Histopathology

Medical students

Pathology took a hit after the GMC's Tomorrow's Doctors and almost vanished from some curriculums.¹ Ten years on, we may again have the chance to contribute to undergraduates' understanding of disease mechanisms and how knowledge of these underlies evidence based medicine. It may require a bit of work to grasp these concepts but they do form the foundation of rational therapy. Let's be sure—we do expect recently graduated doctors to tell patients what is wrong with them. Students devote much effort to developing skills in breaking bad news—maybe in-depth knowledge of the pathological process of the bad news helps them to discuss issues with patients in an informed manner. We can provide content, context, and perspective to facilitate such learning.

Foundation years

Foundation programmes are one of our opportunities to teach motivated young doctors about our subject in a way that is useful to them. They learn what histopathology can and cannot do. They can see the relevant time frames within which we work and can develop a feel for reasonable expectations of the service. This may benefit their patients and the laboratories in future. And who knows, we might just attract people into the specialty.

Training in histopathology

The Royal College of Pathologists has a curriculum approved by the Postgraduate Medical Education and Training Board and implemented in England in 2005. Scotland will see run-through in 2007. As a result of fairly well matched senior house officer and specialist registrar numbers, transition to run-through is not a problem. Trainees follow a diverse programme being involved in surgical pathology—dealing with biopsies and resected specimens, cytopathology both in diagnostic work and cervical cytology; and in postmortem work. We see our trainees developing competencies in established practices of handling diagnostic material but also, certainly in the north of Scotland, in patient-centred environments, taking fine needle aspirates they will later report. Reporting them in a multidisciplinary clinic provides immediate insights. Overall, our trainees are enthusiastic and engaged, even seeming to enjoy themselves at RITAs (record of in-training assessments).

Consultants

Much has changed. Routine molecular investigation of tumours using various techniques is now standard. Cancer care prioritisation has made histopathology more immediately relevant to ward based doctors and so to patients. This is because pathology has become important to underpin diagnostic and prognostic discussions. Evidence based studies have acknowledged the importance of tumour classification, grading, and staging. What we say often has considerable bearing on which treatment modality will result in the most favourable outcome. The expression of molecules by tumours is often linked directly to the prescription of anti-cancer drugs such as tamoxifen, rituximab, and inimitab.

We use telemedicine daily for conferencing. Specialisation of reporting has made clinicians more aware of patients and has made us venture out from a laboratory to work with ward based colleagues. I know of histopathologists who attend specialist oncology clinics to explain a pathology report.

Post mortems are under increased scrutiny since the advent of the Human Tissue Act. The changes in postmortem regulations might seem daunting but I perceive increased public engagement as a chance for us to inform. Enabling patients to signal a wish for a post mortem as opposed to asking newly bereaved relatives for authorisation might fuel interest, as with transplantation and anatomy donation. Standard setting and audit may also be drivers. This, with continued input from the Forensic Service, may help enliven postmortem training.

Future

So, where are we going with this specialty? Shifting glass on a microscopic stage is daily fare but perhaps I am allowed speculative crystal? We will not see much in the way of further consultant expansion but our capacity will have to increase as the demands of evidence driven healthcare proliferate. Teletechnology may assist. Biomedical scientists with extended roles will help and will thus put histopathologists more in the role of supervisors, standard setters, and auditors, much as is the case in cervical cytology today. Medically qualified histopathologists will remain an essential component, dealing with complex cases and coordinating the communication of results to relevant people, among whom I would increasingly number patients. Our reliance on molecular techniques increases by in fine-tuning diagnosis and prognosis, but glass is cheap and quick and the trained eye is particularly smart at spotting transgression.