My route to immunology
My mother was the first to attend university in her family, and qualified as a doctor in Hyderabad, India. Although there may have been subliminal compulsion to follow in her footsteps, there was never any overt pressure. After strongly considering law and engineering, I eventually settled on medicine. I attended Trinity Hall, University of Cambridge, with clinical training at Guy’s & St Thomas’ Hospitals, qualifying in 1993 with distinctions in medicine and pathology. Although I really enjoyed immunology at medical school, I was not aware of immunology as a specialty.
Initially, I undertook medical rotations, completing the Membership of the Royal College of Physicians and obtaining a registrar post in nephrology/general medicine. In 1998, I completed a master's in immunology at King’s College, and decided to make the switch to immunology – the immunological aspects of renal disease were most attractive to me. I was Clinical Lecturer/ Honorary Specialist Registrar in Immunology at King’s College London/Guy’s & St Thomas’ Hospitals from 1998 to 2004. During this time, I had the opportunity to continue working on lupus under Professor Graham Hughes, who first reported the anti-phospholipid syndrome.
In 2004, I was appointed as a Consultant Immunologist at Frimley Park Hospital, and then at Guy’s & St Thomas’ in 2005. I split my time between Frimley Park and Guy’s & St Thomas’, becoming Clinical Lead in Immunology at the latter.
In 2018, after almost 25 years in the NHS, I took the opportunity to travel abroad to work at Sidra Medicine, a new tertiary paediatric and maternity hospital in Doha, Qatar. I am currently Division Chief of Hematopathology (Hematology/ Immunology/Transfusion) and Senior Attending Physician in Immunology.
We need to increase awareness of the range of career possibilities in pathology to attract the new generation of physician pathologists who are comfortable in the clinic, ward and diagnostic laboratory.
While working as a busy clinical pathologist, it can be challenging to maintain an academic interest, and to continue with research, achieve grants and publish. I have been fortunate to lead and collaborate with excellent colleagues in research projects complementing my clinical interest in autoimmunity. I have authored 80 publications and chapters, and been lead or co-principal investigator on grants totalling £1.5 million.
Novel diagnostics and therapies in autoimmune disease
My particular interest has focused on improving the management of patients with autoimmune disease through improved diagnosis, alternative immunosuppressive strategies and a holistic approach beyond achieving clinical remission. This approach widens the scope to include long-term complications of the disease and its treatments.
In the early 2000s, I led the earliest single centre study of mycophenolate mofetil in systemic lupus erythematosus (SLE) at the St Thomas’ Lupus Unit, following its successful use in transplantation. We published two early reports of 22 and then 86 patients who had failed standard therapies, and I subsequently participated as an investigator on an international multicentre study of mycophenolate in lupus nephritis.
I co-wrote several articles on the use of thalidomide in the treatment of resistant cutaneous lupus. Subsequently, these treatments were utilised in routine practice in our clinic and in lupus units around the world, with mycophenolate becoming standard of care for lupus nephritis. In 2008, I received a grant under the New Services & Innovations Scheme to study novel Luminex/multiplex bead technology in the diagnosis of autoimmune disease. Our team were able to evaluate against both standard enzyme immunoassay techniques and classical methods such as countercurrent electrophoresis. Following successful evaluation in SLE, vasculitis and coeliac disease patients, we introduced this technology into the routine immunology laboratory, while continuing to act as a referral centre for gold standard autoantibody techniques.
Publishing recommendations for secondary immunodeficiencies
In the Lupus Unit, I worked alongside consultants in rheumatology and nephrology, where the complementary skillsets and experience of the specialists enabled a more comprehensive approach to patient diagnosis as well as to the management of complications and disease flares. We recognised that an increasing number of our autoimmune rheumatic disease patients were developing recurrent, atypical or severe infections.
In 2015, I established a specialist secondary immunodeficiency clinic to improve the investigation and clinical management of this group. In particular, this enabled early recognition of antibody deficiency in patients treated with B-cell targeted therapies, and ensured the appropriate usage of replacement immunoglobulin infusions. Professor Jayne (Cambridge), Dr Mukhtyar (Norwich) and Dr Wijetilleka (Cardiff) and I established a national task force group, which published recommendations for the management of secondary hypogammaglobulinemia due to B-cell therapies in autoimmune rheumatic diseases.
Setting up an immunology laboratory service
When I started at Sidra Medicine in 2018, my role was to develop the laboratory immunology service from scratch at a greenfield site. Immunodeficiency disorders are more common due in part to consanguinity and large family sizes, thus implementing investigations of immune competence is a priority. Our division introduced immunology tests not available elsewhere in the country. However, for complex or novel cases where standard diagnostics fall short, it has been important to establish strong relationships with the excellent research branch for cutting edge investigation of children with immunodeficiency and autoimmunity disorders.
The hospital has staff representing over 80 nationalities, and it has been particularly instructive to work with pathologists and biomedical scientists from around the world. I have learnt about similarities and differences in test validation, diagnostic approach, accreditation and pathologist training. This has provided an important opportunity to consider which aspects I can bring back to the UK in the future.
Participating in national and international organisations
From 2005 to 2008, I was a member of the British Society for Allergy and Clinical Immunology Council, and Chair of the Clinical Immunology Committee from 2014 to 2017. Between 2009 and 2013, I represented immunology as the professional representative on the Royal College of Pathologists’ Lay Advisory Committee. I was an Expert Member for the NICE Quality Standards on Drug Allergy in 2015, and on the Guidelines Committee of the UK-Primary Immunodeficiency Network from 2016 to 2018, which published on non-infectious complications of common variable immunodeficiency.
Since arriving in Doha, I joined the Education Committee of the World Association of Societies of Pathology and Laboratory Medicine, leading to an invitation to speak at the International Pathology School co-hosted by the Jordan University of Science & Technology and the Royal College of Pathologists.
I recently had the opportunity to lecture on the relationship between COVID-19 and immunodeficiency at MedLab 2022 in Dubai, on behalf of the Royal College of Pathologists.
There are a whole range of challenges facing pathology, but I have focused on those which are close to me.
The changing role of pathologists
The balance between patient-facing and laboratory work in specialties such as immunology and haematology has changed over the last 20 years. Trainees and consultants are increasingly spending time in the clinic and on the ward, and less so in the laboratory. There is a danger that as we spend more time in patient-facing roles, we start to lose the essential skills needed to work within and to lead the diagnostic laboratory. We need to ensure that our training programmes remain designed for trainees to attain the necessary knowledge and skills to be competent in the laboratory. Indeed, in immunology, the General Medical Council (GMC) has now approved two different pathways: namely allergy and clinical immunology, or allergy, clinical and laboratory immunology, with only the latter pathway requiring FRCPath.
As immunologists and pathologists, we need to translate our subject in a comprehensible manner, and find practical ways to express our own enthusiasm for our subject.
Incorporating pathology results into algorithms
In some ways, I have been surprised that the use of algorithms and artificial intelligence has not yet become more prominent in clinical diagnosis. Nevertheless, this represents the future and is likely to become part of routine practice within the next decade. It is essential that pathologists of all disciplines play an active role in the design and implementation of such workflows. Such technologies should be welcomed as complementing the knowledge and clinical experience of pathologists rather than being considered as a replacement strategy. It is vital to ensure that pathology has a seat at the table within the senior management structures entrusted with delivering such changes. Regrettably, in hospital management decisions, pathology is often not considered, or is simply an afterthought.
Inspiring and attracting trainees to pursue pathology
Although at first glance attracting trainees may seem the same issue that pathology eternally faces, it links into the changing nature of pathology roles. When I was a medical student, and even as a medical senior house officer in the 1990s, I had never heard of immunology as a specialty.
Raising the profile of pathology
The first challenge is to ensure that we raise the profile of pathology and all its specialties as much as possible. We need to be out there at every opportunity, raising the profile of pathology within the hospital, and to medical students and junior doctors. This could start early, e.g. by offering clinical rotations and electives in pathology, or by attending and holding events for medical students and junior doctors. For example, my colleagues Dr Eileen McBride and Dr Jason Ford offer an elective in hematopathology to the fellows in paediatric hematology/oncology and to the paediatric residents. Our department also offers a pathology elective to senior medical students at the Weill Cornell Medicine Qatar where they can spend two to four weeks in one or two pathology specialties.
Engaging with medical students
When we do teach medical students, we need to be teaching at an appropriate level. For example, in immunology, it is common for students to find the subject matter confusing and overly complex, and consequently to be put off the subject for life. As immunologists and pathologists, we need to translate our subject in a comprehensible manner, and find practical ways to express our own enthusiasm for our subject. I recently presented a case-based format for enhancing basic science knowledge in medical students and trainees at the British Society for Immunology annual congress.
Highlighting the role of pathologists
We need to increase awareness of the range of career possibilities in pathology to attract the new generation of physician-pathologists who are comfortable in the clinic, ward and diagnostic laboratory.
The critical role of pathologists in diagnosis should be highlighted wherever possible, e.g. in multidisciplinary team meetings where junior doctors who may be undertaking rotations in other specialties will encounter histopathologists and hematopathologists.
My first tip is leave work when you leave the hospital; however, my wife and children will confirm that I am terrible at taking my own advice. Try to avoid continuously checking emails when not on duty. Digital pathology and remote desktop access can be a double-edged sword!
My second tip is holiday = holiday. As my current boss often says to me and my colleagues: ‘You don’t need to do that now – you are on holiday’.
Finally, it's worth keeping in mind that these tips are much easier said than done