One thing is certain: 2019 is another Gregorian calendar year with a great deal of uncertainty. When we think about the world, there is a great deal of turmoil. For those in Europe, we are facing a frantic first quarter period of international diplomacy to try to establish trade and practical working agreements between the UK and the European Union. For those of you in areas where you are living with daily threats from violence, uncertainty about survival and the society in which you live has become part of your life.
Uncertainty is an uncomfortable feeling for most of us, but it is also such a key feature of life for our patients. A while ago I was asked to talk with members of parliament interested in blood cancer. In preparation, I asked a great friend of my son, who has had a lymphoma, if I might use his story to illustrate the role of the many disciplines in pathology. He was kind enough to agree, and was happy for us to use his experience to help spread the word about the role of pathologists in diagnosis and treatment. While I made a rough tally of the many years of training and expertise that pathologists contributed, just to the diagnosis, (at least 88, by the way, including the work-up exclusion of diagnoses by microbiologists, clinical biochemists, etc.), I also tracked his journey to his first treatment. The period of uncertainty while he waited to find out from a bone marrow trephine whether his lymphoma was stage 1 or stage 4 was particularly striking. He knew he had cancer, but he didn’t know quite how bad it was...
Professionally, across all our diagnostic areas, we ‘major’ on reducing uncertainty. Uncertainty over a cause of infection, the potential presence of drugs or toxins, the meaning of aberrant liver enzyme results or blood profile, uncertainty over the type, grade or stage of a tumour. Sometimes it may take a while to track down what is going on, but we try to get to the heart of the matter as quickly as possible. Any delays in getting a patient the correct diagnosis and the appropriate treatment don’t sit well with us. This is where we come to things stopping us doing what we need to do as fast and as safely as we can.
Workforce. You are key, and we know you are stretched. I know that I have written about this previously, but it is really important to us all and I do know that not all of you read every Bulletin cover to cover (Shame!). Hopefully you will have seen at least some of what we have been doing to try to make sure we have enough pathologists, of all disciplines, to diagnose and care for patients. We have been collecting data through workforce surveys, the first of which has been published, and which has had a significant impact and very good coverage. We have another in the last stages of preparation for publication, and a third just gone out to the haematologists. (Please make sure your department completes them – accurate data are essential). More will follow, and the College workforce team have been epic in this.
In parallel with our diagnostic work on workforce issues, we have been ramping up our efforts to attract people into our professions, through activities with undergraduates, postgraduates and trainees. We are also trying to make sure that the training and working life is attractive, as I have written about before. In Aberdeen, on a recent #labtour visit, I saw some great examples of doctors being attracted into training as pathologists through foundation rotations in different pathology disciplines. The conversion rate into pathology training was impressive.
Some new developments in relation to training: in the UK there has been a lot of discussion over the format of training, and the ability to be more flexible in training patterns. In particular there is discussion over competence-based training, rather than adhering to a strict timescale. There is obviously a limit to training truncation because of the need for experience and exposure to clinical variation, but people do learn different skills at different rates and some have prior experience that brings them up to speed faster. Some centres have reported that ‘restarting’ programmes can be problematic for those with some prior experience in pathology because of current rules in some training programmes, and a little more flexibility would be helpful for these trainees. There is also discussion about the ability to do ‘step on step off’ patterns, where you might wish to stay at a particular level for longer, to suit your circumstances, and family locations, rather than the virtual ‘lockstep’ year by year based system we have currently. It also raises the possibility of simpler recognition of competencies gained outside a formal training post. So all very intriguing and with great possibilities - if thought through properly, if done with trainee input, and with the ability to do some in-flight re-adjustment if needed!
The pathology network programme in England continues under the leadership of NHSI, as does the procurement process for primary HPV screening in cervical cytology, and the roll out of the genomics centres via NHSE. Similar programmes are in progress in many other countries. All these processes have highlighted the need for close liaison of those commissioning programmes and diagnostics with professionals and for truly informed commissioning.
There is also a continuing need for bodies such as NHSI, HEE, NHSE and PHE to work together. The voice of the profession has been heard in this respect in England at least, as joint structures are being formed between NHSE and NHSI, and HEE now has links with NHSI. Apart from the glossary and masters level education needed to understand exactly what these bodies are, do and how they have previously interacted (or not), we are pleased that the silo working that has produced many troubling situations (and about which we have been pressing) is being reconsidered. For example, there was the decommissioning and reduction of cervical screening for high-risk women through sexual health clinics when the latter moved out of NHSE commissioning structures into local authorities. This screening has now been reinstated. Thankfully.
Hopefully, the beginnings of better coordination of working will continue and we will continue to encourage this. We still have lots to do though, to make sure that some of the difficulties of the past will not be repeated. These are best avoided by early, continued and genuine engagement with the professionals who know what they are doing! ‘I told you so’ is not a great place to be in for us, or for patients.
I have continued to visit labs (#labtours) and to learn about the great work being done. The design of the Royal Derby Hospital mortuary area and ‘zig zag’ viewing gallery is particularly innovative and I had mortuary envy for the first time (ours at the Royal London Hospital is good too, but the gallery at RDH is superb). In relation to mortuary issues, we have done some work with the Human Tissue Authority (HTA) on a simple guide to mortuary regulation and some of the incidents and events that need to be avoided. The summary is available as a learning module on the eCPD app, or via the HTA website. Please direct your medical director, chief executive and board to this: they need to know, and to make sure that this key area for patient dignity is properly supported. Mistakes in mortuary practice can be distressing and high profile. The learning, if not the precise regulation, is applicable to every centre that has a mortuary or body store.
The fabulous advances in science and technology being driven by pathologists working with a wide range of other disciplines have been showcased at a range of recent meetings. These changes (coming soon to a lab near you) include scanning mass spectrometry, point of care blood counts, extended rapid point of care respiratory infection screening and AI systems. I was particularly taken with an AI system that highlights potential helicobacter in a whole slide imaged haematoxylin and eosin stained slide, and a system that shows areas of potential malarial parasites on a scanned blood film. While these are not autonomous, and will always require professional judgment, it might be nice to have a system that helps you not miss things.
Patient safety is a key theme for this Bulletin, and whilst we are one of the most advanced professions in terms of quality control and safe systems, we are always striving to do better, and I hope that you will enjoy the articles.So lots to do, and lots to look forward to in 2019, and I wish you all the very best for the coming year!