Pathogenesis, Treatment and Prevention 22 - 25 July 2007 Sydney, Australia www.ias2007.org 22 9th Indo-Pacific Congress on Legal Medicine and Forensic Sciences 22 - 27 July 2007 Colombo, Sri Lanka [email protected] 28 Current Issues for Legal Medicine 28 - 29 July 2007 Canberra ACT, Australia [email protected] Kuala Lumpur, Malaysia [email protected] SEPTEMBER 2007 15 The Greek Conference KOS 2007 15 - 21 September 2007 Dodekanese, Greece [email protected] 23 International Clinical Trials Symposium 23 - 26 September 2007 Sydney, Australia www.clinicaltraials2007.com OCTOBER 2007 10 5th Annual Pathology Refresher Course 10 - 12 October 2007 Budapest, Hungary www.ryalsmeet.com/meetings/ISSP101007/ main.htm NOVEMBER 2007 2 Short Course in Forensic Pathology 2 - 4 November 2007 Hobart, Australia [email protected] PATHWAY_65 PathWay #12 - Text 23/5/07 2:08 PM Page 66 rearview Dark side of Venus PINPOINTING THE TRUE ORIGINS OF SYPHILIS HAS PROVED TO BE A TRICKY HISTORICAL TASK, WRITES DR GEORGE BIRO. e would need the wisdom of for Europe,” according to author Andrew China, India, and Africa. King Charles Solomon to resolve big questions Nikiforuk.1 himself died of syphilis, aged only 28. W such as how, when and where syphilis started in Europe – and who gave it to whom. The French blame the English, the English suspect the Neapolitans, and on it goes. So many mysteries, but no definite answers. Many Europeans blame the Americans. It’s believed that men who sailed with Christopher Columbus caught syphilis in the West Indies in 1492–93 and brought it back to Europe. “Just as smallpox became the Old World’s calamitous gift to the New, syphilis was America’s biological surprise Some say that Columbus himself went mad and died of syphilis. In the 1490s, the French army of King Charles VIII were besieging Naples. Some of Columbus’s sailors had joined the Spanish defenders. The besieged men expelled from the city the harlots they had infected. As planned, the prostitutes in Much later, the author Voltaire lamented: “France didn’t lose all she had won in this campaign. She kept the pox.” Fifteenth-century syphilis could turn you into a leprous-looking wreck in weeks and bury you within a year – if the agonising pain did not lead you to kill yourself first. Victims were afflicted with pustules spreading from the genitals, turn, infected more and more of the agonisingly swollen joints, fever, rotting besieging army. flesh and blindness. Within a year, syphilis forced the French to abandon Naples. As they scattered, they spread syphilis around Europe; then sailors carried it to One man, Joseph Grunpeck, picked up syphilis at a banquet “attended by Venus as well as Bacchus and Ceres”. He himself beat the odds and lived to 81, but his fellows did not: “so filthy and repugnant… hoped to die. Some moaned and wept and uttered heart-rending Syphilis does not spare the famous O ne report blames Cardinal Wolsey for giving syphilis to King Henry Vlll by whispering in his ear. 2 cries…” One misogynist doctor insisted: “The disease is contagious… through copulation… with an unclean woman.” But within 50 years after Columbus sailed the ocean blue, the disease was becoming less virulent, and changed from A list of people alleged to have had syphilis reads like a historical and artistic Who’s Who. From Russia we have Ivan the Terrible, Peter the Great and Catherine the Great, who gave her son Paul l congenital syphilis. From other corners of the globe we have Herod, Charlemagne, Goya, Keats, Napoleon, Gaugin, Nietzsche, Oscar Wilde, Scott Joplin, Al Capone and Randolph Churchill (Winston’s father). being a lethal epidemic to a chronic The great John Hunter (1728–93) believed that syphilis and gonorrhoea were just one disease; in a tragic self-experiment he inoculated himself and reportedly ended up with cerebral and cardiac syphilis. When Samuel Johnson’s biographer, randy James Boswell (1740-1795) enjoyed women of the night, he sometimes used “armour” (a condom of animal gut). No, he wasn’t fussed about getting them pregnant, he was just protecting his own crown jewels. condition”, then washed and covered with At first the author Guy de Maupassant was proud of his syphilis, but ended up in an asylum suffering general paralysis of the insane. And Sir William Osler (1849–1919) taught that he who knows syphilis, knows medicine. infection. The treatments were imaginative, if not too effective. Quacks advised people with chancres (initial syphilitic lesions) to have them first sucked by a person of “low a live flayed chicken. But the main remedy was topical or oral mercury. Wits quipped: “A night with Venus meant a lifetime with Mercury”. Though mercury did kill some spirochaetes (slender, corkscrew-like bacterial micro-organisms), it also killed some patients. Other users went bald and lamented their lost love life. The bark of 66_PATHWAY 23/5/07 2:08 PM Page 67 PHOTO CREDIT: JEAN-LOUP CHARMET / SCIENCE PHOTO LIBRARY PathWay #12 - Text A 19th century illustration of an emaciated man suffering from syphilis. “Fifteenth-century syphilis could turn you into a leprous-looking wreck in weeks and bury you within a year – if the agonising pain did not lead you to kill yourself first.” the ‘Holy Wood’ (guiac) from America also had a vogue. Around 1909, after hundreds of failures, Dr Paul Ehrlich (1854–1915) synthesised two arsenical compounds, Salvarsan and then Neosalvarsan, which proved an effective treatment. Sad to say, he did not live to receive his Nobel Prize. The Viennese psychiatrist Julius Wagner von Jauregg injected syphilis patients with malaria parasites, so causing high fever and achieving some remissions. Another Nobel Prize. Nowadays penicillin is still clearly the best treatment. One view is that syphilis, or a closely related disease, existed in Europe before Columbus. Supporters cite evidence from skeletons found in the early 1990s in an ancient Greek cemetery in southern Italy. Other skeletons come from the site of an ancient friary in Hull. Both sets of skeletons are said to predate Columbus and to show evidence of syphilis. So was there syphilis in Europe long before the fifteenth century? Some authorities read syphilis into Biblical references, such as that of David, King of Israel: “My wounds stink and are corrupt because of my foolishness. My loins are filled with a loathsome disease…” Could the Biblical warning “The sins of the fathers shall be visited upon the children” refer to congenital syphilis? Perhaps the spirochaete existed in both the Old and New Worlds at the same early time, and Columbus’s sailors just brought back an unusually virulent variety. Or perhaps what people in medieval times called leprosy was actually syphilis or a close relation. Another theory involves tropical diseases related to syphilis and also caused by the same Treponema spirochaete. Whereas syphilis is a venereal disease of adults, the other three are nonvenereal diseases of children, spread via the skin or mouth. Yaws is common in Africa; bejel, sometimes called nonvenereal syphilis, occurs in the Near East, and pinta is found in Central America. Some believe that African Negroes, who the Portuguese navigators captured in the early 1400s, brought yaws with them to Europe. Then, as it infected the fully clothed Portuguese and Spaniards, non-venereal yaws gradually became venereal syphilis. Some microbiologists regard the agents causing human treponematoses as variants of one ancestral spirochaete. So, are these treponematoses varieties of one disease that originated in Africa, its manifestations varying with climate and culture? The debate goes on. 1. The Fourth Horseman. London: Fourth Estate, 1991. 2. Wilkins, Robert. The Fireside Book of Deadly Diseases. London: Robert Hale, 1994. PATHWAY_67 PathWay #12 - Text 23/5/07 2:08 PM Page 68 postscript Nutmeg liver and sago spleen THE CREATIVITY OF PATHOLOGY LECTURERS INJECTED SOME MUCH-NEEDED EXCITEMENT INTO DR PAM RACHOOTIN’S MONOTONOUS MEDICAL DEGREE. and google them to get help from sites such as the Undiagnosed Symptoms Support Forum. n American humourist once said, “Our great difficulties in life aren’t caused by what we don’t know, but by the things we know – and that aren’t so.” A In this forum a qualified medico attempts to elicit a more meaningful history and then provide some advice, while a virtual community of patient advocates comment from the sidelines and share similar experiences. The only lectures in medical school that kept me awake were the stimulating sessions presented by the real entertainers of the medical world. There was nothing like a seasoned pathologist fearlessly hitting the high Cs of clinical–pathological correlation. The banter continues with results of MRI scans and blood tests. Armed with printouts of a battery of investigations that someone else received, the now confident patient presents to their GP, demanding a quick confirmation. And the story line! Who could possibly sleep through the who-done-it suspense, as clue accreted to clue on the troubled road to the differential diagnosis? What investigations would help support or refute the various alternative hypotheses? Forget medicine, forget science – this had all the makings of great literature. This message of hidden truths was reinforced during our required attendance at three autopsies. If one just kept sufficiently out of the way, it was possible to witness the careful uncovering of discrepancies between the presumed diseases and the actual underlying medical conditions. The lesson: one’s clinical judgment does not necessarily match reality. Alas, today’s focus on problem-based learning puts the magic wand in the unguided hand of the sorcerer’s fumbling apprentice, with all the predictable results. Sure, let’s limit student interaction with pathologists, ban students from autopsies, and call it a ‘new curriculum’. That sounds modern, doesn’t it? Through their lectures, pathologists provided the foundations of medical practice for me, as well as contributing to my sense of language and aesthetics. Their use of metaphor spiced up what otherwise might be a dry, scientific lexicon. If the practice of medicine has long been recognised as an art, we owe pathologists credit for engaging our senses of smell and taste to bring us a more culinary appreciation of disease and death. 68_PATHWAY Pathologists appear to have been salivating over their work for years. A tantalising array of mouth-watering pathological treats abounds – with a focus on sweets. They include chocolate cyst ovaries (endometriosis), strawberry gall bladder (cholesterolosis), sago spleen (infiltrated with amyloid), honeycomb lung (fibrosing interstitial disease or emphysema), and bread-and butter serositis (pericarditis) with icing sugar spleen (in non-specific splenitis). This is not to neglect the main course – what with nutmeg liver (chronic venous congestion), beefy lung (showing consolidation in gross appearance), cauliflower-shaped colonic tumours, anchovy sauce amoebic abscess, rice water stools (cholera), Swiss cheese (endometrial hyperplasia), and rice or melon seed bodies (in tuberculosis arthritis). Did the pathologists who popularised these descriptions lead a double life as frustrated chefs? Or did hunger stimulate their imaginations while they worked through their lunch breaks? Meanwhile, patients have embraced their own pseudo clinical–pathological correlations. They have symptoms such as “attacks of feeling off” or just plain “weirdness” Although GPs have struggled for years to come to terms with vague presentations by patients, such histories do not deter the cyber space support network. Take this mythical exchange between bloggers. A blogger, who warns that she “may be unreasonably grumpy for a few days… having simultaneously infected [herself] with both bronchitis and a sinus infection” is advised to: “Chicken soup it until it comes out of your ears.” Alternatively, a nurse practitioner asks, “Have you tried pantothenic acid? It’s been known to stop even asthma in its tracks…” Whereas patients may turn to advice from anyone with an internet connection, medicos put their trust in pathologists to get them going in the right direction, notwithstanding the occasional mishap. Like the throat swab sent off for microscopy, culture and sensitivity, with its finding of: “Normal vaginal flora”. Or the biopsy from a specimen described as a “large polyp”, submitted by a registrar performing his first sigmoidoscopy. The pathologist, who maintained strict professionalism, wrote a succinct conclusion: “Normal cervix”.