PathWay Autumn 2007 - Issue #11
Autumn 2007 | Issue #11
Bodies of Evidence:
PROTECTING OUR PRECIOUS PATHOLOGY SPECIMENS
PROTECTING OUR PRECIOUS PATHOLOGY SPECIMENS
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TEACHING STANDARDS: UP TO THE MARK?
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Bodies of Evidence
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ADVISORY BOARD
Contents
Dr Debra Graves (Chairman)
Chief Executive, RCPA
Dr Bev Rowbotham
Vice President, RCPA
Associate Professor Jane Dahlstrom
Representative, Committee of Deans of
Australian Medical Schools
Dr Tamsin Waterhouse
Deputy CEO, RCPA
PATHWAY
Autumn 2007
Issue #11
Wayne Tregaskis
S2i Communications
PUBLISHER
Wayne Tregaskis
EXECUTIVE EDITOR
Dr Debra Graves
EDITOR
Kellie Bisset
ART DIRECTOR
Jodi Webster
ADVERTISING SALES DIRECTOR
Bronwyn Sartori
PUBLISHING CO-ORDINATOR
Andrea Plawutsky
PathWay is published quarterly for the Royal College
of Pathologists of Australasia (ABN 52 000 173 231)
COVER STORY
Bodies of evidence:
Protecting our pathology museums – a precious medical resource
8
FEATURES
Movers and shakers
Populate or perish: WA and Qld pathologists are getting
impressive results in reversing the workforce shortage
14
In profile
A magnificent obsession: why Professor David Weedon doesn’t
have time for holidays
17
Hot topics
Testing times: how the new HPV vaccine will affect the future of
cytology
21
Spotlight on disease
Clearing the way: a cure for cystic fibrosis still eludes us
26
Foreign correspondence
Mission, possible: Dr Richard Davey is relishing the challenge of
his Papua New Guinea locum posting
30
Disciplines in depth
Getting back to basics: current standards of pathology teaching in
Australia’s medical schools are far from uniform
33
At the cutting edge
The philadelphia experiment: Adelaide researchers are leading
the way on chronic myeloid leukaemia
39
Testing, testing
42
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A tale of two microbes: pathology’s role in rubella and pertussis
PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES
IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE
www.rcpa.edu.au
Cover
Professor Robin Cooke, a published expert on pathology museums,
examines some interesting specimens.
PHOTO: GIULIO SAGGIN
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REARVIEW
PAGE 64
REGULARS
From the CEO
Welcome from RCPA CEO Dr Debra
Graves
4
Under the microscope
News + views
6
The GP view
All in the balance: Dr Linda Calabresi
reflects on the youth of today
20
Conference calendar
67
Postscript
68
Cutting it fine: an early forensic
pathology pioneer left some room for
improvement.
A HAPPENANG THANG
PAGE 48
LIFESTYLE
Travel
A happenang thang: Malaysia has even more to offer this year
as it celebrates its 50th anniversary of independence
46
Private passions
Sax appeal: Dr Richard Steele takes some time off pathology to
indulge his musical side
50
Travel doc
Aegean pearls: Dr Michael Harrison is already dreaming of his
next trip to the Greek Islands
52
Working holiday
Maltese moments: Dr Jane Dahlstrom won’t forget the magical
islands of Malta
55
Recipe for success
A class of his own: Tony Bilson reflects on the state of Australian
fine dining
57
The good grape
Give us this day our daily red: Ben Canaider wonders if you can
get too much of a good thing
60
Dining out
Good morning: Pathway explores some favourite breakfast haunts
61
Rearview
64
On fertile ground: early pregnancy tests aren’t what they used to be
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from the CEO
Welcome
to the first Edition of PathWay for 2007
or those of you who may be reading it
for the first time, PathWay is a unique
magazine in Australian publishing. Now
into its eleventh edition, Pathway is a
publication of the Royal College of
Pathologists of Australasia (RCPA) in
association with S2i Communications,
and is provided to over 30,000 doctors,
medical students, health administrators,
politicians and the general public
throughout Australasia. The purpose of
the magazine is to promote an
understanding of what pathology is and
what pathologists actually do.
F
Most people are unaware that
pathologists are the doctors who
diagnose every detected cancer in the
world and that they are involved in the
diagnosis and monitoring of all acute and
chronic illnesses, such as diabetes, blood
disorders and infections. Even less well
known is that pathologists are also
intimately involved in the management of
these often life threatening conditions.
The RCPA is committed to enhancing
the medical and general communities’
understanding of pathology and hopefully,
at the same time, entertaining you with “a
good read”.
We hope you enjoy this edition of
PathWay, which explores several important
topics, including pathology education.
Our cover story, “Bodies of evidence”
looks at the important part pathology
museums play in teaching medical
students about the pathological basis of
disease. We also highlight that museums
can be used to teach the general public
about the origins of disease. The
University of NSW has an innovative
program opening the museum to school
4_PATHWAY
students and the general public. In fact on
Saturday 3 March, 2007, there will be an
Open Day at the Museum for the general
public. Please see page 7 for details.
been driving these changes and plans to
establish a Centre of Excellence in
Pathology to help address some of the
problems caused by the workforce crisis.
There has been considerable
discussion in the general media in recent
times about medical school curricula and
concerns over the paucity of pathology
and anatomy teaching in some medical
courses in Australasia. In our ‘discipline in
depth’ section, the article “Getting back
to basics” looks into this issue. We speak
with a number of academic pathologists
about their concerns and explore some
solutions to try and address them.
In Queensland, Professor Sunil
Lakhani is rebuilding the University of
Queensland’s Pathology Department.
Being a Queensland graduate myself, it
has been disappointing to see the once
excellent department struggling to survive.
It is really great to see things improving.
Academic medicine in general needs
more support to ensure that there are
robust departments in universities to
provide high quality teaching and
research that is so important in assuring
good medical care. Having such
departments will also hopefully
encourage young doctors to consider a
career in academia. This is even more
pertinent for pathology, where lack of
support from some universities has
meant that pathology departments have
been decimated. As a consequence, the
amount of pathology taught in many
medical courses has been inadequate.
In our ‘movers and shakers’ section,
we highlight two areas where attempts are
being made to improve academic
pathology departments. The University of
Western Australia has, in principle, agreed
to reverse a decision made about seven
years ago to amalgamate the
departments of pathology and surgery.
And the professor of pathology position,
which had lapsed, is to be reinstated. Dr
Peter Flett, Director of PathWest, has
Speaking of academic pathology and
Queensland, we profile Professor David
Weedon, who was a very inspirational
pathologist at the University of
Queensland for medical students (me
included!) in the seventies and eighties.
Now a senior pathologist at Sullivan and
Nicolaides in Brisbane, his passion for
teaching pathology continues at Bond
University. Indeed as a testament to his
dedication the University’s Pathology
Museum bears his name and in 2006 he
was awarded the Bond University Student
Council’s Award for Academic Excellence.
There are many other articles in the
edition which we hope you will find
informative and entertaining. Enjoy!
Dr Debra Graves
CEO, RCPA
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under the microscope: news + views
Prenatal test taking guesswork
out of foetal abnormalities
The pregnancy-associated plasma
protein-A (PAPP-A) test has been used
clinically around the world since 2000
and, when used in combination with
nuchal translucency screening at 10 to 13
weeks’ gestation, can improve Down
syndrome detection rates by 10–15%.
But according to the test’s developer
and RCPA associate member Dr Michael
Sinosich, it is also useful in determining a
pregnancy’s future viability.
Scientific Director of Prenatal Testing
at the Sonic Clinical Institute, Dr Sinosich
said the institute was taking the test one
step further than Down syndrome
detection, where it was most commonly
used.
W
“Even in the presence of normal
ultrasound, you can still identify [with the
PAPP-A test] pregnancies that may fail,”
Dr Sinosich told PathWay.
PHOTO CREDIT: EAMON GALLAGHER
biochemical prenatal screening test
developed in Australia is slowly
changing attitudes towards early
detection of foetal abnormalities.
A
“The biochemistry looks at the
placenta; ultrasound looks at the baby –
sometimes you get a discordancy. The
reality is you can have a placenta without
a baby, but you can’t have a baby without
a placenta, and people are becoming
more attuned to this.”
Dr Sinosich said more women were
learning about the test, and while it was
well known to specialists, many general
practitioners were unaware of it.
“In reality only about 30% of all
pregnancies are screened [using the test],
Dr Sinosich said. “It is available more in
urban teaching centres and not so much
in rural areas.”
problems. It can make an emotional
difference, but also potentially it could
save someone their reproductive function
if they were at risk of losing their fallopian
tubes.”
However, he said the potential
benefits of early diagnosis were important.
Dr Sinosich and the Northern Sydney
and Central Coast Area Health Service
have taken out a patent on the test, which
was licensed by biomedical testing
manufacturer Beckman Coulter.
“Because a fair proportion of early
pregnancies fail, if women have this
marker available it could save them
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6_PATHWAY
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Screening helps babies with
rare metabolic disease
A
ustralian researchers have
shown that neonatal screening
by tandem mass spectrometry
dramatically improves outcomes for
children with medium-chain acylCoA dehydrogenase (MCAD)
deficiency – a genetic disorder that
affects the body’s capacity to break
down fats.
MUSEUM OF
HUMAN DISEASE
OPEN DAY
On Saturday March 3, 2007 the
Museum of Human Disease at the
University of New South Wales will
open its doors to the public. The
Museum contains more than 2,700
specimens and exhibits. The
collection features rare disease
specimens such as diphtheria, and
A study published in The Lancet
(2007;339:37–42) suggested the
screening was effective since early
diagnosis reduced deaths and severe
adverse events from the disorder in
children up to age four.
Honorary RCPA Fellow Professor
Bridget Wilcken* and colleagues
studied nearly 2.5 million patients, a
third of whom underwent neonatal
screening for MCAD deficiency.
Comment by UK and US
researchers published in the same
issue of the journal said the study was
important new evidence that showed
newborn screening seemed to prevent
death in 10% of children diagnosed
with MCAD deficiency. They said
similar research was needed for other
disorders diagnosed by tandem mass
spectrometry.
* Professor Wilcken is the Clinical
Director of NSW Biochemical Genetics
and Newborn Screening at The
Children’s Hospital at Westmead.
Clarification
In the article ‘What is Immunopathology’
on page 42 of our last issue it has
been suggested that some of the
information on training may need
clarification.
There are three categories of
immunopathologists/clinical
immunologists:
• those primarily responsible for
providing laboratory services (for
this you’d generally train as a
pathologist, but may also choose to
train as an internal medicine
specialist)
• those who provide both patient
care and laboratory services
(generally you’d train as both a
pathologist and an internal
medicine specialist)
• those primarily responsible for
patient care (generally you’d train
as an internal medicine specialist,
but may also train as a pathologist).
Those electing to train in both
pathology and internal medicine
generally undertake training that is
supervised and accredited by the
Joint Specialist Advisory Committee of
the RCPA and RACP.
specimens showing the effect of
more common ailments such as heart
disease, stroke, and cancer.
Visitors will be able to view
specimens and exhibits and attend
presentations highlighting specific
conditions.
NOTE: Some individuals, children and
cultural groups may experience
Pathologists recognised in
Australia Day honours
he Fellowship of the college congratulates the following Fellows who received
awards in the honours list, Australia Day 2007.
T
Order of Australia Companion (AC) in the general division
sensitivity due to the nature of the
museum specimens and suitability of
this material should be considered
when planning a visit.
Dr John Robin Warren, Northbridge WA. For service to medicine and medical
research, notably the discovery of the Helicobacter pylori bacterium and its role in
gastritis and peptic ulcer disease.
Member (AM) in the general division
Saturday 3 March 2007
10:00am – 4:00pm
Museum of Human Disease
Ground Floor, Samuels Building
Professor Clive Gordon Harper, Sydney NSW. For service to medicine in
neuroscience, chiefly research into the neuropathological consequences of alcoholrelated brain damage and for input into public health policy.
Bookings are Essential
Dr Svante Rikard Orell, Adelaide, SA. For service to medicine in diagnostic
pathology, chiefly the introduction of fine needle aspiration biopsy, and to medical
training.
For further information please call
Medal (OAM) in the general division
9385 1522 or visit
Professor Donald Murray Walker, Dorset, Britain. For service to oral pathology
and oral medicine as an academic and clinician, and to public health through
research and diagnostic services relating to oral and maxillofacial pathology.
The University of New South Wales
www.hallofhealth.med.unsw.edu.au
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cover story
Bodies
of evidence
AUSTRALIA’S PATHOLOGY MUSEUMS MUST BE PRESERVED
TO PROTECT OUR PRECIOUS MEDICAL HISTORY FOR FUTURE
GENERATIONS OF DOCTORS AND PATIENTS.
DAVE HOSKIN REPORTS.
I
Allen Museum of Anatomy and Pathology, I
can't help feeling he's onto something.
expiring approximately 60 years ago.
Unlike most museums, these
collections are as much about the present
as the past. When a pathology museum at
the university was first proposed in 1859, its
chief aim was not simply preserving the
historical record, but to illustrate
morphology. Specimens were gathered to
demonstrate body structure, to illustrate
disease and to chart the way its patterns
change over time. The result was that
museums such as this became an essential
aid in teaching doctors about disease.
n a way, I'm looking at a murderer. The
victim has been dead a long time,
We know their death was quick, but
the perpetrator of the crime is still present
at the scene. It sits there like a massive
shadow cast over the right-hand side of
the victim's brain – a perfect example of
intracerebral haemorrhage.
Around me are thousands of other
deadly killers, all neatly labelled. Behind
me, the tiny body of a child floats in
yellow preserving solution, the top of its
head ruined by anencephalus. A few
steps onward is a heart, its surface blown
outwards by cardiac infarction.
As I lean closer to the glass, I'm
reminded of an interview in which film
director David Cronenberg talked about
his fascination with the body's interior.
Arguing that there's just as much beauty
under the skin as there is on the surface,
at one point Cronenberg even suggested
there should be a beauty contest for our
internal organs.
It's an odd idea, but standing here in the
University of Melbourne’s Harry Brookes
8_PATHWAY
They have also kept pace with
technology. A visitor to the Museum of
Human Disease at the University of New
South Wales would never know that once
upon a time most of its specimens were
simply stored in jars of alcohol. Today
digital microscopes and virtual
microscopy provide a far closer view on
disease than ever before, and computers
are ubiquitous.
Every exhibit has been completely
photographed and digitised; every image
has been linked to its histology, radiology
and clinical history; every student has
been given a copy of this resource on CD.
>
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PHOTO CREDIT: WARREN CLARKE
PathWay #11 - Text
Professor Denis Wakefield among some pathology specimens at the
Museum of Human Disease, University of New South Wales.
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PHOTO CREDIT: WARREN CLARKE
PathWay #11 - Text
Professor Robin Cooke: many factors have played a part in pathology museums’ decline as a teaching tool.
Modern obstacle course
Despite these efforts to move with the
times, these days many pathology
museums are under threat.
One of the principal reasons is
obvious: running a museum is an
expensive exercise. A successful
collection requires considerable storage
facilities, specialised expertise in
preparing and maintaining specimens, and
many man-hours of hard work to host
quality exhibitions.
“There's less and less funds available
within medical schools and universities to
do these types of things,” explains
Professor Denis Wakefield, head of the
Museum of Human Disease and the
School of Medical Sciences at the
University of New South Wales.
“Often medical schools look around
and say 'where can we cut the cost?',
and one of the obvious places is to get
rid of museums.”
Just as serious is the increasing difficulty
in obtaining tissue specimens. There are a
number of reasons for their scarcity, but one
of the most obvious is simply a change in
accepted medical practice.
10_PATHWAY
The number of specimens obtained
during surgery, for example, has been
significantly reduced.
“It's all done by keyhole surgery,”
Professor Wakefield says.
“You can't bring out a big specimen
that way. You break it all up and suck it
through tubes and you end up with
nothing to show anybody.”
Similarly, because of the demand for
more detailed pathological analysis, more
incisions are being made in specimens
than was previously the case. The result is
that even if large surgical specimens are
retrieved intact, they may be too damaged
to be worth displaying.
The other traditional source for
specimens was autopsies, but
unfortunately, for many reasons the
autopsy rate has dropped to almost zero
in some hospitals.
“Pathology departments are being
pushed,” says Professor Paul Monagle,
head of the Department of Pathology at
the University of Melbourne.
“Autopsies are an awful lot of work,
and unfunded work. There is no Medicare
benefit for an autopsy outside of the
perinatal period.”
A major shortage of anatomical
pathologists in Australia’s teaching
hospitals also hasn’t helped matters.
However, Professor Monagle doubts that
the decrease in autopsies can be
attributed to work practices alone.
“I think the major issue is that our
clinical colleagues often just don't wish to
ask for autopsies anymore,” he says.
“Part of that may be because they
believe they already know why their
patients are dying, and part of that may
be because that, in this day and age, we
have to get full informed consent.
“Many people, when faced with the
prospect of going and asking people 'can
we take the specimen for a pathology
museum?' find that rather daunting and
don't wish to do that.”
In the public interest
This delicate process of obtaining patient
consent is another hurdle for pathology
museums to overcome.
“Probably one of the biggest things
you can do in life is to donate something
of yours,” says Rita Hardiman, curator of
the Harry Brookes Allen Museum.
>
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“There's nothing better than to be able to actually
see disease to appreciate how it works.”
Our pathology museums:
a selection
INTERACTIVE CENTRE FOR HUMAN DISEASES, UNIVERSITY OF SYDNEY
One of the most intriguing items in an Australian pathology museum is an unopened flask of beef
broth. The last of 12 such flasks sent to Australia by Louis Pasteur, the broth was intended to
culture a chicken cholera virus for the extermination of rabbits.
HARRY BROOKES ALLEN MUSEUM OF ANATOMY AND PATHOLOGY,
UNIVERSITY OF MELBOURNE
One of the largest repositories of historical specimens in Australia, notable exhibits include injuries
suffered in World War I and the death masks of bushrangers Ned Kelly and ‘Mad Dog’ Morgan.
RA RODDA PATHOLOGY MUSEUM, UNIVERSITY OF TASMANIA
Many collections reflect the interests of their founders, and this is no exception. Influenced by
Roland Arnold Rodda's fascination with brain disease, the museum has a notable selection of
specimens such as tumours, stroke and Huntington's disease.
MUSEUM OF HUMAN DISEASE, UNIVERSITY OF NSW
As Australia's oldest surviving collection of medical specimens, some of the most intriguing exhibits
are those all but eradicated by modern medicine. A perfect example is the museum's brain and
bone samples of tuberculosis – specimens now impossible to acquire.
HADLEY PATHOLOGY MUSEUM, UNIVERSITY OF WESTERN AUSTRALIA
Another collection distinguished by the interests of a major donor, in this case that of Rolf EJ ten
Seldam. His donations stem from his work in countries such as Indonesia and Papua New Guinea;
the specimens include many advanced malignancies and examples of rare tropical disease.
PATHOLOGY MUSEUM, UNIVERSITY OF ADELAIDE
The museum contains approximately 1300 specimens (some nearly 100 years old) that demonstrate
a wide range of common and important diseases. Updated catalogues include clinical information,
a description and diagnosis of each specimen.
JAMES VINCENT DUHIG MUSEUM OF PATHOLOGY AND
THE MARKS-HIRSCHFELD MUSEUM OF MEDICAL HISTORY,
UNIVERSITY OF QUEENSLAND
The museum contains about 3500 specimens, covering the full spectrum of common disease. Both
museums are currently in the process of relocation, refurbishment and modernisation within the
Royal Brisbane Hospital site.
PATHWAY_11
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“Patients take up the opportunity to donate their
tissue with great gusto.
About 96% of all patients we have contacted
have consented.”
The good news is that
although doctors may be reluctant
to broach the subject, patients
are often very keen to become
tissue donors.
Professor Jane Dahlstrom has
established a Surgical Specimens
Teaching Museum at the Australian
National University Medical School.
Having decided to concentrate solely
on tissue that remains after pathological
assessment, she reports an astonishing
rate of success.
“I think the reason is that generally
people are very giving and see that if the
tissue is of no use to them but is of use
to somebody else, then that's great,”
she says.
PHOTO CREDIT: WARREN CLARKE
“Patients take up the opportunity to
donate their tissue with great gusto.
About 96% of all patients we have
contacted have consented.”
Professor Robin Cooke, a published
expert on pathology museums, also
reports little difficulty in obtaining consent
for retaining organs for demonstration in
teaching museums.
Head of femur showing signs of osteoporosis
and pin to reinforce fracture
“It's very important to treat that with
the utmost respect.”
Consequently, in considering the ethics
of displaying human tissue, pathology
museums err on the side of caution.
Legally, only the donor can veto how
their body is exhibited, but if their family
has a strong objection the museum staff
will do their best to respect their wishes.
In the same vein, as technology plays a
greater part in how people experience the
exhibits (for instance, placing
photographs of specimens online), those
responsible for the museum need to
consider whether this wider distribution is
ethically appropriate.
12_PATHWAY
He says recent unfavourable press
given to the retention of human tissue and
a shift in the attitudes of medical
educators have played a part in the
decline of pathology museums as a
teaching tool.
Seeing is believing
“In the second half of the twentieth
century the philosophy of the medical
teachers has changed,” he contends,
“placing less and less emphasis on the
use of three-dimensional pathology
specimens in teaching medical students
about diseases.”
He notes that this is not a uniquely
Australian problem, with most overseas
museums grappling with similar
difficulties.
However, Professor Cooke believes
that it is the advanced Western
communities that suffer most from this
trend, perhaps because they have more
money available for ancillary testing.
“You cannot do without ancillary
testing,” he stresses, “and it's been a
wonderful advance in the diagnosis of
disease. But I think – and I guess I'm not
alone in this, at least among pathologists
– that the pendulum has swung too far in
favour of relying totally on ancillary
investigations during life for making a final
diagnosis.”
The chief casualty of this trend is medical
students’ ability to think about disease in
three dimensions. Textbooks and photos
are all very well, but they can’t replace the
immediacy of real specimens.
“There's nothing better than to be able
to actually see disease to appreciate how
it works,” Professor Wakefield says. “For
example, if it's a malignancy, how it
spreads, how it causes problems in
adjacent organs and tissues, and then to
relate this to the physical findings that you
find in an individual who happens to suffer
from that disease.”
Professor Dahlstrom also points out
that this interest in specimens is not
confined to those in the medical
profession.
After writing to patients to ask if
they'd be willing to become tissue donors,
a certain number will ring her to ask
questions. Some simply want to know
what she plans to do with the tissue, but
others have a deeper motivation.
“Often when they ring, I know it's
because they really would like to see the
specimen themselves,” she says.
“Often when something's inside of
you, you can't really visualise what it’s
like. Maybe if it's a broken leg you can
see that, but if it's, say, a problem with
your gall bladder, all you can do is
imagine what it must look like. So patients
actually come along and see their own
specimens. And when they do, it often
gives them a bit of closure.”
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This rare opportunity to get a
glimpse of what lies under our skin may
ultimately prove to be pathology
museums' salvation.
PHOTO CREDIT: WARREN CLARKE
Professor Wakefield is quick to
highlight the public's keen fascination in
medicine and pathology, and believes
that tapping into this interest can be of
enormous mutual benefit.
“There are a number of strategies that
people could put into place,” he explains.
“One of them is to make museums
open to the public. Also, turn them into a
profitably run business unit, and this can
be done basically by putting on
exhibitions, putting on education
programs. Not just for the medical
profession, but for the general public.
That's what we've done and that's been
quite successful.”
The result of Professor Wakefield’s
strategy is a true repositioning of the
Museum of Human Disease, moving it
beyond the realms of elite academia and
into the community at large.
The museum staff talk enthusiastically
of queues stretching for hundreds of
yards at each open day, not to mention
the thousands of students that visit every
year as part of their HSC biology studies.
Most rewarding of all is that there
often seems to be a student that is
changed by what they see.
They begin to ask more searching
questions, begin to make connections,
and as they do a career in medicine
suddenly becomes tangible, interesting,
something to aspire to. In this way, as
they walk out the door with heads full of
ambitions, these high-school students
become the most important thing a
museum can produce.
Of course the bones of the past are
important, as is the study of disease in
the present.
But it’s the doctors of the future that
are the most precious things of all.
Volunteer Dr Victoria Velens
at the UNSW Museum of
Human Disease with manager
Robert Lansdown.
VOLUNTEERING:
vitally rewarding
t was an advertisement in the paper that attracted Victor Wong Doo's
attention: the Museum of Human Disease was looking for volunteers to help
run its new community outreach program.
I
“I'm a retired medico, so I thought I could be of some use to the museum,”
says Dr Wong Doo. “I thought it'd be something interesting to do.”
Launched in 1996, the outreach program was intended to raise the
museum's profile in the wider community, focusing particularly on HSC biology
students.
As the visitors explore the exhibits, the volunteers stand ready to help out.
“We explain all the ins and outs of the disease process and answer any
questions they might have,” Dr Wong Doo says.
Most of the volunteers are retired, but they come from a variety of
backgrounds. Dr Wong Doo was a radiologist before he retired, and fellow
volunteer Dr Victoria Velens was a GP.
Some enjoy the social aspect of being part of the team, while others find it
a good opportunity to enthuse young people about medicine.
“I like students,” Dr Velens says. “I like their enquiring minds, and they want
to know things in depth which is rather nice.”
She also feels that the museum can give the students a unique perspective
on disease. “They have all looked at books, they have all looked at the
computer. They're quite surprised when they see it in three dimensions. It
doesn't look the same.”
Museum manager Robert Lansdown is delighted with the success of the
outreach program.
“It's incredibly satisfying,” he says. “And without the volunteers it just
wouldn’t be possible.”
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movers and shakers
Populate or perish
TWO DEDICATED PATHOLOGISTS FROM OPPOSITE SIDES OF THE CONTINENT ARE GETTING
IMPRESSIVE RESULTS IN THEIR BID TO REVERSE THE PATHOLOGY WORKFORCE SHORTAGE.
CATHY SAUNDERS REPORTS.
hen he took on the task of
conducting a detailed analysis of the
pathology workforce in Western Australia,
Dr Peter Flett got something of a shock.
W
“I realised that within 10 years, 40% of
the current pathologists will have either
retired or died,” he says.
Dr Flett was given the challenging task
18 months ago of merging all the WA
public pathology services into one body
he now heads, called PathWest.
And already he is making substantial
progress in shoring up the workforce loss.
The number of new registrar places
increased by three last year, and this will
jump to 10 extra this year, making a total
of 40 registrars in training.
“The plan is for the next five years to
continue to expand as much as possible
to ensure we have adequacy of the
pathologists’ workforce for the future,”
he says.
But more needs to be done, so Dr Flett
has focused on the all-important attraction
and retention rates.
their rates competitive with those offered
by the private sector.
Another drawcard for the profession is
some newly established Fellowships –
funded by PathWest – enabling
pathologists to spend three or six months
overseas on further training in areas such
as cancer diagnosis and genetic testing.
Early success
The strategies appear to be working, and
medical graduates are now waiting in the
wings to take up training places.
“We did a pretty big sell last year and
we were over-subscribed in all the subspecialties,” Dr Flett says, pointing out that
advertisements for the training places
attracted more than double that number of
applicants.
As the workforce shortage is
particularly dire in country areas,
consideration is also being given to
following the lead of the mining industry
and offering fly-in, fly-out work.
Dr Flett has been doing a lot of talking
– not only to governments and pathology
groups, but also to academics.
School of Pathology and Laboratory
Medicine that will train not only medical
but also science students.
All of these strategies add up, Dr Flett
says, to a plan to establish a WA Centre of
Excellence in Pathology which will lure
pathologists from all over the world to
work with highly skilled colleagues in
state-of-the-art applied research
laboratories that are being developed for
each of the sub-specialties.
This he will take one step further.
“You have to not only develop a Centre
of Excellence, but become the employer of
choice,” he says.
“That is being able to be flexible with
what you can offer prospective employees
– if female pathologists only want to work
part time, that is fine by me. And we need
to, sooner or later, be prepared to take on
part-time training of registrars too.”
Dr Flett is also prepared to pay now to
ensure he has a workforce in the future
and is in discussions with Curtin University
about initiating cadetships for science
students in pathology.
He’s doing the hard sell to potential
trainees about the big choice of pathology
sub-specialties, predictable working hours
and the opportunity to be jointly qualified
as a physician and a pathologist, ensuring
clinical skills are not lost.
As a result, the position of professor of
pathology at the University of WA, which
had lapsed, is to be re-established and
applicants are now being called for.
PathWest will pay their HECS fees for
four years and in return, once graduated,
they would be expected to work for the
organisation, possibly for three years and
potentially in rural areas.
The hip-pocket nerve has also been
targeted. This year, WA public pathologists
will enjoy a pay rise of about 25%, making
Moreover, the university has agreed in
principle to split the School of Surgery and
Pathology and create a stand-alone
To keep his current workforce, Dr Flett
has no hesitation in hassling any
pathologist he talks to.
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“You have to not only develop
a Centre of Excellence, but
become the employer of
PHOTO CREDIT: TONY MCDONOUGH
choice.” - Dr Peter Flett
“The message I say to everybody – all
the clinicians – is ‘you can’t retire, you
have to keep working’,” adding that he is
happy to be very flexible with their work
conditions.
“The point about all this is we haven’t
got much time. If we sit on our hands we
are going to be caught. The clock is
ticking on this one.
“I think it is up to us in each of the
states to be far more vocal than we have
been in pathology and take it to the feet of
the ministers who matter and make them
realise that if they don’t do something,
they won’t have a pathology service in 10
years time.”
WA Minister for Health Jim McGinty
says the WA Government sees the
provision of pathology services as a
priority and is confident that the
government-funded health reform
initiatives – which include the strategies to
attract, train and retain pathologists – will
significantly impact on the pathology
workforce.
Meanwhile, back in Qld…
On the other side of the country, University
of Queensland pathology professor Sunil
Lakhani is working to ‘hardwire’ the
relationships between the university’s
pathology department, the Queensland
Institute of Medical Research (QIMR) and
the statewide Queensland Health
Pathology Service (QHPS), which are
independent but which he believes can
help each other on various levels.
Professor Lakhani arrived in Brisbane
in late 2004 to head the university’s
academic department. He and his
research group – now based at the QIMR
– came from the UK to new horizons in
Australia.
His clinical work as a breast cancer
pathologist for QHPS at the Royal
Brisbane and Women’s Hospital means he
has “a foot in each place”.
The first task was to build up the
university department.
“The academic department was pretty
much down to one senior person when I
came,” he says.
“It had been struggling – as have all
academic departments around the world –
chiefly due to an inability to recruit staff.
This is due to a shortage of trained
academics with a strong research
background and the huge differential in
income, which has fallen way behind
compared to that of clinical pathologists.
“Until the government addresses these
issues, it will continue to be so.”
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PHOTO CREDIT: GIULIO SAGGIN
PathWay #11 - Text
“What is needed are good role
models, people who are good
diagnostic pathologists and also
good researchers.”
- Professor Sunil Lakhani
Talks are underway with the
Queensland state government to improve
academic pay rates, but at present the
problems of recruitment continue.
Nevertheless, Professor Lakhani is
pushing on in rebuilding the department.
A French pathologist has been
appointed senior lecturer, an associate
professor who is a non-clinical researcher
heads a laboratory, and there is funding for
another senior lecturer or associate
professor who is yet to be appointed.
Recently, Professor Lakhani gained
extra funding from the university for an
academic pathology registrar who is
teaching and conducting research in the
university department as well as doing
hospital clinical work.
“This position forms part of the
[pathology] training rotations through the
hospitals and the university, in order to
further the links between academic and
clinical departments and to encourage
other trainees who are in the full-time
diagnostic training to rotate into the
academic department,” he says.
Each year, a new registrar will be
offered this position.
“This means that we will slowly expose
the whole pool of registrars to academic
activities in the hope that we can
demonstrate the role of academic work to
our trainees and also rebuild the academic
infrastructure in Queensland.”
Another academic registrar, funded by
the Ludwig Institute for Cancer Research,
has been lured from Brazil on a Fellowship
to do his PhD in Professor Lakhani’s
research laboratory.
It is hoped that his lifestyle of clinical
activity, research, writing papers and
presenting at international conferences will
help to change the ethos and be a role
model for local registrars.
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Professor Lakhani has also established
a link with a medical education unit in the
School of Medicine so that new clinical
registrars who participate in teaching
medical students learn strategies for
teaching and assessing the students.
“This will not only provide valuable
skills to registrars, but will further enhance
the links between clinical and academic
work,” he says.
A further line of attack has been made
possible by his role of running a research
laboratory at the QIMR, which is located
on the same campus as the medical
school and the Royal Brisbane and
Women’s Hospital.
“Having a research laboratory on the
campus means we can get registrars and
other interested colleagues to come and
have a look at how it is possible to do
good clinical work and bring questions
into the research laboratory, in the hope
that answers can be translated into clinical
management of patients,” he says.
“What I am trying to do is to hardwire
relationships between these three
organisations – teaching, research and
clinical work.”
While building up academia, Professor
Lakhani has also been working as a
specialist breast pathologist with QHPS,
where similar expansion and recruitment
has also happened.
There are only a couple of vacancies
for pathologists in the metropolitan area,
and these are for newly funded specialist
positions. Negotiations to fill the only
regional position are underway.
Moreover, according to a spokesman
for QHPS, two new registrar training
positions were approved from last July
and eight were approved from January. All
but one have been filled. Six positions had
also previously been approved in 2005.
For the first time, three of the positions
are for general pathologists who, it is
hoped, will end up working in regional
centres, which are always harder to staff.
The QHPS has chalked up further
success. All but one of last year’s
graduates have opted to stay in the public
system, lured largely by a new package of
improved conditions introduced in January
last year, which include a 7% pay rise and
higher on-call and private practice
allowance rates.
Professor Lakhani says he is getting
good feedback from registrars who are
slowly being exposed to the rewards of
teaching and research in pathology.
“What is needed are good role models,
people who are good diagnostic
pathologists and also good researchers,”
he says.
“When they see how research affects
diagnostic practice and clinical
management, they are able to grasp the
central role that pathology plays in science
and medicine.”
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in profile
A magnificent obsession
TIRELESS ENERGY,
DEDICATION TO DETAIL AND
AN ABILITY TO JUGGLE A
HERCULEAN WORKLOAD HAVE
CATAPULTED PROFESSOR
DAVID WEEDON TO THE
HEIGHT OF HIS PROFESSION.
MELISSA SWEET LOOKS AT
WHAT LIES BENEATH.
risbane pathologist Professor David
Weedon is famous for many things,
including his internationally acclaimed
expertise in skin pathology, workaholism
and dry sense of humour.
B
PHOTO CREDIT: GIULIO SAGGIN
His obsessiveness is also legendary;
indeed he is almost obsessive about
acknowledging this trait, and has the
evidence ready for display when we meet in
his office at Sullivan Nicolaides Pathology
in the leafy Brisbane suburb of Taringa.
First exhibit is his bare desk. It is
always left spotless, he declares proudly.
Years ago, after finishing a stint at the
celebrated Mayo Clinic in the United
States, he was presented with a miniature
dissection board “because I was known
for being so obsessive about it always
being kept clean”.
Next exhibit is a spoon, engraved
“Weedon’s spoon. Hands off.” It was a
present from medical students working at
Sullivan Nicolaides, Professor Weedon
explains, because of his insistence that noone else use his utensil in the tea-room.
>
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“I don’t mind being known as
obsessive,” he says. “Obsessiveness goes
with being a pathologist – one has to be.”
It is a Monday morning but Professor
Weedon has already completed a full shift
– as usual, he started work the previous
evening, finishing his last pathology report
by 6am. He works through the night so the
days can be devoted to other projects,
whether teaching, writing or chairing
committees – and it also means a speedy
response for referring doctors and their
patients.
When asked if his glass collection
includes vases, he responds drily: “You
don’t ever use the word ‘vase’. It’s ‘tall
forms’. I have a few tall forms. I try to avoid
tall forms because too many of them look
like vases.”
deprecating humour could easily obscure
his achievements.
A life less ordinary
But computers are one domain
Professor Weedon has not mastered – his
loyal secretary of 20 years, Pam Kent, runs
his email program – so he may not realise
the multitude of glowing reviews revealed
by a Google search for the second edition
of his landmark text, Skin Pathology.
Most days he grabs no more than four
hours sleep, and it is not unusual for 24
hours to pass without a snooze.
Last Christmas, Professor Weedon
received a copy of an autobiography,
Morbid: A Pathologist’s Life, from Dr
Alastair Burry, who was Director of
Pathology when the young Weedon was
training at Royal Brisbane Hospital in the
1960s. It is inscribed: “To my best pupil.
Didn’t he do well!”
“I do feel tired all the time,” he says,
admitting a tendency towards irritability.
“I am sure it affects my health.”
Dr Burry writes in the book of the
trainee setting a standard that “his fellows
struggled to emulate”.
Professor Weedon has, however, been
known to nod off while queuing through
the night to purchase newly released
banknotes. An avid collector, he has sold
most of his coin and banknote collections
but continues to amass glassworks,
paintings and watches.
“His witty and novel paper on acne
convulsed the audience with laughter and
was followed by loud stamping of
approval,” he adds.
He stopped stockpiling elephants
because “people start giving you cheap
ones for Christmas so you are burdened
by variants you don’t want”.
This is only partly a joke – he then
admits to finding clinical medicine
“demanding emotionally” – but it suggests
that Professor Weedon’s dry, self-
Asked why he chose to specialise in
pathology, Professor Weedon is quick to
reply: “Because I hate people.”
CV in brief
PROFESSOR DAVID DE VAUX WEEDON, AO
(OFFICER OF THE ORDER OF AUSTRALIA)
1964
1966
1983–1984
1995–1996
1996–
1998–2001
BMedSc (Pathology)
MBBS (First-class Honours)
President, Queensland branch, Australian Medical
Association
President, Australian Medical Association
Member, Professional Standards Review Panel
Chair, Medicare Services Advisory Committee
2001–2003 President, Royal College of Pathologists of Australasia
2004–
Chair, Prostheses and Devices Committee
2006
Bond University Student Council Award for Academic
Excellence
2005–
18_PATHWAY
Chair, Steering Committee for the Medical Education Study
As one associate notes, he manages a
workload that would normally exhaust
three people – hence the ‘Superman’ cake
colleagues once bought to celebrate his
birthday.
“The author, who is a well
acknowledged, world known expert in this
field has to be commended for having
painstakingly undertaken this gigantic task
of not only updating his previous edition
but who seems to have given his ‘all’ to
produce this masterpiece,” says one
review.
The third edition, now in development,
will be even more extensive, citing at least
30,000 references, while Professor
Weedon’s book on the pathology of the
gall bladder is also much cited.
Other career highlights include taking
the first photograph of apoptosis in a skin
cell in 1978, and becoming one of a
handful of non-Americans to be made an
honorary member of the College of
American Pathologists, as well as a regular
on the international lecture circuit.
A vision splendid
Apart from his many medical
commitments, Professor Weedon has also
been politically active. He was prominent in
student politics at the University of
Queensland and later joined the Liberal
Party (which once considered him for a
Senate vacancy), until resigning his
membership in 1983, when he became
Queensland president of the AMA.
He remains close to a former AMA
colleague, Federal Minister for Defence Dr
Brendan Nelson, who last year appointed
him to chair a national inquiry into medical
education.
But Professor Weedon is not easy to
pigeonhole politically.
He hated being federal president of the
AMA, largely because of the intrusive
media demands.
“I am not particularly good at thinking
on my feet,” he says. “I think of all the right
things (to say) after the event.”
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Making a difference: In his uni days Professor Weedon was active in student politics, later joining
the Liberal Party before heading the AMA.
He has been a greenie since “before it
was fashionable”, and believes it may be
difficult for the Howard Government to win
the next election because of its slowness
to embrace environmental issues.
“The last major holiday was to write the
last edition of the [Skin Pathology] book,”
he says. “I can’t recall ever having more
than one week’s holiday of relaxation.”
“I think the future is absolutely dismal,”
he says. “This generation has used millions
of years worth of the earth’s basic biologic
products. The current generation, from
about 1950 on, has just been profligate.”
Just your regular superguy
Professor Weedon also feels
passionately about the “immorality” of
banks allowing customers to accrue huge
credit-card debts, the limitations of
problem-based learning in medical
schools, and the need for national
healthcare reform.
“I am a very strong believer that the
states exist to name football teams only,”
he says. “The states promote noncohesiveness in a nation.”
In an ideal world, he says, Australia
would be divided into 10 different regions
responsible for healthcare delivery, with
local representation on regional boards
working to national policies.
Not that he expects such changes in
his lifetime. At 65, Professor Weedon is
obliged to retire as a Sullivan Nicolaides
partner at the end of June, but no-one
expects him to retire from his many other
careers – pathologist, writer, teacher,
committee chair – anytime soon.
No-one, least of all the man himself,
can even imagine him taking a long
holiday. He recently cashed out 13 weeks
of vacation leave.
On Friday mornings, after another night’s
work, Professor Weedon grabs a
McDonald’s hamburger for breakfast. He
eats it, tea towel across lap, while driving
to Bond University at the Gold Coast.
There he gives lectures, tutorials or works
on the pathology museum, named in his
honour, that he has set up.
Last year, he won the Bond University
Student Council Award for Academic
Excellence and, according to Professor
Chris Del Mar, Dean of the Faculty of
Health Sciences and Medicine, is
extremely popular with students, not least
because he pays for their colour
photocopies of his handouts to ensure they
have the best possible materials.
Professor Weedon’s work at Bond
University is honorary.
“I don’t take any money so they can’t
control me,” he says, in what seems
another half-joke. But it doesn’t obscure
another of his well-known traits.
“The most defining characteristic of
David is his enormous generosity,” says a
Sullivan Nicolaides colleague, Dr Richard
Williamson, who was taught by Professor
Weedon at the University of Queensland in
the 1980s.
Professor Weedon is known for being
generous with both his time – including
tutoring individual students – and his purse.
Many have benefited from his largesse.
Ms Kent, who has worked for him for
almost 20 years, says he is liked and
respected by staff because of his
willingness to help and his lack of
grandstanding.
“The side that impresses staff the most
is that he will get in and do the most
menial of tasks,” she says.
“When we had a flood and water
coming inside the building, the first person
out there in the rain, clearing the drain with
his hands, was Dr Weedon.”
Professor Weedon once bought a
hamburger shop on the Gold Coast to help
set up a friend; when the arrangement
didn’t work out, he was known to lend a
hand in the kitchen after finishing his
pathology shift.
It’s a safe bet that he also took the
opportunity to indulge his sweet tooth – he
is not remotely health conscious, despite
having type 2 diabetes (“like the rest of the
world”) and having had open heart surgery.
Professor Weedon feigns horror when
asked if he exercises.
“Heavens no,” comes the quick reply, “I
run down people and leap to conclusions.”
No wonder so many colleagues
call it a pleasure to work with someone
they affectionately tease as a “grumpy
old man”.
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the GP view
Reality check
MAYBE TODAY’S YOUNG DOCTORS COULD TEACH THE REST OF THE PROFESSION A THING OR
TWO, WRITES DR LINDA CALABRESI.
from teaching or working for a division, to
research or assisting in surgery.
ou know you’re getting old when you
find yourself whingeing about the
‘youth of today’.
Y
Others pursue interests outside
medicine. Some simply opt to reduce their
consultation hours and work part time.
That’s exactly what I was in the throes
of doing at a recent lunch with similarly
aged friends.
But generally speaking it appears
variety is the goal, rather than seeking an
alternative career or better remuneration.
We were united in our bemoaning of
how Generation Y has, almost by
definition, a strong sense of entitlement,
despite having yet to prove their worth or
demonstrate their commitment to a job or
a profession.
From the perspective of the medical
world I quoted examples of young doctors
who weren’t interested in working long
hours or doing after hours, who appeared
to put their commitment to their family
before ensuring their patients were
medically looked after around the clock.
It’s that variety that appears to create
a better work–life balance. And perhaps
our more mature new breed of doctors
already know that.
Dr Calabresi is a practising GP and Editor
of Medical Observer
We were certainly on a roll…
On reflection, however, I believe the
reality is – as always – not so black
and white.
Recent statistics from an Australian
Institute of Health and Welfare report on
the medical labour force showed the
number of full-time equivalent GPs fell
from 102 per 100,000 people in 2000 to
98 in 2004.
This is despite an increase in the
actual number of GPs, and directly relates
to GPs choosing to work fewer hours.
Attributing this trend solely to young
doctors preferring to work part time would
be simplistic at best, and unlikely to be
borne out on further analysis, just as
laying the blame on that other common
lament – the feminisation of the workforce
– has been shown not to be the single
culprit in the trend toward fewer
consulting hours.
It would seem this trend is more a
reflection on society as a whole. ‘Work–life
balance’ is the new catch-cry. And
considering the nature of the work, it is
not surprising this phenomenon has
become evident in general practice.
20_PATHWAY
No matter how rewarding general
practice can be, seeing large numbers of
patients all day, every day, five or six days
a week, is emotionally exhausting for
most people.
By the time medical students
complete the prerequisite university time,
hospital time and GP training course, they
are more likely to be in their 30s (rather
than their mid 20s, as was the case a few
decades ago).
Ten years more life experience must
make a difference to a person’s priorities,
especially when those 10 years may have
included finding a life partner and maybe
starting a family.
They will be entering general practice
at a point at which those of us who
started younger didn’t arrive until much
later, after many years working in the
profession.
Trying to meet each patient’s
expectations, be attentive to their
complaints and vigilant for any hidden
pathology or any opportunity for
preventive care is challenging. Especially
when the process needs to be repeated
and recorded with the same enthusiasm
and attention to detail every 15 minutes
over 30 times a day.
If we admire the maturity and
experience in the newest members of our
profession then, to a certain extent, we
have to expect that those qualities will
also be employed when they are looking
at their work schedules and entitlements.
I know there are GPs out there who do
this, many of whom have been doing it for
years. They genuinely have my unqualified
respect and admiration.
It’s those qualities that will have
them seeking variety in their work from
the outset, and making work–life balance
a priority.
However, for the majority of GPs I
have met over the years, such a schedule
would be considered too gruelling and a
recipe for burnout at the very least.
Whether this is better or worse, who
can say?
By necessity, luck or design, the
majority of GPs I know vary their working
week by including elements other than
face-to-face consultations. These range
But the statistics support the premise
that the ‘youth of today’, at least in
medicine, have the same ideals as the
rest of us.
So maybe I need a new topic of lunch
conversation.
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hot topics
PHOTO CREDIT: EAMON GALLAGHER
Testing times
WHAT WILL THE NEW HPV
VACCINE MEAN FOR THE
FUTURE OF CYTOLOGY?
KATE WOODS REPORTS.
here is no denying it.
The advent of the prophylactic human
papillomavirus (HPV) vaccine has been
one of the most exciting recent
developments in medicine.
T
It promises to prevent more than 90%
of genital warts, eliminate at least 70% of
cervical cancers and save the lives of up
to 300 Australian women each year.
And with the vaccine now part of the
National Immunisation Program Schedule
and therefore more affordable for a
significant number of women, these
predictions could become reality before
too long.
But while there are undoubted
national advantages to an HPV vaccine,
it’s not all good news for cytology. If the
mood among cytopathologists is a little
more reserved, it’s because this latest
development has thrown up some tricky
issues regarding the future of their
discipline.
The Pap smear process of course
involves the role of scientists working as
cytology screeners, as well as
cytopathologists trained in anatomical
pathology.
When a sample is taken from the
cervix and placed on a slide, the cells
are viewed by cytology screeners, who
detect any abnormalities and refer them
on to the cytopathologist for review and
a final diagnosis.
An existing shortage of
cytopathologists however, could be
compounded in this new landscape,
according to one of the vaccine’s
developers Professor Ian Frazer.
A weakening of expertise among
established cytopathologists and cytology
screeners and the potential for laboratory
performance measures to become
outdated once the vaccine’s impact starts
to be felt, are other hurdles to be cleared,
he says.
Same work, just
different
“The vaccine won’t alter the screening
program for cervical cancer because
firstly, most of the people vaccinated will
be young women and the screening
program is aimed at women aged over 20
years,” Professor Frazer says.
“Secondly, the vaccine only protects
against 70% of the strains that cause
cervical cancer, so even in a vaccinated
population, screening will still be needed.”
But while the workload will remain
constant – the same number of Pap
smears will still cross the desk – Professor
Frazer says that the chances a smear will
be abnormal will be significantly reduced.
In fact, he predicts that over the next
8–10 years there will be a 75% drop in the
number of abnormal smears, and 50% of
these will be high-grade abnormalities.
As a consequence, the National
Pathology Accreditation Advisory
Council’s performance measures – which
outline the number of abnormalities
laboratories and pathologists are required
to see over a set period of time – will
need to be revised, he says.
Dr Marion Saville, director of the
Victorian Cytology Service, agrees. She
says full-time screeners currently see
about 200 Pap tests each week, of which
one is generally a high-grade abnormality.
But if the prevalence of high-grade
abnormalities falls by 50%, she says this
figure would drop to one a fortnight.
“There will also be a reduction in the
positive predictive value of these highPATHWAY_21
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PHOTO CREDIT: EAMON GALLAGHER
Dr Gabriele Medley:
“There are many
pieces that need to
be fitted into this
complex jigsaw.”
grade reports purely on the basis of
reduced prevalence,” she adds.
and a member of the RCPA Cytopathology
Dr Gabriele Medley, head of
cytopathology at Melbourne Pathology
standards need to be revised will depend
Advisory Committee, says whether the
on whether there are eventually fewer labs
Prophylactic vaccines:
a profile
p to three-quarters of all sexually active people acquire the human
papillomavirus (HPV) at least once during their life, making it the most common
sexually transmitted viral infection in the world.
U
But with two HPV prophylactic vaccines – one already approved for use, the
other on its way – experts are hoping this could soon change.
The first vaccine, Gardasil, is a quadrivalent vaccine made up of highly purified
‘virus-like’ particles based on the recombinant capsid protein L1. These particles
induce a strong humoral immune response to protect people against HPV types 16
and 18 – which cause 70% of cervical cancers – and types 6 and 11, which account
for about 90% of genital warts.
While the vaccine has been shown to be almost 100% effective, duration of
protection beyond five years is still unknown.
The second is a bivalent vaccine known as Cervarix. It has not yet been
approved for use but manufacturer GlaxoSmithKline says it is hoping for some
positive news soon.
While the two vaccines work in a similar manner, Cervarix’s L1 capsid protein
was produced using a recombinant baculovirus propagated in insect cells, while
Gardasil’s was produced using transgenic yeast.
Cervarix targets HPV types 16 and 18, but may also protect against HPV types
31 and 45, which are responsible for up to 10% of all cervical cancers. If approved,
GSK is hoping it will be indicated for women aged 10–55 years.
A number of therapeutic vaccines have also been developed, but most are still
undergoing early-phase trials.
around the country performing
gynaecological cytopathology.
“If we end up having fewer
laboratories doing more smears because
of the cost of the machines and the
shortage of cytopathologists and
cytoscreeners, the current [NPAAC
measures] would be fine,” she says.
“But if the current laboratory structure
is to persist then yes, they may need to
be revised.”
Dr Saville warns a drop in
abnormalities could lead to further
workforce shortages, with lecturers
already seeing some reluctance from
science students to choose cytology as a
major area of study.
“Informally we believe this is due to the
publicity about the vaccine and students’
belief that this skill will not be relevant for
the entirety of their working lives.”
As a result, it’s possible we could see
a decline in the capacity to report Pap
tests before there is a decline in demand.
To further complicate matters,
anatomical pathologist Dr Nick Mulvany
believes it will become increasingly
difficult for established anatomical
pathologists to maintain their expertise in
cytopathology over the coming years.
“People need to see a certain volume
of material to become and stay good at
diagnosing abnormalities. With fewer
abnormal cases coming through, I strongly
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be financial 'trade-offs' because these
suspect it will become more difficult for
cytologists to pick them up.”
Dr Nick Mulvany:
maintaining expertise.
additions won’t be cheap.
Then there is the issue of training.
“It may well be that we will need to
“This is a highly subjective field – it’s
have a two-tiered screening system where
more subjective than histology and
those who have been vaccinated are
certainly more difficult and more subtle
screened every five years and those who
in its interpretations,” says Dr Mulvany,
haven't are screened every three years,”
senior anatomical specialist pathologist
Dr Medley suggests.
at the Austin and Mercy Hospital in
“There are many pieces that need to
Melbourne.
be fitted into this complex jigsaw, and I
“Trying to get consistency from one
cannot stress too strongly the importance
institution to another is and will become
of dealing with the Cervical Cancer
an increasing problem.”
Screening Program as a whole, and not in
a piecemeal way.”
Technological boost
In contrast, Dr Saville believes it will
Dr Mulvany suggests the solution may
be far too complex to introduce two
be to introduce liquid-based cytology
different screening programs.
Instead, she suggests it may be
PHOTO CREDIT: EAMON GALLAGHER
and automated screening.
ThinPrep and SurePath are the two
liquid-based cytology devices currently
available in Australia.
Compared to the Pap smear, these
tests are easier and quicker to examine
because they produce slides containing
cells that are evenly distributed in a
A computer-assisted primary
screening system has also been produced
women commence cervical screening to
age 25 – after vaccination – and then
using the HPV test as the primary
screening tool and cytology as a follow-up
for those who are HPV positive.
This method is currently being trialled
overseas. “The main drawback of this
concentrated area, without obscuring
agents such as blood and mucus.
worthwhile moving the age at which all
looks for evidence of the viruses that
cause the abnormal changes.
The federal government’s Medical
for use in association with the tests.
Services Advisory Committee is expected
Currently being trialled in a number of
to review a proposal to fund liquid-based
strategy in the current environment is that
at 25 years of age about 20% of women
can be expected to test positive for
high-risk HPV.
“However, if almost all women had
Australian laboratories, this system
cytology in combination with DNA testing
been vaccinated, then the proportion of
locates and displays potential abnormal
later this year.
women testing positive to high-risk HPV
could be expected to dramatically decline.
cells for cytologists to view.
Dr Paul Shield, chief scientist at
Sullivan Nicolaides Pathology, says
preliminary trial results suggest the
automated device provides at least an
equivalent level of sensitivity to manual
screening, but higher productivity.
If it does prove successful, it could
help reduce the problems associated with
maintaining expertise and staff shortages.
Vaccine not the whole
answer
While it’s still uncertain whether these
tests will become standard practice, Dr
Medley says the assumption that cervical
cancer – and therefore cervical screening
– will disappear with the vaccine is a very
simplistic view of the situation.
The vaccine's duration of protection
This will improve the specificity of HPV as
a primary screening test.”
Whatever happens though, with a
number of new technologies available at a
time when vaccination is also to be
introduced, all decisions must be
evidence-based, Dr Saville argues.
“We should be anticipating the
evidence that would be needed to support
remains uncertain, and the community
change and be proactive about trying to
technology – use the machines to do the
has not yet fully accepted the need to
get the evidence if it is not already
searching and the trained scientists or
immunise all children, she says.
available.”
“This would be a good way to use the
pathologists to do the interpretation.”
Dr Medley says liquid-based cytology
has the added advantage of being able to
be used for high-risk (HR) HPV DNA testing.
Unlike the Pap smear (designed to
pick up abnormal cell changes in a
woman’s cervix), HR HPV DNA testing
Also, many unvaccinated women
Dr Medley agrees all changes and
remain at risk of developing cervical
introductions need to be evidence based,
cancer.
but says good evidence favouring the new
However, if we do move to a system in
which cells are assessed using HR HPV
technology is available.
“So far, the reason it has not been
DNA testing and are then prescreened by
taken up is because of the costs, not
automated technology, there will need to
evidence.”
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inview
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Coloured scanning electron micrograph of
melanoma cells, the most serious of human
skin cancers.
Melanoma is a tumour of melanocyte cells
that produce the melanin pigment in skin.
Here, large rapidly dividing (malignant)
cancer cells are seen with tiny projections
which enable the cells to be motile and to
spread.
Melanoma is able to spread from the skin
through the blood, lymph, or across a body
cavity to other parts of the body.
This cancer is most common in people
exposed to strong sunlight for a number of
years.
PHOTO CREDIT: NATIONAL CANCER INSTITUTE / SCIENCE PHOTO LIBRARY
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spotlight on disease
Clearing the way
ADVANCES IN OUR UNDERSTANDING OF CYSTIC FIBROSIS HAVE SEEN GREAT LEAPS IN
OUTCOMES FOR PATIENTS, BUT A CURE REMAINS ELUSIVE. MATT JOHNSON REPORTS.
mbedded in the walls of nearly every
cell in your body are small pumps.
E
Made of protein, they are constantly
working to maintain the delicate
chemical balance required for cells to
function normally.
Depending on the protein and cell
they inhabit, they can permit, assist or
reject the passage of sodium, chloride,
potassium and a host of other
electrolytes.
Suffer a mutation of the gene that
instructs these pumps and, for the sake of
a few electrolytes, your lungs can become
congested and inflamed, your pancreas will
struggle to provide the enzymes necessary
to digest your meals, your liver can fail,
and your life expectancy plummets.
Cystic fibrosis (CF) occupies an
uncomfortable place in modern medicine.
The genetic cause of the disease was
established as early as 1949, when
researchers investigating the disease’s
pattern of inheritance suggested it was
produced by a single defective gene. It
took another 35 years to localise that
gene, and during that time sufferers would
rarely reach adolescence before their
lungs failed.
With knowledge comes hope,
however, and identification of the gene
sequence in 1989 offered the possibility of
curing one of medicine’s more cruel
26_PATHWAY
conditions. Indeed, life expectancy has
more than doubled in the past 40 years to
a median age of 37.
But there is still no cure. While one
school of research has discovered how a
faulty protein causes the disease and
tested a number of potential cures, the
improvements in morbidity and mortality
have come from another camp of
researchers, which has been working to
identify the disease as early as possible,
isolate the pathogens that accelerate its
progression, and develop better nutrition
and physical therapy. The latter group has
improved the length and quality of life of
people with CF, but with the knowledge
their patients will ultimately succumb to
the disease.
The genetic component
The CF gene lies on the long arm of
chromosome 7 and produces a protein
that determines a cell’s ability to move
chloride and other ions across the cell
membrane. Early attempts to identify this
protein found high levels of salt in the
sweat of CF patients, whose glands, it was
discovered, are impermeable to chloride.
Subsequent studies of epithelial cells
from the airways of these patients also
provided evidence of a chloride
permeability defect in the lungs.
The protein was eventually identified
and named the cystic fibrosis
transmembrane conductance regulator
(CFTR). It’s found in membranes of cells
that line the lungs, liver, pancreas and
reproductive tract.
In patients with CF, the dysfunctional
(or absent) CFTR protein causes the lungs
to produce a thick, extremely viscous
mucus. Unable to clear this mucus, the
CF lung is susceptible to chronic infection
with pathogens such as Staphylococcus
aureus and Pseudomonas aeruginosa that
are nearly impossible to eradicate once
established. Inflammation from the
dysfunctional CFTR and chronic infections
create a cycle of tissue destruction and
airway obstruction that, over a long period
of exacerbations and partial recovery,
eventually leads to respiratory failure.
In the pancreas, the large quantities of
thick, viscous mucus block the flow of
digestive enzymes through the ducts,
food cannot be properly absorbed and
weight gain is limited. Eventually the
blockages can cause cysts and scar
tissue to develop that ultimately may
cause diabetes.
Mucus can also block the bile ducts,
and 98% of men with CF are infertile
because of blocked seminal vesicles.
The discovery of elevated serum levels of
immunoreactive trypsinogen (IRT) in
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PHOTO CREDIT: PAUL WRIGHT
PathWay #11 - Text
“The expectations for patients with CF are so much better today, and probably the main reason
is because we have much more coordinated care.” - Professor Peter van Asperen
infants with CF resulted in the first
community-wide newborn screening
programs for the condition in NSW in
1981. Since then, all Australian states
have introduced newborn screening.
The initial screening programs
conducted an IRT test on day four, with a
second test at six to eight weeks for
infants who returned a positive result on
the first test. A second positive result
would prompt a sweat test, in which the
amount of sodium in the child’s sweat
was analysed.
The discovery of the gene responsible
for CF added genetic analysis to the
screening program, and all states in
Australia now use a combined IRT/DNAbased screening regime. An IRT is now
performed between 48 and 72 hours after
birth, and infants with an elevated IRT
have a CFTR gene mutation analysis
performed from the same blood sample.
Screening struggle
Professor Bridget Wilcken is the Clinical
Director of NSW Biochemical Genetics and
Newborn Screening at The Children’s
Hospital at Westmead in Sydney and an
Honorary Fellow of the RCPA.
“Different parts of the world have
responded differently to newborn
screening, with some more enthusiastic
than others,” she says.
“In some places it’s been a struggle.”
Here, she is referring to an ad hoc
committee of North American
paediatricians who suggested that the
testing wouldn’t be sensitive enough to
pick up pancreatic insufficiency and that
identification would stigmatise the child
and interrupt mother/child bonding.
Professor Wilcken struggles to
understand this continued reluctance.
“The test has proved both accurate
and sensitive, and it’s now quite clear
there is a benefit in early diagnosis of CF:
there’s a lot of data that children
diagnosed at birth don’t get as sick early
in life, they spend less time in hospital,
they get better nutrition earlier and there
are fewer childhood deaths.
“There have also been some studies
linking late diagnosis to poor nutrition and
subsequent poor intellectual
development,” she adds.
“You get improved lung function with
early diagnosis – and while it’s a big
shock for most parents, you have to
remember the alternative is a prolonged
period of various illnesses while they
search for a diagnosis.”
While genetic analysis has made
testing for CF more accurate, the nature
of the mutation means not every newborn
with the disease is identified.
“The common deltaF508 mutation
represents 75% of all mutations,”
Professor Wilcken explains, “and as
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Identification of the gene sequence in 1989 offered the possibility of curing one of medicine’s
more cruel conditions. Indeed, life expectancy has more than doubled in the past 40 years
to a median age of 37.
94–95% of babies who have CF will have
at least one copy of this mutation, we only
test for that common mutation in NSW.”
Funding at present doesn’t allow
Professor Wilcken’s service to routinely
test for the other mutations, a process
that would require an extra $34,000 a year
to identify just one extra case.
subsequent pregnancies, with studies
showing about two-thirds of parents
would alter their reproductive activity if
they were aware of their genetic status.
Ensuring access
“It’s not an aim of newborn screening to
“But mutation testing will become
easier as technology develops, and if we
were able to test for six or seven
mutations we could cover half the babies
we don’t find at the moment. We’re
constantly considering it and it will be
included eventually.”
identify carriers but can be useful for
While the genetic component of the test
has added a degree of certainty to the
diagnosis, it has also raised issues for
parents. Part of Professor Wilcken’s
program directs parents to genetic
counselling.This includes parents of
children with the disease, as well as those
who are carriers.
screening, she argues.
Counselling includes advice on
prenatal testing for parents prior to
children will find themselves patients of
parents, and we need to ensure they have
access to the counselling they need,”
Professor Wilcken says.
And while the move towards prenatal
testing is probably unavoidable, it
shouldn’t be at the cost of newborn
Despite advances in screening,
children with CF will still be born and, until
a cure is discovered, their quality and
length of life will depend on treatment of
the disease.
Once identified, many of these
Professor Peter van Asperen, head of the
CF: incidence and inheritance
Department of Respiratory Medicine at
The Children's Hospital at Westmead.
“The expectations for patients with CF
are so much better today, and probably
the main reason is because we have
much more coordinated care,” he says.
“Sure, we don’t have a cure, but
we’re developing better treatments and
we’re delivering those treatments much
more effectively.”
The thick mucus produced in the
lungs of CF sufferers obstructs airflow, but
also allows viruses and bacteria to
colonise the lungs. These infective
exacerbations and the inflammation they
cause accelerate the respiratory failure.
But they also offer a potential avenue for
therapeutic control.
“While there was a lot of expectation
when the gene was discovered, there
unfortunately hasn’t been a lot of progress
– and until there’s a cure, treatment is
really aimed at slowing the progression of
the disease,” Professor van Asperen says.
“The principles are basically: mobilise
the thick secretions and reduce the
infections. The most recent area to
emerge is using new therapies to treat the
inflammation.”
Individuals who become symptomatic will have two copies of a
mutated CFTR gene, one from each parent.
Oral steroids have been shown to improve
outcomes in CF, but they also carry
significant side effects. The search for
better anti-inflammatory drugs has
recently uncovered azithromycin: an
antibiotic that also appears to have antiinflammatory properties.
Carriers will have one normal and one mutated CFTR gene and
their health will not be affected. However, carriers have the
potential to pass on the gene to their offspring. Brothers and
sisters of affected individuals are at increased risk (one in four)
of having CF because both parents will be carriers.
“The control trials have been good in
patients with advancing lung disease,
but there are also promising results
coming from trials in patients with early
lung disease.”
If two carriers of the mutated CFTR gene have children, there is a:
The other area of focus is the removal
of secretions and there are several
therapies Professor van Asperen says can
be effective.
CF is one of the most common life-threatening autosomal
recessive conditions affecting Caucasians. The incidence is
1/2500 to 1/90,000, depending on the population. It is uncommon
in Asians and Africans.
•
one in four chance their baby will have CF
•
one in four chance their baby will not have CF or carry a
CFTR mutated gene
•
two in four chance the baby will not have CF, but will carry
one CFTR mutated gene.
28_PATHWAY
“Inhaled hypertonic saline softens the
mucus and makes it easier to clear and,
given with a bronchodilator, it’s an
inexpensive, safe and effective therapy.
We’re currently also assessing mannitol to
see if it has a similar effect.”
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Until then, experts had thought a sugar
called alginate thickened the secretions,
but when UQ researchers analysed the
substance they found far more DNA than
alginate. This has led to the development
of a new type of drug that breaks down
the DNA in the film, reducing the tenacity
of the mucus and allowing antibiotics to
attack the pathogen.
Controlling the colonisation of
P. aeruginosa is a major focus for Professor
van Asperen as studies show that
eradicating early infections dramatically
slows the disease.
“We’re trying to learn more about the
organism, more about its colonisation,
about the possibility of vaccination – but
we’re also taking a very different approach
to infection control,” he says.
Within his hospital, CF patients with
Pseudomonas (and other common
infections) are segregated from those who
remain unexposed to the organism.
“The practicality varies with different
hospitals, but we’ve set up age-based
clinics where preschool-age patients start
and remain until they are colonised with
Pseudomonas. We then have school-age
and adolescent clinics, where the majority
of patients have Pseudomonas.”
Another change has been to develop
chest physiotherapies and breathing
techniques to assist lung function that can
be performed by the patient without
needing to visit a clinic.
“It not only allows patients to be more
independent, but it leads to later
colonisation.”
And when the treatments are no
longer effective, Professor van Asperen
now has the option of using bi-level
positive airway pressure and continuous
positive airway pressure – devices to
assist with breathing - that can bridge
PHOTO CREDIT: PAUL WRIGHT
Perhaps the most significant recent
breakthrough occurred when researchers at
the University of Queensland (UQ)
discovered that common bacterial
pathogens in CF, Pseudomonas aeruginosa,
glued themselves together with a ‘biofilm’
to protect themselves from antibiotics.
“There’s a lot of data that children diagnosed at birth don’t get as
sick early in life, they spend less time in hospital, they get better
nutrition earlier and there are fewer childhood deaths.”
- Professor Bridget Wilcken
patients with end-stage disease to a
lung transplant.
“Outcomes from transplants are
improving all the time and they are now a
serious option for end-stage patients.
Until we find a cure, they are our only
opportunity to improve the eventual
outcome of the disease.”
Towards a cure
Nearby, clinical geneticist and genetic
pathologist Professor John Christodoulou,
Director of the Western Sydney Genetics
Program, will not put a time frame on a
genetically modified viruses, others have
used lipid capsules, and others are trying
to get naked DNA into the cells.
“They all have their positives and
negatives, but the major issue is the
consistency and efficiency of the delivery.”
Far from being despondent, Professor
Christodoulou (who recently became an
RCPA fellow) is confident the techniques
will eventually be found, and until then,
learning more about the hundreds of gene
mutations that contribute to CF will allow
researchers to provide a more accurate
prognosis and effectively treat the disease.
“Since we’ve discovered the mutation
cure, but he is confident it will one day
we’ve identified a much wider spectrum of
emerge.
CF, and we now find patients with milder
“Understanding of the genetic basis of
forms of the disease, like men presenting
CF has improved our understanding of the
at infertility clinics. It’s these people that
disease and how other treatments could
may give us a better understanding of
be effective, but despite a lot of work and
how to treat – and then ultimately, cure –
hype, gene therapy is struggling to
the disease.”
provide a cure,” he notes.
“The problem for gene therapy is
delivering the corrected gene to the target
tissue. Some researchers have tried using
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
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foreign correspondence
PHOTO CREDIT: DR RICHARD DAVEY
Mission, possible
A LOCUM POSTING IN PAPUA NEW GUINEA HAS SEEN CHEMICAL PATHOLOGIST DR RICHARD
DAVEY TACKLE EVERYTHING FROM OTITIS MEDIA TO THE THREAT OF BIRD FLU.
KIM COTTON REPORTS.:
O
n the surface, Dr Richard Davey’s
practice appears to be as typical as
that of any other physician.
Dr Davey is the medical counsellor at
the Australian High Commission in Papua
New Guinea (PNG).
“Every other week there is someone
with a middle-ear infection. There are kids
always bursting, busting, breaking or
slicing open themselves and have to be
sown back up,” he says.
His 400 patients comprise the
Australian diplomatic, AusAID, Australian
Federal Police and Australian Defence
Force community employed by the
Australian government to work at the
mission, along with their families.
But it soon becomes apparent that Dr
Davey’s workday presents challenges not
faced by most doctors practising from the
relative comfort of Australia.
The looming threat of avian flu, for one.
“Our clinic male and female external
toilets you can hardly get into because of
the boxes of masks and gowns,” he says.
“There are parts of my consulting room
that I can hardly move in because there
are boxes of the anti-influenza drugs.”
30_PATHWAY
Aside from tending to bladder
infections, the odd pulmonary embolism
and “a lot of respiratory-related infections
because the air in the dry season gets
absolutely foul”, the Melbourne-born
chemical pathologist also advises the Head
of Mission on public health issues such as
the potential risk of avian influenza.
Cases of the virus in domestic birds
have been reported by the World Health
Organization in the Indonesian province of
West Irian Jaya (West Papua), and it is only
a matter of time before it presents in PNG.
“Avian influenza is a matter I had
thought a little about before coming here
and rapidly had to research more
intensively, and now keep a very close
handle on,” Dr Davey says.
“The border between West Papua and
PNG is just a line on a map and the birds
and the virus are not going to respect the
line. Once the thing turns to human-tohuman transmissibility, the aim would be
to keep the mission open as long as
possible to help the Australians who can
go home, go home.”
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Dr Richard Davey is keen to help raise
pathology standards in PNG.
Left: Port Moresby, PNG.
PHOTO CREDIT: JOE IVAHARIA
Charting new territory
Dr Davey arrived in PNG in May 2006,
having decided to spend his two years’
long service leave as a locum abroad.
He officially retires from his post as
chemical pathologist at Royal Melbourne
Hospital in December next year.
While he’d considered working with an
international aid organisation, he first
approached the Department of Foreign
Affairs and Trade (DFAT) and within a
week was touching down at Jacksons
International Airport in the PNG capital,
Port Moresby.
Two months turned to four months
and now Dr Davey will stay until
November before looking at other DFAT
locums in Burma, Laos, Indonesia, East
Timor or Cambodia.
This is his third visit to PNG – once as
a student and twice in his current role.
And while he’s familiar with the territory,
he still finds the pathology standards
difficult to accept.
“The pathology availability in the town
is roughly like what you would have found
in Australia in 1960,” he says.
“There is modern technology to do the
assaying, but the range of assays
available is extraordinarily limited – you
can’t even get thyroid function tests. They
have to be sent to Cairns.”
To compensate, he has had to be
more clinically alert than would otherwise
be demanded in conditions where
pathology is advanced. But he believes
his training in general pathology in the
1980s has given him an edge.
“People like myself who trained as
general pathologists back then are getting
thinner on the ground.
“What you did then was two to three
years of histopathology and one year
each in chemistry, haematology and
microbiology. It was almost like doing
your medical degree all over again from
the point of view of aetiology.”
During his time in PNG, Dr Davey is
not interested in popular challenges such
as trekking the Kokoda Track: “I have
seen the countryside and have read the
books and can mentally put the two
together,” he laughs.
Five things
you didn’t know
about PNG
However, he is keen to see
pathology standards raised in the
postcolonial country.
•
“Pathology does need to be better
regulated up here because some of the
results coming out of the laboratories are
physiologically untenable. They couldn’t
be the results from a live human.”
There are more than 800
indigenous languages spoken
in the country.
•
The world’s largest butterfly,
the Queen Alexandra
Birdwing Butterfly, with a
wingspan of up to a foot is
found only in Oro Province,
Papua New Guinea.
•
Discussions are currently underway with
the Royal College of Pathologists of
Australasia and the National Association
of Testing Authorities.
Portuguese explorer Don
Jorge de Meneses is credited
with naming the principal
island "Papua" - a Malay
word meaning frizzy hair.
•
It is a delicate project Dr Davey
believes will occur over a decade, with
its viability dependent upon
collaboration with the local authorities
and medical fraternity.
Papua New Guinea is one of
only three places on earth
with snow capped tropical
mountains.
•
Life expectancy is 55.7 years.
Tuberculosis prevalence is
448 cases to every 100,000
people.
Having met another two pathologists
in PNG who have the RCPA Fellowship a bacteriologist and a haematologist – as
well as a histopathologist who trained in
the UK, the possibility of developing
national standards is taking shape.
Making inroads
“If in one year, one could set
something in train that over the next five
to 10 years could lift the game of the
practice here bit by bit, that would be
something useful,” he says.
“The key to success is convincing the
local people that they have done it
themselves and indeed, if they haven’t
done it themselves, then it won’t
succeed.”
Sources:
Ethnologue: Languages of the World, Fifteenth
edition
AusAID
Department of Foreign Affairs and Trade
World Wildlife Fund
United Nations Development Programme Human
Development Report 2006
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disciplines in depth
Getting back
to basics
HOW DO CURRENT STANDARDS OF
PATHOLOGY TEACHING IN AUSTRALIA’S
MEDICAL SCHOOLS STACK UP?
PAM WILSON INVESTIGATES.
ike a pilot learning to fly without
knowing the workings of a plane,
medical students emerging as doctors
without a solid understanding of the first
principles of medicine is risky business.
L
Twenty years ago, medical schools
were renowned for producing doctors
who could pick an enlarged liver in
seconds, but had little idea how to break
the news to a patient.
Now there is concern medical schools
have gone too far the other way and are
marginalising the disciplines of pathology
and anatomy.
If there is one thing pathologists,
doctors, medical educators and
students agree on it’s that pathology is
the basis of all medicine and is vital to
medical education.
However, it can be difficult to find
enough pathologists to teach the growing
number of students. And there are
concerns that pathology has a low profile
among policymakers who control the
funds required to put it higher on the
agenda in medical schools.
Dr Debra Graves, CEO of the Royal
College of Pathologists of Australasia
(RCPA), feels the increasing emphasis on
integrated curriculum and problembased learning are factors contributing
to the downgrade of pathology in
medical education.
She is concerned that the basic
principles of medicine are being taught in
an ad hoc fashion and that students are
simply not being taught enough histology,
anatomy and pathology.
It is also worrying that many university
lecturers teaching pathology are not
specialists in the field, she says.
“It was a pretty dramatic change when
they started restructuring the curriculum
10 or 15 years ago. In relation to the
amount of pathology in the courses, it
was a total change of philosophy as to
what medical students should get taught.”
Dr Graves concedes that universities
have difficulty employing specialists
because most academics are poorly
remunerated and a workforce shortage
means many pathologists simply don’t
have time to teach as they are coping with
huge diagnostic workload demands.
But she feels that if universities put
pathology higher on their agenda, this would
go some way to attracting specialists.
Rules of attraction
The RCPA developed a core pathology
curriculum in 2002, but uptake has been
slow. Dr Graves says it has only been
adopted by ‘passionate pathologists’
eager to boost pathology within their
curriculum, and adds that those
universities teaching pathology well all
have dedicated academic pathologists at
the helm.
At the universities where pathology is
not taught extensively, students are
emerging with a reduced knowledge in the
first principles of medicine, she says.
The decreased exposure to pathology
also means fewer are choosing it as a
specialty. “We are noticing that,
particularly from the universities where we
know there isn’t much pathology taught,
the number of graduates wanting to do
pathology is much lower,” she adds.
This is bleak news given there is
already a serious shortage of pathologists
across Australia. The country has lost 70
pathology positions over the past
decade, and faces an uphill battle to get
funded training positions from
governments to replace the rapidly
ageing pathology population.
A lack of teaching around how
pathology integrates with the clinical
process also means many young
doctors will not know what pathology
tests to order, what they mean and how
they relate to the clinical process, Dr
Graves says.
“If you don’t know what you’re
ordering or what you’re looking for, you’re
probably going to order inappropriate
pathology tests and not use the resources
as wisely.”
Dr Graves is hopeful the federal
government’s Medical Education Study
into undergraduate-level medical
education in Australia will go some way to
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Dr Angela Barbour, head of the
Department of Pathology at the
University of Adelaide, believes the
increased focus on integrated
assessments in many medical schools
means students are not forced to
become competent in pathology.
“They can pass without reaching a
certain standard of knowledge in pathology
and other subjects such as anatomy.”
She also believes the change to nongraded passes in some schools reduces
the incentive for students to improve
and excel.
From the ground up
Eminent general practice educator
Professor John Murtagh agrees most
medical students are graduating without
sufficient knowledge in the basic
medical sciences including anatomy,
pharmacology and pathology.
But he’s not sure how big a problem
this will be long-term for the nation’s GPs.
PHOTO CREDIT: EAMON GALLAGHER
Doctors truly begin to learn their trade
when they graduate and begin work as
interns under supervision, he says.
“So the doctors will learn because
they simply have to, but they may not be
so efficient or discriminate in their
ordering of pathology tests and other
investigations such as imaging.”
Professor Paul Monagle with med students Kah
Lok Chan and Helen McDougall: “Students learn
things off by heart, but we don’t get them to
that core basic knowledge”.
highlighting these problems and make
recommendations to help rectify the
situation. The study’s supervising
committee will meet again in June before
it can produce its report.
Sydney, former Director of Forensic
Medicine at Westmead Hospital and now
works as a regional forensic pathologist
with Queensland Health Scientific
Services.
However, she insists the responsibility
largely lies with medical schools and their
commitment to ensuring students are well
educated in the most important
disciplines. “There needs to be an
underpinning in the first couple of years of
[student] training where they get
dedicated pathology training by
pathologists.
He agrees that the amount of didactic
teaching has dropped dramatically in
recent years.
“In the latter stages of the course,
there needs to be involvement with
pathologists who are in practice.”
going to be prodding around people’s
Dr Peter Ellis is a former senior
lecturer in pathology at the University of
Inadequate assessment of pathology
is also a concern.
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“I’ve had students observe autopsies
and … for a large number of them it was
the first time they had seen the inside of a
body,” he says.
“It’s a concern when you have
someone who is within 12 months …
abdomens hoping to find an enlarged liver
and they have never seen one before.”
Professor Murtagh, Adjunct Professor
of General Practice at Monash University,
argues that the quality of medical
graduates in Australia remains superb and
that the relative lack of training in the
basic sciences does not put patients at
any increased risk.
“The risk comes from poor clinical and
communication skills, which still remains
the core focus of undergraduate
education,” he says.
Ask students their opinion and they
are happy with the status quo. When the
Australian Medical Students Association
(AMSA) conducted its Medical Education
Survey last year, the verdict from more
than 600 reviewed responses was that
the amount of pathology taught was
‘just right’.
But AMSA President Rob Mitchell
says medical schools can’t rest on their
laurels. “Medical education is constantly
evolving and in a climate where student
numbers are increasing exponentially it’s
important that in new models of curricula
we maintain a balance … and don’t forget
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that an emphasis needs to be placed on
pathology,” Mr Mitchell says.
“This has never been the responsibility
of the RCPA,” she says.
He adds that the survey also found
that students valued problem-based
learning, but felt it only worked if they first
had a scientific basis to work from.
“We are a member-based organisation
with responsibility for post medical degree
pathology education and while we try to
influence pre medical degree education
Further, he feels the university has a
strong teaching team.
And while they were happy with some
self-directed learning, they felt it shouldn’t
replace traditional teaching styles
delivered by trained doctors.
“We’re lucky in Brisbane as we have
support from public hospital colleagues –
at a consultant and training level – as
well as from pathologists in the private
sector who help with the teaching
program”.
Resource issues
Proponents of problem-based learning
and integrated learning feel the problem is
not with the style of curriculum or how it
is applied.
One university acknowledged as
making great inroads in pathology
education is the University of New South
Wales (UNSW).
They blame a lack of teaching
resources in the clinical years, increased
student numbers, increased student
workloads and a lack of authority by the
medical fraternity over policymakers.
Professor Nick King, head of the
Department of Pathology, says that while
the curriculum is integrated, he thinks
pathology is well represented in the first
two years.
But he does agree pathology needs a
higher profile and more teaching
resources throughout Australia.
“The way to address the problem …
is by increasing the number of teachers
or the College committing more of its
own resources to doing this in a more
formal environment.”
Professor King feels it’s time the
RCPA, educators and practising
specialists came together to discuss
creative ways to solve the problem and
persuade policymakers to boost the
profile of pathology.
“If the College took the lead, they
would be in a better position to dictate
what the government changed, rather
than the government dictating to them.”
Dr Graves says the college would
welcome the opportunity to sit at the table
and discuss with universities ways of
addressing this critical issue.
But she points out that it’s not the
college’s role to commit resources to
university education.
Cutting through
In the past six years, its Department of
Pathology has won an unprecedented
nine faculty- and university-level awards
for pathology teaching.
PHOTO CREDIT GIULIO SAGGIN
The University of Sydney was one of
the first medical schools to move to a
graduate course 10 years ago and is now
conducting a major review of its
curriculum.
electronic format followed by didactic,
small-group teaching sessions to discuss
the lecture. Professor Lakhani feels
pathology teaching at the school is strong
and may even improve after teaching
methods are reviewed.
Dr Peter Ellis: worried students have
insufficient anatomy knowledge.
via developing generic curriculae and
encouraging pathologists to teach, we
have no direct role in delivering university
courses. This is a funding responsibility of
the universities themselves.”
Leading by example
The University of Queensland is also
reviewing the way it teaches pathology to
accommodate increasing numbers of
medical students.
Sunil Lakhani, Professor of Molecular
and Cellular Pathology, says the increase
in student places from 320 to 400 has
made it necessary for electronic and
digital technology to supplement
traditional didactic teaching.
Although first-year students will still
have a lecture-based program, the
teaching for year two is under review as
the school simply doesn’t have enough
lecture theatres to accommodate 400
students.
From 2008, second-year students
may receive some lectures in an
“This is quite a remarkable
achievement given the present situation,
with the dramatic changes that have
occurred in medical education,” explains
Professor Denis Wakefield, head of the
university’s School of Medical Sciences.
The department’s success is partly
due to Professor Wakefield’s approach to
building a strong teaching team of
academic pathologists.
He has created openings not only for
pathologists who have a primary interest
in teaching pathology, but for those
involved in clinical research who have
teaching skills they can offer and for those
available for part-time fractional
appointments.
UNSW Faculty of Medicine Director of
Academic Projects Professor Rakesh
Kumar says the department can also
attribute its success to the fact that
pathology was well represented on every
curriculum committee when the medical
program underwent a restructuring
process from 2002.
“We made sure it was seen not just as
a basic science, but as a clinical science,
and we worked hard to ensure it was not
diluted and lost,” he says.
The University of Melbourne’s School
of Medicine is also driving hard to put
more pathology back into its curriculum.
Professor Paul Monagle, head of the
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“They … have represented pathology
Department of Pathology, says despite
students getting more than 102 hours of
dedicated pathology and additional
integrated problem-based learning
teaching in the first five semesters, it’s still
not enough.
reverse the trend the school has
“[Students] learn things off by heart,
but we don’t get them to that core basic
knowledge where they can think about a
disease process and work from first
principles about what the likely
pathological process is.”
University Medical School (ANUMS) is
seems many academics are now
ensuring clinical and anatomical pathology
conscious of the need to slow the
are very well represented. There are about
process and consider the impact
345 hours of face-to-face teaching for
various external pressures have on
anatomical pathology per year, and at
medical education.
Professor Monagle, who is also
director of haematology at the Royal
Children’s Hospital, adds that much of
what is taught is the pathological basis of
disease and not the use of a pathology
service in the real world. In a bid to
appointed a clinical pathologist who
at all levels of governance and planning in
works part time in hospital to bring that
the ANUMS, from early in its gestation to
‘cutting, real-life edge’ of pathology into
its delivery.”
the curriculum.
The shift in medical education has
been rapid and all encompassing, but it
Meanwhile, the Australian National
least another 100 for clinical pathology.
With this awareness and the call for
greater communication within the
“ANUMS has a high-profile team of
pathologists, [and a] high profile in the
pathology sector, perhaps we are on the
school and the local medical community,”
cusp of a new shift that will eventually see
explains Dr Julia Potter, Professor of
first principles put high on the agenda
Pathology at the school.
once more.
UNIVERSITY OF SYDNEY - graduate entry
Pathology:
what’s on offer
Student numbers
Intake of 284 for 2007
Face-to-face
teaching
Pure pathology includes 26 hours of lectures, 60
hours of practicals and 72 hours of self-directed
learning topics in Years 1 and 2. There are also
additional sessions integrated with other disciplines
In Years 3 and 4 it is delivered off-campus in
hospitals
Staff
7 academic staff
nsw
UNIVERSITY OF NEW SOUTH WALES - undergraduate entry
Student numbers
270 per year of the six-year course (from 2007)
Delivery
PBL, CBL, practicals, lectures
Face-to-face
teaching
Academic staff heavily involved in face-to-face
teaching in Phase 1 and 2 (Years 1 to 4). Exact
hours difficult to estimate due to integrated
curriculum, but Phase 2 has at least 40 lectures and
170 hours of practical class teaching per year
Conjoint academic staff in hospitals teach through
Phase 3
Assessment
Integrated. Case-based, modified essay questions,
single best-answer questions similar to MCQs
Student numbers
80 per year in each of the four years
Staff
7 academic staff; plus additional sessional
pathologists and doctors
Face-to-face
teaching
N/A (fully integrated). But there are defined
pathology outcomes and competencies and it’s
considered an essential element of the course
Delivery
Experiential learning (scenario-based) with lectures,
scenario group sessions, practicals (including
integrated histology/histopathology practicals) and
tutorials
Staff
N/A as teaching is too heavily integrated. School
has numerous staff and honorary commissions
Delivery
Assessment
Integrated. Short answer, MCQ, extended matching,
OSCE
Integrated. This is a new-style clinically driven and
outcomes-based course. Lectures, CBL (no PBL),
practicals, tutorials, specimens
Assessment
Integrated. Multi-station examinations similar to
OSCEs, extended matching, written questions and
assignments, short answer
UNIVERSITY OF WESTERN SYDNEY - undergraduate entry
Student numbers
115 to 120 per year
Face-to-face
teaching
Largely integrated so difficult to be exact; in Years 1
and 2 there are at least 2–3 hours of pathology per
week
UNIVERSITY OF WOLLONGONG - graduate entry
UNIVERSITY OF NEWCASTLE - undergraduate entry
Student numbers
120 per year
Face-to-face
teaching
About 50 hours for the course
Staff
From 2007 a senior pathologist will be Adjunct
Professor, with further university staff appointed in
due course
Staff
Delivery
Uses University of Melbourne curriculum for Years
1 and 2, which is integrated. PBL, CBL, CD-ROM
interactive, lectures, practical classes, tutorials and
videos of autopsies
No on-campus staff. Pathology teaching is
delivered by the Hunter Area Pathology Service as
required by the university
Delivery
Integrated. Pathology and its links to clinical
medicine are a part of all exams. MCQ, short
answer, OSCE
Fixed resource sessions, clinical pathological
conferences (CPCs). The uni is working on
introducing a web-based pathology curriculum
Assessment
Integrated. OSCE
Assessment
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Key
CBL
case-based learning
PBL
problem-based learning
MCQ
multiple-choice questionnaire
OSCE
objective structured clinical examination
act
THE AUSTRALIAN NATIONAL UNIVERSITY - graduate entry
Student numbers
Total of 250 in 2006
Face-to-face
teaching
Integrated curriculum. Pathology introduced as a
discipline from Week 1 of Year 1. Minimum of 345
hours per year of anatomical pathology, plus a
minimum of 100 hours of clinical pathology
Staff
Delivery
Assessment
qld
Student numbers
Intake of 84, plus 149 in Years 2 and 3 (2007)
Face-to-face
teaching
Integrated. In 2006, 18 hours in Year 1, and 60–80
hours per year from Year 2; plus incorporated into
PBL
Staff
4 academic staff, plus additional sessional
pathologists and doctors
Delivery
Lectures, tutorials. No PBL
Assessment
Stand-alone. MCQ, pathology pots, short answer
6 pathologists, 3 registrars for anatomical
pathology; 12 pathologists and 3 registrars for
clinical pathology. Plus additional sessional
pathologists and doctors for both
PBL, practicals, lectures (Years 1 and 2)
CBL, practicals, laboratory, lectures, autopsies,
web-based (Years 3 and 4)
Integrated and stand-alone. Mini-case, MCQ,
extended matching, essay, OSCE
vic
GRIFFITH UNIVERSITY - graduate entry
Student numbers
Intake of 150 for 2007
Face-to-face
teaching
4 hours per week
Staff
2 academic pathologists
Delivery
Lectures, PBL, practicals, web-based
Assessment
Integrated. MCQ, short answer and mini-case
MONASH UNIVERSITY - undergraduate at Melbourne and Malaysia
campuses; graduate entry at Warrigal campus (opening in 2008)
Student numbers
Intake of 220 at Monash Melbourne; 50 at Monash
Malaysia in 2007, expanding to 100 in 2008
In 2008, the Warrigal campus is opening with an
intake of at least 130
Face-to-face
teaching
Year 1 has 36 hours, Year 2 about 60 hours, Year 3
about 120 hours
Year 4 still to be developed, Year 5 has 6 hours
Staff
About 30, plus 6 trainees
Delivery
Lectures and practicals (Years 1 and 2), tutorials
and internet CBL (Year 3), patient-based (Years 5
and 6)
Assessment
Integrated. MCQ (Years 1 and 2), extended
matching and OSCE (Year 3), assessment by case
supervisors (Years 5 and 6)
UNIVERSITY OF MELBOURNE - undergraduate and graduate entry
BOND UNIVERSITY - undergraduate entry
JAMES COOK UNIVERSITY - undergraduate entry
Student numbers
About 100 in Years 1 to 3, and 71 in Year 4 (150 per
year from 2008)
Face-to-face
teaching
Approximately 14 hours per week in Years 1, 2 and 3
About 10 hours plus clinics in Year 4
Staff
10–14 tutors for each year, teaching tutorial groups
of 10 students. Most large classroom teaching is
done by in-house medical specialists and visiting
clinicians
Delivery
Tutorials, PBL, lectures, lab sessions with web
resources
Assessment
Integrated. End of year exam has written papers
consisting of MCQ, key features paper. Practicals
consist of OSCEs
UNIVERSITY OF QUEENSLAND - undergraduate and graduate entry
Student numbers
Increasing from 320 to 400 per year
Face-to-face
teaching
Year 1 has 15 hours of lectures
Year 2 has 35 hours of lectures, 12 hours of
practical tutorial classes and 3 hours of
autopsy/coronial symposium and an autopsy
observation session
Year 3 and 4 is dependent on clinical firms
Student numbers
Intake of 330 for each year
Face-to-face
teaching
102 hours of lectures, seminars and practical
classes in first 5 semesters. Pathology also
incorporated into PBL. More pathology covered in
semesters 8 and 9 through tutorials in hospitals and
CD-based interactive learning
Staff
15–16 staff
Staff
Delivery
PBL, CBL, CD-ROM interactive, lectures, practical
classes, tutorials, videos of autopsies. Semesters 6
and 7 are an elective research year
3 full-time academic appointments (plus 1 vacant)
and 25–30 sessional lecturers, hospital consultants
and registrars
Delivery
Integrated. In practical exams, there are some
dedicated path questions. MCQ, short answer,
OSCE
Small group tutorials, PBL, practicals, tutorials,
autopsies. Some lectures may be replaced by a
web-based program from 2008
Assessment
Integrated. MCA, short answer, OSCE, mini-case
Assessment
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UNIVERSITY OF ADELAIDE - undergraduate entry
Student numbers
130 per year; intake of 144 for 2007
Face-to-face
teaching
More than 22 hours for Years 1 to 3, plus
incorporated into PBL. About 13 hours in Years 4, 5
and 6
Staff
3, plus sessional input from other pathologists
Delivery
Lectures, practicals, PBL, question and answer,
tutorials
Assessment
Integrated. MCQ, short answer, practicals, OSCE
FLINDERS UNIVERSITY - graduate entry
Student numbers
120 in 2007, 135 in 2008
Face-to-face
teaching
Integrated, so difficult to estimate exact hours. For
Years 1 and 2, there are 1–4 hours per week
In Year 3 there are flexible delivery options, but less
face-to-face than Years 1 to 2
Staff
At least 6 staff delivering the anatomical pathology
course, some of whom are sessional
Delivery
PBL, CBL, lectures, practicals, tutorials, web-based,
autopsy, electives
Assessment
Integrated. MCQ, short answer, mini-case, extended
matching, OSCE
wa
NOTRE DAME UNIVERSITY - graduate entry
Student numbers
Face-to-face
teaching
80 each in Years 1 and 2, plus an intake of 100 for
2007
Year 4 still being developed
At least 54 hours in Year 1, 94 hours in Year 2, 100
hours in Year 3
Complemented by micro/path components and
autopsy teaching (introduced in 2007 for Year 3)
Staff
2 (Year 1), 7 (Year 2), 3 (Year 3)
Plus additional clinical academics
Delivery
PBL course, plus lectures, practicals, tutorials and
CBL
Assessment
Integrated. Case-based scenarios, short answer,
OSCE
UNIVERSITY OF WESTERN AUSTRALIA - undergraduate entry
tas
UNIVERSITY OF TASMANIA - undergraduate entry
Student numbers
120 per year
Face-to-face
teaching
Approximately 10 hours per week in Years 1 to 3.
Integrated, but still highly represented
Staff
6 university pathology staff, plus about 10 sessional
pathologists in the public sector
Delivery
Lectures, practicals, integrated tutorials and CBLs.
As many face-to-face small groups as possible
Assessment
Integrated. Mini-case, MCQ, short answer, extended
matching. Clinical case scenarios
new zealand
UNIVERSITY OF OTAGO - undergraduate entry
Student numbers
Intake of 220–240 students into the Dunedin
campus. For Years 4 to 6, the cohort splits, with
some students going to the Christchurch and
Wellington campuses
Face-to-face
teaching
Year 2 has 41 hours of case-based sessions and
lectures
Year 3 has 38 hours of case-based sessions
Years 4 and 5 have 50 hours per year
Staff
35
Delivery
CBL, web, practicals, lectures, autopsies, tutorials
Assessment
Stand-alone and integrated. Format varies
according to year; short answer, EMCQ, OSCE
UNIVERSITY OF AUCKLAND - undergraduate entry
Student numbers
About 150 in each of the 6 years
Also offer undergraduate and postgraduate
pathology papers to science students with
enrolments of 20–25 for postgrad papers and
50–250 for undergrad papers
Face-to-face
teaching
Year 2 has about 63 hours
Year 3 has about 60 hours plus, incorporated into
integrated learning and four to six pathology
lectures in each year
About 10 hours of tutorials and CBL in Years 4 and 5
Student numbers
216 each for Years 3 and 4 (pathology only taught in
these years)
Face-to-face
teaching
Four hours a week in Year 3, and about 1.5 hours in
Year 4
Staff
15, plus hospital staff delivering laboratory
medicine tutorial program
Staff
16–20 (includes sessional lecturers)
Delivery
Lectures, practicals, CBL, web, self-assessment,
combined anatomy and pathology museum
Delivery
Lectures, tutorials, web-based
Assessment
Assessment
Stand-alone. MCQ and short answer
Stand-alone and integrated. MCQ, short and essay
written questions, OSCEs in Year 5 assessment
38_PATHWAY
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at the cutting edge
The Philadelphia experiment
AN ADELAIDE RESEARCH INSTITUTE HAS BEEN QUIETLY LEADING THE FIELD IN CHRONIC
MYELOID LEUKAEMIA, HELPING TRANSFORM IT FROM A TERMINAL INTO A CHRONIC
ILLNESS. LOUISA DEASEY REPORTS.
PHOTO CREDIT: EAMON GALLAGHER
P
rofessor Timothy Hughes has long
held a fascination with chronic
myeloid leukaemia (CML).
of chromosomes 9 and 22, called the
In 1989 as a leukaemia research fellow
at London’s Hammersmith Hospital, the
Director of Haematology Research at
Adelaide’s Institute of Medical and
Veterinary Science (IMVS) was given the
opportunity to work with the world leader
in CML research, John Goldman.
causes two important genes to come
Eighteen years later, Professor Hughes
and his team at the Institute are
considered world leaders themselves, at
the forefront of groundbreaking research
into treatment of the disease.
abnormal behaviour of these leukaemic
In Australia, CML currently afflicts
about 200 new patients per year. It is a
cancer of the bone marrow, caused by a
mutation within a single bone marrow cell.
This mutation is an unusual rearrangement
Philadelphia chromosome.
The fusion of chromosomes 9 and 22
together, producing a fused gene,
BCR–ABL. This new gene produces the
BCR–ABL protein that is responsible for
driving abnormal growth of this mutated
cell, which rapidly divides to produce
billions of copies of itself. All of the
cells can be attributed to the BCR–ABL
protein. This protein is an overactive
tyrosine kinase enzyme that signals the
cells to keep dividing.
CML treatment in the 1990s involved
interferon therapy (which left patients
feeling like they permanently had the flu)
or bone marrow transplants, which can
cure some patients but are high risk.
Both were unsatisfactory treatments
compared to a breakthrough discovery
in 1998.
The development of the tyrosine
kinase inhibitor Glivec (imatinib mesylate)
sparked an exciting time in CML research.
The drug, manufactured by Novartis,
worked by blocking the tyrosine kinase
protein that drove the disease, and was
one of the first ‘kinase inhibitor’ agents
found to be effective in cancer therapy.
This discovery saw many new areas of
CML investigation open up, and Glivec
turned out to be all the researchers had
hoped, offering a 90% success rate in
blocking disease progression.
Five years after the first group of
patients started taking it, 90% of them
were still alive. The challenge now is to
increase the response rate closer to 100%.
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“A physician in New York recently told me that a patient in New York
could not get a BCR–ABL assay for CML. In Australia, virtually every
PHOTO CREDIT: RANDY LARCOMBE
patient is being monitored using the PCR assay.”
Professor Timothy Hughes and senior research scientist Deborah White have
developed a predictive assay that assesses a patient’s sensitivity to Glivec.
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The Institute’s molecular
breakthroughs
Because of his previous work on CML,
Professor Hughes had been busy forming
a team to focus on molecular research
into the disease. So when patients in
Australia and around the globe began
taking Glivec in 1999, the Institute had
already started diagnostic research into
monitoring treatment response and
predicting drug resistance and relapse.
It was a case of perfect timing.
The Institute’s CML laboratory was
specialised and set up so that as soon as
patients started taking the new drug, the
team was monitoring exactly how it
worked, when it didn’t, and how this
could translate into predicting patient
outcomes on the drug.
In 1997, Dr Susan Branford (PhD) had
formed the Institute’s CML molecular
laboratory, to work on developing a highly
accurate and sensitive molecular assay,
which tested the levels of the BCR–ABL
gene using polymerase chain reaction
(PCR) tests and thus monitored a patient’s
response to treatment.
Over two years, Dr Branford worked
with Professor Hughes (an RCPA fellow),
developing this sensitive PCR assay,
which is now at the forefront of global
CML monitoring and research.
Senior research scientist Deborah
White, who has worked at the Institute for
25 years, manages the CML research
laboratory. With Professor Hughes she
developed a predictive assay that
assesses an individual patient’s sensitivity
to Glivec therapy.
She explains the mechanism of action
for this predictive assay:
“In cases of CML there is a
phosphorated form of a protein called
CRKL. By then giving the drug to the cells
in a test tube, we look at changes in the
level of phosphorated CRKL with drug
exposure.
“It essentially means at diagnosis we
can predict, with a reasonable degree of
certainty, how a patient is going to
respond and whether they’ll need a dose
increase, or whether they’d be better on a
different drug.”
To a patient, this knowledge can mean
receiving the most appropriate therapy
right from the start, rather than waiting for
a poor response to standard therapy
before making a change.
Knowing that resistance to Glivec is
mainly due to mutations of the BCR–ABL
gene has led the researchers to theorise
that second- and third-generation kinase
inhibitors currently under development
might be able to specifically target these
mutations and offer an even more
successful treatment option for patients.
Most patients in Australia enrolled in
clinical trials of the newer kinase inhibitors
for CML are monitored by Professor
Hughes and his team using the assays
they have developed. As well as
Australian patients, the Institute oversees
CML patients undergoing clinical trials
from Asia, South Africa and North and
South America.
Achievements honoured
Since starting at the Institute, Professor
Hughes and his team have produced a
number of internationally published
papers on their work. Their laboratory was
one of only three in the world to conduct
a study monitoring the impact of Glivec
on newly diagnosed CML (N Engl J Med
2003;349:1423–32), which proved the
drug’s effectiveness in reducing BCR–ABL
levels for those with CML, compared to
interferon therapy.
The Institute's laboratory testing,
analysis and quantitative research into
CMLwas also recognised last year, with
Professor Hughes receiving the Eric
Susman award for the most outstanding
contribution to the knowledge of any
branch of internal medicine by a fellow of
the Royal Australasian College of
Physicians.
But there is still more work to be
done. The Institute’s PCR assay to
measure serum levels of BCR–ABL is still
not a standardised test across the world.
In an effort to make this happen,
Professor Hughes and his team recently
published a paper on the accuracy and
benefits of BCR–ABL testing in Blood
(2006;108:28–37).
“America has been very slow to adopt
PCR monitoring for patients,” Professor
Hughes says.
“A physician in New York recently told
me that a patient in New York could not
get a BCR–ABL assay for CML. They are
still relying on an assay developed 50
years ago to monitor their patients. In
Australia, virtually every patient is being
monitored using the PCR assay.
“The first thing I look at when I see a
patient is their PCR result. Without PCR
monitoring, we only know the patient is in
trouble when resistance is already quite
advanced.”
Though it may be a year or two off
from standardising the assay
internationally, the Institute is currently
standardising 16 other laboratories
around Australia.
These are exciting times for the
Institute and for CML research in general
as we teeter on the brink of even more
dramatic developments in leukaemia
research.
“Some patients have had dramatic
responses to Glivec where we can’t
detect any leukaemia in their blood or
bone marrow for several years,” Professor
Hughes says.
“The question then becomes, do they
actually need to take Glivec anymore?
We’re now conducting a study in Australia
where patients who have had negative
PCR assays on every single occasion for
two years and who want to be part of the
study, stop the drug and then we follow
them closely with PCR tests.”
To have reached this point after the
drug has only been available in Australia
for seven years is very much due to the
work of Professor Hughes and his team.
But he says haematologists from all
around Australia have contributed to the
research effort, through the Australasian
Leukaemia and Lymphoma Group.
Associate Professor Andrew Grigg,
deputy head of the Royal Melbourne
Hospital haematology department, says:
“The IMVS is a world-class centre
conducting groundbreaking research
which has been published in a number of
front-line journals. On a global level,
they’re up there with the best of them.”
Perhaps the most exciting aspect
about our new knowledge of CML is the
long-term benefit for patients, Professor
Hughes says.
“Those of us working in CML have
been riding a wave of exciting progress
that has turned a terminal illness into a
chronic one, and provides hope that a
cure based on drug therapy alone may be
around the corner.”
Declaration of interest: Professor Hughes and
his team receive research funding support
from the Leukaemia Foundation of Australia,
the Cancer Council of Australia, the NHMRC,
and several pharmaceutical manufacturers
including Novartis.
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testing testing
A tale of two microbes
RUBELLA IS ON ITS WAY OUT, BUT PERTUSSIS REMAINS A SIGNIFICANT PUBLIC
HEALTH CHALLENGE. TONY JAMES REPORTS ON PATHOLOGY’S ROLE IN
CONTROLLING THESE INFECTIOUS DISEASES.
wo diseases, two vaccines, and two
persistent cough. Some experience
very different stories.
more serious disease, with
Vaccination against pertussis
complications such as pneumonia
T
(whooping cough) and rubella (German
and problems from sustained, forceful
measles) has been routine for many years,
coughing, ranging from urinary
but there’s little similarity in the recent
incontinence to inguinal hernia and
history of these diseases.
pneumothorax. About 7000–10,000
While pertussis persists as a common
respiratory disease in adults and continues
to challenge the medical profession,
rubella is close to being eliminated.
cases a year are notified in Australia,
with distinct epidemics occurring in
addition to a stable background level
of infection.
Although some immunity is
Pertussis at large
provided from the mother at birth, this
wanes quickly, so a first vaccination as
Pertussis, caused by the bacterium
soon as possible after two months is
Bordetella pertussis, is highly infectious.
essential. Pertussis vaccination has
Between 70% and 100% of non-immune
long been included in routine childhood
people living in the same household as
vaccination schedules, in combination with
an infected person are likely to develop
diphtheria and tetanus (DTP).
the illness.
However, pertussis remains a public
also a factor. In the first year after a primary
course of three injections there is virtually
100% protection against fatal or severe
disease, but only 90% protection against
typical disease and 70% against mild
health challenge worldwide due to the
disease. Immunity after vaccination has
typically causes a persistent and
continuing high rate of disruptive
been estimated at 4–12 years, compared
distressing cough and can lead to severe
respiratory disease beyond childhood, the
to up to 20 years after natural infection.
complications including pneumonia,
failure of vaccination to provide sustained
seizures and brain damage. The infection
protection, and a risk of complacency
causes about 250,000 deaths a year in
about routine childhood vaccination.
In babies and young children, it
developing countries, but vaccination
Despite widespread vaccination,
Adults are an important source of
infection for vulnerable infants, so a number
of countries have recommended boosters
after childhood. The NHMRC suggests a
programs have made fatalities a rarity in
pertussis has never been eliminated from
developed countries, with Australian
booster can be given at any age from eight
any population. In fact, increased infection
years onwards, and recommends that it be
authorities usually recording only one or
rates have been described in some
considered in adolescents aged 15 to 17,
two deaths each year.
developed countries, but the reason for
for both partners planning a pregnancy, for
Pertussis causes much less severe
this is far from certain. Better diagnosis
adults working with young children in
disease in older children, adolescents and
might account for part of the rise, and
healthcare or child care, and in any adult
adults, who might have just a simple but
incomplete protection from vaccination is
expressing an interest.
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Pertussis remains a public health
challenge due to the continuing high
rate of disruptive respiratory disease
beyond childhood... and a risk of
complacency about routine
PHOTO CREDIT: PAUL WRIGHT
childhood vaccination.
Above: Dr David Mitchell: “Much of the data on the epidemiology of pertussis is unreliable.”
Left: Scanning electron micrograph of Bordatella pertussis infection (green).
Pertussis in the path lab
Pathology tests for pertussis are designed
to diagnose current infection or to confirm a
recent infection. Dr David Mitchell, an
in very small samples, are now the
other macrolide antibiotics can reduce the
during the first few weeks of infection.
severity of symptoms and can help
Aspirating fluid from the nasopharynx
infectious diseases physician and
is the optimal method of obtaining
microbiologist at Sydney’s Westmead
specimens, but the procedure is
Hospital, says the organism is fastidious
uncomfortable and disliked by adults, in
and very difficult to culture in the laboratory.
whom throat swabs are usually adequate.
“Growing the organism is the ideal
“PCR has limitations too,” Dr Mitchell
way to make a diagnosis, and it also
says. “For example, it detects dead
allows us to study the bacterium, its
organisms as well as living ones, so it
sensitivity to antibiotics and the way that it
can’t be used to monitor the success of
might be changing over time, but in most
treatment.”
cases this is not an option,” he says.
“Only a few specialised paediatric
laboratories have the facilities for culture.”
Polymerase chain reaction (PCR) tests
for fragments of bacterial DNA, detectable
Early treatment with erythromycin or
method of choice for identifying pertussis
Diagnosing a current infection has the
greatest benefit where the patient might
prevent infection of close contacts.
But decisions about excluding a staff
member from work, monitoring others for
infection, and possibly treating others to
prevent infection can have serious
implications and therefore require good
evidence that the infection exists.
Serology – testing for antibodies to
pertussis – can help confirm that the
infection has occurred in people who
have experienced typical symptoms, but
is not particularly reliable.
“The tests available for routine
pose a threat to others, for example a
laboratory use are neither sensitive nor
staff member working in a neonatal
specific for pertussis and can lead to
intensive care unit, Dr Mitchell says.
over-diagnosis,” Dr Mitchell says.
>
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Rubella infections have continued to decline and now
number fewer than 200 a year, compared to about 3000
annually in the early 1990s.
“This can be a problem when we are
Only 10–20% of babies are affected
factors such as vaccination history,
attempting to control an outbreak or
if the mother has rubella after 16
previous antenatal screening tests, and
restrict the spread of the disease in a
weeks’ gestation.
the date and duration of possible contact
workplace. It also means that much of
Girls were first vaccinated against
with other infected people. A sharp rise in
the data on the epidemiology of pertussis
rubella in the 1960s, and immunisation –
IgG antibodies can also be detected
is unreliable.”
like natural infection – provides long-term
within four to five days of symptom onset,
protection. Rubella is now combined with
but patients are rarely tested at this early
measles and mumps vaccinations (MMR)
stage. IgM levels remain elevated for 8–12
in routine immunisations.
weeks after infection.
Careful interpretation
Like all pathology tests, the results of
pertussis serology have to be interpreted
carefully in light of the patient’s illness. In
a general practice environment, evidence
that a patient has developed antibodies
to pertussis after an episode of typical
illness can provide some reassurance
about the cause and likely course of the
illness, and help rule out other causes of
persistent cough.
Serology tests are not needed, and
A national ‘catch-up’ campaign in
be used to check for foetal infection if a
Australian adolescents, particularly the
woman wishes to continue with a
cohort of boys who had missed childhood
pregnancy after contracting rubella. Tests
immunisation. As a result, rubella
include IgM levels in foetal blood sampled
infections have continued to decline and
from the umbilical cord, or testing for viral
now number fewer than 200 a year,
genetic material in foetal blood or
compared to about 3000 annually in the
chorionic-villus samples.
early 1990s. Only one or two cases of
congenital rubella syndrome are reported
in Australia annually.
aren’t helpful, in deciding whether an
adolescent or adult should be
revaccinated.
Greater success, however, has been
achieved in controlling rubella.
This virus usually causes a self-limiting
disease in adults. Inhalation typically leads
to multiplication in the upper respiratory
tract, then fever, a skin rash and spread of
the virus to organs including the placenta
of pregnant women.
In 1941 an Australian ophthalmologist,
Norman Gregg, first made the link
between rubella and birth defects.
He observed that some babies were
The main aim of diagnosing current or
recent rubella infection is to assist a
pregnant woman to make an informed
sufficiently high uptake of MMR
sexes. The NHMRC recommends
vaccination of non-pregnant women
lacking antibodies, and female immigrants
who have entered Australia after the age
of routine vaccination – especially those
baby and whether the pregnancy should
from Asia, where natural infection rates
be terminated. Serological tests for
and levels of immunity are low.
antibodies are required in any pregnant
woman who is thought to have rubella or
Screening for rubella antibodies is
now a standard part of antenatal care.
who has been in contact with others who
have the disease, regardless of their
vaccination history.
A number of other rash-causing viral
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
illnesses – including measles, parvovirus
B19, human herpesvirus 6 and enterovirus
– can closely resemble rubella and cannot
mothers had rubella during pregnancy.
be distinguished clinically, so laboratory
very likely to lead to foetal damage, with
some years until there has been a
decision about the risk to her developing
with congenital heart disease – after their
in the first 8–10 weeks of pregnancy is
The risk of rubella will continue for
vaccination by children and adults of both
Role of rubella lab tests
born with congenital cataract – some also
It’s now known that maternal infection
Specialised pathology tests can also
1998 aimed to ensure vaccination of all
Further reading
Crowcroft NS, Pebody RG. Recent
confirmation is essential to make the
developments in pertussis. Lancet
diagnosis.
2006;367:1926–36.
The presence of rubella-specific IgM
Banatvala JE, Brown DW. Rubella. Lancet
long-term consequences such as
strongly indicates current or recent
2004;363:1127–37.
blindness, deafness, mental handicap and
infection, but the result must be
NHMRC, The Australian Immunisation
cardiac abnormalities.
interpreted by a specialist in light of
Handbook, 8th edition, 2003.
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lP ia t hfWe
s
t
y
l
e
ay lifestyle
travel
46
private passions
50
travel doc
52
working holiday
55
recipe for success
57
the good grape
60
dining out
61
rearview
64
conference calendar 67
postscript
68
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travel
a happenang thang
PENANG HAS ALWAYS BEEN A RICH MIXING POT OF CULTURES AND CUISINES, BUT THIS
YEAR THE TINY ISLAND STATE PROMISES TO BE EXTRA FESTIVE, WRITES JUSTINE COSTIGAN .
here’s a certain romance about
approaching a new country by sea
that puts all other forms of transportation
to shame, no matter how comfortable,
fast and modern they may be.
T
As land looms in the distance and your
boat gradually brings the coastline into
focus, the slow discovery of the land’s
shape and form – its mountains, natural
forest and beaches, small towns and
finally, the distant outline of a city skyline –
is always one of excited anticipation. And
while the feeling is probably intensified if
you’re travelling in style on a luxury yacht,
a humble ferry can be just as wonderful a
travelling experience.
For many travellers exploring the Straits
of Malacca or taking the slow meandering
route from Thailand down the coast to
Malaysia, the ferry is the only form of
transport. But it’s also the most reliable
and efficient form, and one that offers the
46_PATHWAY
most interesting way of exploring
Malaysia’s wonderful western coastline.
places that invites – no, demands –
wandering by foot.
Just one caveat: the day I took the
ferry from Langkawi to Penang, an
unseasonal downpour transformed the
calm emerald seas into angry grey waves
and lashed the ferry’s windows with rain
and seaspray.
A gorgeous time in
Georgetown
Penang emerged from the sea through
mist and rain and my arrival, though just
as interesting as I’d hoped, was a little
more Melbourne in winter than island
paradise in summer.
Luckily, then, Penang is more than just
a beautiful beach destination. This little
island has a rich and fascinating history
that is most evident in its capital,
Georgetown, one of the most accessible
and visitor-friendly cities in South East
Asia. Just big enough to be called a city,
Georgetown is one of those wonderful
With its English history evident in the
architecture of almost every street, it’s
easy to get lost in a Somerset Maughamesque fantasy of English colonial life.
And there’s no better place to catch a
glimpse of the past than at the imposing
Eastern & Oriental Hotel – the first hotel
opened by the Armenian Sarkies brothers,
who later established Raffles in
Singapore. Afternoon tea continues to be
one of the lovely traditions upheld by the
hotel, which looks polished and beautiful
since its renovation a few years ago.
A round of scones with jam and
cream, delicate smoked salmon
sandwiches and little cakes accompanied
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by tea in a silver teapot soothes the soul,
even if it does serious damage to the
credit card.
nineteenth century has been recreated,
illustrating the lifestyle of the family of a
wealthy Chinese businessman.
While its British history might be one
of the dominant features of the
Georgetown architectural landscape,
Penang has its own distinct personality
that draws on many cultures.
From the kitchen with its dozens of
tiffin containers to the half-dozen cabinets
filled with delicate Chinese porcelain, the
museum is filled with the work of expert
craftsmen. Intricate wood carving, painted
glass doors, and the embroidery on bed
linen and clothing are all to be admired.
As a crucial port in the development
of the spice routes, Georgetown quickly
became an important trading city with
strong Chinese and Indian communities
as well as its ethnic Malay population.
Although the island was eventually
overtaken by Malacca in importance,
Georgetown remained a bustling and
prosperous city. The confluence of cultures
– Chinese, Indian, Malay and British –
continues to guarantee a rich tapestry.
In the Peranakan Mansion, a
fascinating museum in the heart of
Georgetown, a home from the turn of the
Cause célèbre
In fact, any visitor to Malaysia this year
will find it hard to avoid learning
something about the country’s history.
Celebrating the 50th anniversary of
independence on August 31, Malaysia is
gearing up for a year of non-stop events.
It’s an unashamed and deserved year
of congratulation, and one that’s also
Newly opened, the museum is
privately owned and was conceived to
preserve a part of the city’s history that
the community is fiercely proud of.
being used to encourage visitors to the
You could spend days in
Georgetown’s museums taking in the
history of the island from indigenous
arrival (only shortly before the British in
the seventeenth century) to its trading
past, World War II history and subsequent
independence.
major music festival, dragon boat racing
country and its surrounding islands. As
part of the celebrations, Penang will host
several of its own big events including a
and the annual Lantern Festival.
This is one event I’d love to see.
Already filled with light, colour and people
at night, the city’s month-long festival
must be truly spectacular. Wandering
through the streets of Georgetown, the
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Perhaps the strongest and most spectacular symbol of ‘Visit Malaysia Year 2007’ is the giant
‘Eye on Malaysia’ wheel, pictured here against the backdrop of the world’s largest towers,
Petronas Twin Towers, Kuala Lumpur
The night markets draw crowds of both locals and tourists to
enjoy one of Penang’s most highly regarded attractions: its food.
city already seems to have a permanent
festival atmosphere.
The night markets draw crowds of
both locals and tourists to enjoy one of
Staying in Batu Ferringhi, the stunning
stretch of beach a 15-minute drive north of
the city, I caught a daily glimpse of the
Malaysian personality in every driver and
Penang’s most highly regarded
every journey to Georgetown and around
attractions: its food. From the island’s
the island. Every driver was keen to make
famous char kway teow, a delicious dish
sure my stay was enjoyable, offering
of noodles and pork, to the delights of
advice about food or a brief history lesson.
freshly barbecued satay, cane sugar juice
with lime and salted prunes, coconut
pancakes or curry mee, the food here is
spicy, delicious, fresh and inventive.
And everyone has an opinion about it
– especially the island’s well-informed,
articulate and friendly taxi drivers. Ask one
for a restaurant recommendation and
With daily tips and commentary in
the newspapers about welcoming
visitors to Malaysia in this
commemorative year, keeping tourists
happy seems to be a national challenge
everyone is taking seriously.
With national pride at stake on this
you’re likely to get a lively discourse on
important anniversary of independence,
the merits of Peranakan versus Malay or
there’s probably never been a better
Indian cuisine.
time to go.
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VISIT MALAYSIA 2007
n this special year-long celebration of
everything Malaysian, the country has
put together an astonishing calendar that
includes sporting and cultural events,
festivals and competitions, exhibitions
and displays – and of course the year’s
most important event, a nationwide
celebration in August to commemorate 50
years of independence.
I
TAMAN NEGARA ECO-CHALLENGE
MARCH 24–25
Malaysia’s world-famous national park is
the location for this extreme sporting
challenge, open to anyone interested in
mountain running.
MALAYSIA GRAND PRIX CITY
FESTIVAL
APRIL 1–8
To coincide with the F1 Grand Prix, Kuala
Lumpur will host a festival of entertainment
and Grand Prix-related events.
NATIONAL WATER FESTIVAL
APRIL 6 TO MAY 6
Water sports and activities are the focus
of this festival in Langkawi which will
include the Labuan International Sea
Challenge, the Rolex IGFA International
Game Fishing Tournament, the Cross
Channel Swimming Challenge, Round
Island Kayak Challenge and a grand
closing ceremony.
JOHOR INTERNATIONAL ORCHID
SHOW
MAY 25–27
Showcasing orchids from all over the
world, as well as Malaysia’s own
exquisite varieties.
COLOURS OF MALAYSIA
MAY 26 TO JUNE 10
Kuala Lumpur is the host of this festival
devoted to Malaysian culture, featuring a
colourful line-up of food festivals,
parades, performances and exhibitions.
PENANG INTERNATIONAL
DRAGON BOAT FESTIVAL
JUNE 8–10
Colourful dragon boats race to get to the
finishing line accompanied by the
rhythmic beating of drums and the
cheering of the crowds.
MALAYSIA MEGA SALE CARNIVAL
JUNE 16 TO SEPTEMBER 2
Amazing discounts and bargains are on
offer throughout Malaysia during this
festival devoted to shopping.
KUALA LUMPUR FESTIVAL
JULY 1–31
The country’s premier celebration of
Malaysian arts and culture.
WORLD MUSIC FESTIVAL
JULY 20–22
The beautiful surroundings of the Penang
Botanical Gardens come alive to the
sound of music and performances from
around the world.
50 YEARS OF NATIONHOOD
AUGUST
Throughout August, Malaysia will be
devoted to the commemoration and
celebration of 50 years of nationhood.
Events include performances by World
Lion Dance troupes, the Malaysia
International Fireworks Competition, a
grand parade attended by the King and
Queen of Malaysia and a Merdeka
(Independence Day, August 31) Eve
concert, among many other local and
national celebrations.
WASPALM CONFERENCE
20-24 AUGUST
The XXIVth World Conference of
Pathology and Laboratory Medicine will
be held in Kuala Lumpur this year. The
theme is Meeting the Challenges of
Globalisation and Miniaturisation. For
more information visit
www.waspalm2007.org
PENANG INTERNATIONAL
LANTERN FESTIVAL
SEPTEMBER 15 TO OCTOBER 14
Celebrated in the eighth month of the
Chinese Lunar New Year, Penang lights
up at night in a spectacular and colourful
display of lanterns big and small.
KUALA LUMPUR FASHION WEEK
OCTOBER 27–31
Local designers compete for top awards
and recognition as the best of Malaysian
fashion grabs the spotlight.
MALAYSIA INTERNATIONAL
GOURMET FESTIVAL
NOVEMBER 2–29
Malaysian and international chefs tempt
gourmands around the country with
special menus, demonstrations and
celebrations of all things culinary.
* For a full listing of Visit Malaysia 2007 events,
visit www.tourismmalaysia.gov.my
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private passions
Sax
appeal
BY DAY HE’S AN IMMUNOPATHOLOGIST, BUT
PHOTO CREDIT: JEFF MCEWAN
WHEN EVENING FALLS DR RICHARD STEELE
LIKES TO IMAGINE HIMSELF AMONG THE
SMOKY JAZZ JOINTS OF 1950S NEW YORK.
KATRINA LOBLEY REPORTS.
should probably have been born prewar,” says jazz aficionado Dr Richard
Steele. “But I would have had to be born
in the States and I probably would have to
have been African-American to make it
work, I think. Or a heroin addict.
“I
“Those are the two things that seem
to make the best saxophonist.”
Despite suffering the indignity of being
born in the swinging sixties and skipping
the perils of drug addiction, Dr Steele is
managing just fine.
While he’s currently without a band to
display his musical talents, the
immunopathologist and New Zealand vice
50_PATHWAY
president of the RCPA devotes time each
considered one of the most influential
day to his lifelong passion.
tenor saxophonists of all time.
“Playing the saxophone makes me
Others to rate a mention are Charlie
feel, on one level, more human as I can
‘Bird’ Parker of the 1940s, and John
interact on a level outside the normal
Coltrane, Ornette Coleman and Art
professional interactions I have during my
Pepper, who made names for themselves
daily work,” he says. “On another level I
in the 1950s and 60s.
feel more than human as it extends my
ability to communicate beyond language,
voice and gesture.”
It’s an impressive list, but not quite
complete.
“I missed one of my favourites – Eric
Dr Steele’s list of musical heroes is
Dolphy,” he says. “He was also a bass
long. One saxophonist who made a huge
clarinet player. He was just amazing but
impression on him is Lester ‘Pres’ Young,
died very young. He died a few months
a giant of the 1930s jazz scene who is still
before I was born, actually.
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“Playing the saxophone makes me feel,
on one level, more human”
“He was an African-American who
also played in Europe – he played with
John Coltrane and also with a guy called
Charlie Mingus. He was an incredible
sax player.”
Dr Steele can trace his passion for
music back to childhood. He started
playing piano at six. Although he continued
learning until the age of 16, he made the
decision at 13 that the saxophone would
be his instrument of choice.
Did that change of heart have
anything to do with girls?
“No, no … I might be lying,” Dr Steele
says, laughing.
Although he was strongly drawn to
music and had grown up in Wellington, a
hotbed of jazz in New Zealand, the
budding saxophonist moved to Dunedin –
“very much a rock town” – to study
medicine at Otago University.
“I joined a number of bands when I
got to university – I had my own trio,” he
says. “It actually got as big as a quintet
at one point. We performed what I would
call jazz standards but we also
performed our own compositions – a bit
of avant-garde.”
PHOTO CREDIT: JEFF MCEWAN
“I just really liked the sound of it at
that particular point in time. I was a bit
frustrated with pop music. The following
year, me and my parents went off to the
United States and we bought a secondhand saxophone in New York. Then I had
to paint their house for the next two years
to pay them back.”
Prince Alfred hospitals in Sydney. It was
medicine’s turn then, to take control, with
music playing second fiddle.
“That’s where music went into the
background, unfortunately, for a few years
there as I went through my studies and
worked and supported my family through
He also joined forces with several
post-punk bands and played in a soul/
R’n’B covers band, which was often
booked for student balls – including his
own graduation ball.
that period.”
After graduating, the allure of music
saw his medical career take a back seat.
“Basically, I just played music for a
year,” he says.
immunopathologist at Wellington Hospital,
“We used to tour around the South
Island. That was great fun, actually. It was
a really great year.”
“About 80% of my time is spent in the
hospital and 20% is spent in the
community – there’s a laboratory in the
community,” he says.
He returned to medicine in Dunedin
then emigrated to Australia, where he
trained in pathology at Liverpool and
He stayed in Sydney for 11 years
before returning to Wellington in 2003.
Today, Dr Steele works as the clinical
where he specialises in allergy-related
illnesses, autoimmune diseases, HIV and
primary immunodeficiency conditions.
“I’m a sole practitioner and my referral
base is about a million, so it is busy.”
Despite this hectic schedule, Dr
Steele puts time aside each day to pursue
his musical passion.
"What I like about the sound of the
saxophone is that its tone can reflect your
mood. It can sound soft and soothing to
harsh and frenetic to even kitsch,” he says.
“There is a mind–body thing going on,
where you get back in touch with your
body in a very creative way, similar to
many other pursuits such as dancing,
yoga and even sport."
At home, Dr Steele is also recording
and producing an album for Dunedin pop
band The Puddle, in which he played
many years ago. And he just might join a
band again one day.
“I perform to the neighbours at the
moment,” he says.
“They haven’t called the police around
yet or the noise control officer, so I guess
that’s a good sign. I don’t squawk too
badly.”
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travel doc
A tentacular sight at the markets in Naxos;
inset: outside the lace shop in Kritsa, Crete.
PHOTOS COURTESY OF MICHAEL HARRISON
AEGEAN PEARLS
DR MICHAEL HARRISON WAS SWEPT OFF HIS FEET BY THE ENDURING CHARM
OF THE GREEK ISLANDS.
hen a Greek Islands guidebook
appeared in our house a few years
ago it was inevitable we would head in
that direction. So last June we set off,
with sole child Princess Sally, 14, and
niece of same age, Victoria, on a
Singapore Airlines flight to Athens
(something Qantas can’t offer).
W
We were charmed by Athens: hot,
windy and glary, but with friendly locals
and ancient glories such as the Acropolis,
the Temple of Zeus and the Agora all
within walking distance.
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Our best memories of Athens?
Breakfast at the St George Lycabettus
Hotel with the panorama of central
Athens, the Acropolis and the
Mediterranean stretching out in front of
us; the Central Market; and the National
Archaeological Museum with its
Mycenaean gold and classical bronzes
recovered from the sea bed.
Some of the quirks of Greece – the
never finished building projects and
littering – we also saw in Athens.
At Piraeus, where we caught the ferry
to the island of Crete, we were confronted
with another: Greek ferry-terminal
etiquette. No facilities, no queues, just a
basic concrete wharf with unloading and
boarding in an uncoordinated frenzy of
pushing, blowing of whistles and beeping
of horns, as pedestrians and vehicles
compete for ramp space.
We were quite taken aback the first
time but on the next seven occasions we
got into the swing of things and just
joined in.
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“Our advice to first-timers: don’t arrive at night
by hire car, without a map, while staying in a
hotel with pedestrian-only access”
Dr Michael Harrison, daughter Sally (right) and niece Victoria enjoy traipsing around Santorini.
Crete appeared in a soft cloudless
sunset – mountains plunging down to the
sea and arid olive-dotted hillsides. Our
first stop was our base for exploring
western Crete, the charming old harbour
town of Chania. It’s also known as Xania,
Canea and Khania, with all four different
names appearing on road signs at
various times.
Our advice to first-timers: don’t
arrive at night by hire car, without a
map, while staying in a hotel with
pedestrian-only access...
Highlights of Crete included the ruins
of the Minoan palaces of Phaistos
(Festos); Matala on the southern coast
with its Roman cave tombs; the Phaistos
disc in the Irakleion (Herakleion)
Archaeological Museum (probably the
oldest example of writing yet discovered);
and surprisingly, the Commonwealth War
Cemetery near Chania.
Unlike other public places in Greece,
this was immaculately maintained and its
poignantly inscribed headstones even
more significant after reading The Fall of
Crete by Alan Clark.
There was also Kritsa, a mountain
village that specialises in lace and
embroidery, where purchases were made
from the very lady who appeared in the
guidebook. On hearing that niece
Victoria was buying for her Grandma,
she cluck-clucked with approval and
threw in a few extras.
I went snorkeling at Chania and every
subsequent destination – the clear blue
water was surprisingly cool despite air
>
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Going to extremes: soaking up the Agean view; squashing aboard the ferry
at Piraeus.
spectacle of Santorini – thousand-foot
black and red cliffs dripping with
whitewashed stone buildings and bluedomed churches plunging down to
cruise ships on the blue waters of the
flooded caldera.
we were atypical Greek Island tourists,
The panorama is simply entrancing,
but if you can wrench your eyes away
from it there are ‘distractions’ such as
the 68 jewellery shops in Fira or a boat
trip to Nea Kameni. This barren island
emerged recently in the caldera formed
by the devastating eruption of 1450 BCE.
Sulfur still issues from its fumaroles and
you can swim in a sea warmed by
volcanic activity.
preceded it – we made it to Mykonos, and
see some parts we couldn’t fit in this time.
Santorini was worth waiting for. It’s on
my list of the top 10 places in the world I
have visited.
The 1000-foot climb up from Fira port
was made on donkeys by the girls, but we
adults couldn’t subject the poor animals
to that and used shank’s pony instead.
We arrived in a moonlit Athinios
Harbour and next morning awoke to the
Next stop was Naxos – a bit like a
mini Crete but with better beaches. Here
temperatures of 30ºC plus. The range of
fish and other marine life was interesting –
sea urchins were common, as were
beautiful jellyfish. Unfortunately the litterstrewn land is replicated underwater: the
water is so clear you can easily see the
plastic bags on the bottom.
Our base in eastern Crete was
Elounda near Agios Nikolaos – beautiful
scenery and even better snorkelling.
A north wind blew 30 knots and
stayed with us for the rest of our time in
the islands. Our next leg – the
Crete–Santorini route – is long and
unprotected, and the fast ferries were
cancelled for three days, forcing us onto a
larger and slower ship-type ferry.
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rejecting the sun lounges and the
beaches and instead cruising historic
sites and museums.
Finally – with some trepidation as its
reputation of over-commercialisation
found Mykonos town a delight.
The Greek Islands were everything we
thought they’d be: blue sky, blue sea, blue
fishing boats and blue-domed churches;
white houses; wonderful history, relics and
ruins; harbours and ferries.
We skimmed the surface and dived
the deep end and know we’ll be back to
One place we’d always return to is
Santorini: it really is something special.
Dr Michael Harrison is the CEO of Sullivan
Nicolaides Pathology.
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working holiday
Maltese moments
A WORK TRIP TO THE ISLANDS OF MALTA ALLOWED PROFESSOR JANE DAHLSTROM A BRIEF
TASTE OF A COUNTRY WITH A FASCINATING ARCHITECTURE AND HISTORY.
he conference itself was memorable:
the world’s experts in breast
pathology gathered together to honour
the contribution of Professor John
Azzopardi to the field.
T
Focused and intensive, it was an
important opportunity to learn from
colleagues. But when it was over, the
chance to relax for a day was welcome.
Having never been to Malta, I was
curious about this tiny group of islands in
the Mediterranean that joined the
European Union in May 2004. I was
fortunate that the Maltese High
Commissioner to Australia, HE Dr Ivan
Fsadni, had organised for his sister, Ms
Marika Fsadni, to show me round the
main island.
Extremely picturesque, Malta is a
popular destination for diving and
yachting enthusiasts. Its waters, caves
and rocks, gentle hills and craggy cliffs
attract outdoorsy types all year round,
even in the cooler winter months.
My real interest, however, was in the
beautiful towns and villages. Their
extraordinary limestone buildings and
vibrant and unique culture have been
influenced over the ages by various
civilisations, from the Romans to the
British, who prized Malta’s harbours and
ports as a mid-point in the Mediterranean.
Valletta, the fortified capital built by
the Knights of Malta who ruled over the
islands from 1530 to 1798, is embellished
with some of the finest Baroque
architecture in the world. Malta’s war
museum is often a stopping-off point for
pilgrims to Gallipoli. Many soldiers injured
in the fighting in the Mediterranean were
tended to in the British hospital located
there during World War I.
One of the first things you’ll notice
about Malta is the wonderful golden hue of
the islands’ limestone, from which so many
of the older buildings have been built. This
golden stone prompted the name ‘Melita’,
which means ‘island of honey’, and it has
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IMAGES COURTESY OFWWW.CHOOSEMALTA.COM
been used for building throughout the
islands for around 7000 years.
This very traditional Catholic country
(98% of the population is Catholic)
naturally has some magnificent churches.
The St John’s Co-Cathedral is home
to two masterpieces by Caravaggio, The
Beheading of St John the Baptist and
Saint Jerome. And in Mdina, the island’s
ancient capital, you’ll find the stunning
Baroque cathedral dedicated to Saint
Peter and Saint Paul.
Malta’s typically delicious
Mediterranean cuisine focuses on seafood
but you’ll also find Middle Eastern, North
African and strong Italian influences – and
the occasional British oddity.
Despite the large number of tourists
(there are direct flights from most major
European cities) and all its modern
I had just a day to explore the island
before returning to Australia but was very
quickly charmed. I have no doubt I will be
spending more time discovering Malta on
one of my next trips to Europe.
As a visitor I felt warmly welcomed
and appreciated. No wonder Malta has a
reputation as the undiscovered gem of the
Mediterranean.
amenities, Malta remains well preserved.
The islands have maintained their old-world
charm and the locals are very welcoming.
Professor Dahlstrom is an anatomical
pathologist and Professor at the Australian
National University Medical School.
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recipe for success
class of his own
RENOWNED CHEF TONY BILSON TALKS
TO WENDY LEWIS ABOUT HIGH-QUALITY
PRODUCE, UP AND COMING CHEFS, AND
PHOTO CREDIT: MICHAEL AMENDOLIA
THE STATE OF AUSTRALIAN FINE DINING.
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“Great food is driven by generosity – a quality shared by most
Australians, one that we should celebrate more often.”
nyone unaware of Tony Bilson’s
A
contribution to fine food in Australia
may well have been hiding under a
barrowful of fresh Périgueux truffles for
the past 40 years. One of Australia’s most
skilful chefs, Bilson has established and
transformed numerous eating
establishments.
Along the way, he has challenged us
to rethink the whole ethos of food in
Australia: its social aspects, its European
versus Asian influences and its place in
the nation’s identity.
Early in his career, Bilson’s stint at the
Albion Hotel in Melbourne’s Carlton
brought new taste sensations of the très
French kind to an eagerly receptive crowd.
In the early 80s he was behind
Kinselas, that brazen wine bar, restaurant
and cabaret that hit Sydney’s Oxford
Street with a flourish.
His ambitiously chic restaurant
Ampersand (now L’Aqua) at Cockle Bay,
Darling Harbour was the talk of the town
during the Sydney 2000 Olympics.
And he is now the driving force behind
Bilson’s in the Radisson Plaza Hotel,
where one can savour the delights of
Lasagne of Freshwater Marron Lobster or
perhaps succulent Grimaud Duck,
followed by an exquisite Tart of Pear with
Almond Frangipane and Chocolate
Fondant…
Bilson is well known for his penchant
for superb-quality French-influenced
cuisine. He is equally prominent for his
long-term stance against the so-called
‘fusion’ approach to much Australian
cooking today.
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For a restaurateur, Bilson is something of
a raconteur, not averse to taking
entrepreneurial risks.
This could be because he sees dining
not as some peripheral activity at the end
of a busy day but as a key element in a
nation’s culture.
Arts, architecture, sport, economics …
food and drink? Do Australians see their
evening meal and themselves that way?
And just how does Australia rate for the
discerning diner seeking a world-class
dining experience?
Room to improve
We may blithely assume that Uluru,
Port Douglas and other hot spots will
keep overseas visitors flocking to our
distant shores. But Bilson can quote the
figures. And the figures show that
Australia’s hotel occupancy rates are
among the lowest in the world. The
hardened urbanites among us may think
we live in a thriving metropolis with the
best of the best on tap; perhaps such an
assessment has a hint of self-delusion.
What about the difficulties in importing
(relatively small) quantities of exotic
produce? There are two schools of
thought, Bilson says.
In Bilson’s view, we’re sailing along quite
nicely in terms of mid-range dining. But
when it comes to first-class
establishments, it’s not so breezy.
Restaurants can go through the
rigmarole of bringing in out-of-season
produce to cater for the international palate.
Or they can choose to use local produce or
imported foods that are easily sourced.
Tetsuya’s is a stand-out, he says. But
as for other international-standard
restaurants, we still have room for
improvement. Bilson pinpoints two factors
holding us back: difficulties associated
with importing high-quality produce, and
our small market.
Most establishments in Australia
favour the latter approach, using strictly
seasonal produce to create dishes with a
local emphasis. It is a ‘brave few’, says
Bilson, who cater for the international
market by procuring exotic, less readily
available goods.
Australia has a small population. We
have long been constrained by our
location and geography. We can increase
our market base by encouraging more
cashed-up visitors to our shores. That
seems relatively simple.
Bilson suggests there needs to be a
reassessment of the way Australia is sold
internationally – and this applies to our
national image as well as the goods we
sell. There are many sorry tales of
Australian companies selling themselves
short through cultural misunderstandings
or mismanagement. He cites the example
of Australian beef in Japan: this was a
quality product, branded well, that failed
miserably because it was so heavily
discounted in Japan that customers
wrongly perceived it as cheap and nasty
and turned away in droves.
But consider the recent ‘Where the
Bloody Hell Are You?’ campaign. As
Bilson points out, it didn’t exactly attract
the elite – or anyone else for that matter –
even if it was a supposedly clever reinvention of Paul Hogan throwing another
shrimp on the barbie as he did ad
nauseum in the 80s.
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PHOTO CREDIT: MICHAEL AMENDOLIA
But all is not lost. It does well to
reflect on the positive aspects of
Australian culture when it comes to fine
dining: our widespread Italian/Southern
French approach to cooking which is
healthy and climatically appropriate; the
importance given to the matching of
wines and food; and the availability of
fresh foods, especially fruit.
Sunny side up
The trend for extended breakfast-cumbrunch is also a good thing: anything that
creates a leisurely, pleasurable and social
dining experience gets the thumbs up
from Tony Bilson.
Also, up and coming young Australian
chefs are well-regarded overseas, he
says, for their ‘can do’ attitude and
winning approach to creative cookery. We
may be a world away from European
trends, but young chefs based here have
something rather special, having grown up
in a culture that has long been exposed to
the flavoursome world of Asian cuisine
and its influences.
This insight gives them a brilliant
headstart in the use of aromatic flavours,
spices and unusual taste combinations.
Even a Francophile like Bilson
tactfully suggests that the French can be
a little heavy-handed with their use of,
say, Indian spices, simply through their
lack of familiarity.
How far have we have come as a
nation in our attitudes to food? Have we
become more aware of the importance of
presentation, variety and good nutrition?
Bilson would say that Australians have
long been aware of these issues, despite
our past reputation as a nation of breadand-dripping eaters.
He cites Philip E. Muskett’s seminal
The Art of Living in Australia, first published
in 1893. This book encourages a
Mediterranean-style approach to eating
and drinking as it is well suited to our
climate. It also features handy hints such
as detailed instructions for the making of a
French salad, and expounds on the
possibilities for Australian viticulture and
the monotony of the Australian breakfast,
with a plea for something better. Clearly the
taste for languid al fresco breakfasts is
nothing new.
Long will Australia’s talented chefs
gently yet deftly shape this nation’s
culinary scene. And Bilson will continue to
create signature dishes – especially duck
in all its glorious forms – with his
inimitable style. In the past he has led
gastronomic tours in France, fusing travel
and dining. These days, his energies lie in
his restaurant, especially in mentoring
emerging talents.
In his own home, he opts for the
simple pleasures. Roasted and grilled
meats, the barbie on the balcony, an
abundance of seasonal vegies and loads
of fresh fruit, sitting down for an enjoyable
meal with his wife Amanda and two
teenage children.
“Great food is driven by generosity – a
quality shared by most Australians, one that
we should celebrate more often,” he says.
Relaxed social interaction coupled
with simple and delicious foods: this is the
art of good eating.
If we can get that right, says Tony
Bilson, we’re not doing too badly at all.
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the good grape
GIVE US THIS DAY
OUR DAILY RED
A new take on the ‘French paradox’ gives a bitter twist to the saying
‘what’s your poison’, writes Ben Canaider .
he wine diet. It was only a matter of time, I suppose.
want to eat fatty foods lest it makes them, well, fatty. Not to
Every other area of human endeavour has been so ‘lifestyled’
mention unhealthy. Oh dear.
T
that it’s a wonder wine has stayed below the radar. Except for a
new book: The Wine Diet, written by Roger Corder, a
cardiovascular expert and professor of experimental therapeutics
at the University of London’s William Harvey Research Institute.
This is a volume on the positive effects of moderate red wine
This is where Professor Corder’s wine diet idea falls over. He
is recommending gruff red wine styles that are not really
beverages. He thinks the best way to dilate your arteries is to
drink some of the most undrinkable reds in the world – and to
drink them young, to boot. Take Madiran, for instance – the Biro-
consumption, but the idea is not new. Popularised by the 1983
ink red from the south of France. Anyone drinking this young
American 60 Minutes report on the so-called ‘French paradox’,
would not only be called mad, but also convicted for infanticide.
this 17-minute television endorsement sent red wine
consumption – and wine consumption overall – sky-rocketing,
helping wine beome the beverage phenomenon that it is today.
The French paradox suggested that despite high tobacco and
alcohol consumption, southern French farmers lived longer and
Corder also uses his platform of wine dieting to overlook
what the true role of wine is: to relieve the mundane, irksome
nature of our day to day. If we spend that day satisfying our
moronic food dieting needs, what role can wine then properly
play when we get home and try to relax?
healthier – all thanks to red wine.
This have-your-cake-and-drink-it-too mentality appealed to a
lot of Americans. And many others besides.
The Wine Diet is the latest generational manifestation of this
Paradox idea.
Professor Corder’s thesis – much like the French paradox
theory – rests on polyphenols. These are the compounds found
in red grape skins and seeds – the very same vehicles that give
us tannin and astringency in wine and provide red wine with its
Wine is not a diet pill, nor is it an excuse. It is unalloyed relief,
which is a point Corder’s book mostly overlooks.
But there are problems at all points of wine’s new dietary,
healthful veneer.
The World Health Organization still recommends three
standard drinks a day for the average human: four for men; two
for women, with two alcohol-free days a week.
The sum of the parts is about three 150 mL units of table
longevity. Cabernet, for example, has high tannin levels, which is
wine every day: a pint for men and a half-pint for the ladies. For
part of the reason it needs time to mature in your cellar.
the genderless average that’s 450 mL a day, five days a week. Or
But back to Corder’s theory. Polyphenols are full of flavonoids.
2.25 litres a week. Or 117 litres a year. That’s about 88 bottles,
The best sorts of flavonoids are the procyanidins, which make for
give or take the odd bit of spillage, breakage or corked wine. For
a drying effect in your mouth when you swallow wine.
men, 156 litres per annum; for women, 78. Therefore 117 litres of
They have a second job, however: they act as antioxidants,
and help metabolise fat and protect you from the bad LDL
cholesterol.
More importantly Professor Corder likes the way these
wine per capita, on average, is in accordance with safe winedrinking guidelines as formulated by the WHO…
The French nowadays drink just less than 60 litres per capita;
ditto the Italians – indeed, they are now closer to 50. The USA’s
compounds dilate blood vessels, thereby reducing blood
proud and free consumers average about nine litres; Her
pressure. Apparently this is good if you have heart disease…
Majesty’s loyal subjects in the UK quaff about 17, but that’s
The only problem is the way red wine is now made.
rising. The Austrians drink 27, which puts Australians to shame;
Australians – people who grow, make and sell so much of the
Corder believes that more polyphenols are found in red wines
made very traditionally: hand-picked, basket-pressed, unfiltered
sorts of red wines. Red wines, in other words, fit only for heroes.
However, most red wine nowadays is made with an eye to
immediate comfort. Old-fashioned reds need time in the bottle to
soften, or they need fatty foods to assuage the tannins in the wine.
New World’s wine – only drink about 20 litres per capita. And
that’s been stable for about a decade and a half.
No-one anywhere else in the world comes close to the
WHO’s recommendations.
Maybe then we all need to go on a PlentifulWine Diet?
Here we strike another problem: not only do people
nowadays not like astringent, manly red wine, but they do not
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50_PATHWAY
The Wine Diet by Roger Corder is published by Little Brown.
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diningout
Good Morning
Restaurant Lurleen’s
The ricotta hot cakes, caramelised bananas, macadamia and
ost breakfast menus in Australia pay homage to English
traditions and Restaurant Lurleen’s, just south-east of
Brisbane, is no exception.
special days when celebrating are an ideal accompaniment to
M
Offering old favourites such as eggs Benedict, Lurleen’s
version features toasted English muffins, spinach and
hollandaise sauce, and a choice of leg ham or smoked salmon
to accompany this well-presented dish. There is also grilled
black pudding with minute steak, fried eggs, tomato, chips and
toast. Or superbly subtle English herb and pork sausages in
the big breakfast, which also includes bacon, hash browns,
baked beans, corn fritters and Portobello mushrooms. And if
you choose, most of these items can be ordered as sides to
satisfy the most committed Anglophile.
There’s a big focus on fresh produce at this establishment,
located at Sirromet Wines, between Brisbane and the
Gold Coast.
Much of the produce is grown in the winery’s organic kitchen
garden on site (including all the eggs), and the best of locally
grown fruit and vegetables also flavours what is on offer first
thing in the morning.
Our mid-summer breakfast included warm banana bread with
honey yoghurt, local Redlands strawberries, and roasted
almonds – a sweet yet piquant quartet for those who don’t
favour a savoury start to the day.
praline ice cream and maple syrup are wonderful and on those
the sparkling NV Vineyard Selection Brut Reserve ($7 per glass).
Grilled WA sardines with semi-dried tomatoes, parsley and
basil butter accompanied by thick-cut sourdough toast are a
robust flavour hit without being overwhelmingly large. The
coffee is superb, service attentive and friendly, and the wellcredentialled reputation suggested by the restaurant’s many
awards is supported by the breakfast experience here.
Lurleen’s, led by high-profile executive chef Andrew Mirosch,
overlooks the 240-hectare winery site, most of which is planted
with grape vines (heavily laden at the time of our visit).
With distant views over Moreton Bay to Stradbroke Island, this
restaurant has become a destination in its own right.
Although it’s often heavily booked for lunch and dinner,
breakfast is a great way to secure a table here and sample
Sirromet’s wares. To my mind, it remains the best-value
breakfast in and around Brisbane.
- Louise Martin-Chew
Restaurant Lurleen’s at Sirromet Wines
850–938 Mount Cotton Road, Mount Cotton, Qld
Ph: (07) 3206 2999
Breakfast available Mon–Sat from 9am, Sunday from 8am
About $40 for two
>
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Bottom left & left: Urban Bistro,
co-owner and chef Bethany Finn
Below: Lurleen’s
Right: Cafe Xeons
Urban Bistro
ny place that offers you 1990 Krug Champagne at 7.30am
obviously takes breakfast very seriously.
A
Okay, instead of forking out $500 for a bottle you could opt
instead for a glass of Barossa Valley moscato at $7.50 or even a
Bloody Mary, but most people choose something like freshly
squeezed organic ruby grapefruit juice or an apricot lassi.
Even sweaty joggers sitting down to breakfast at Urban don’t
smell quite so sweaty, such is the civilising influence of this
great breakfast spot overlooking Adelaide’s famed parklands
and the Victoria Park racecourse.
This is the sort of place people go when they can’t be bothered
cooking at home, but don’t want to put on airs and graces, let
alone the family pearls.
In other words, Urban is very much a suburban bistro whose
style is that of a large, modern – even sharp-edged – private
dining room.
It’s comfortable and relaxed, with a large communal table for
those inclined that way, and is especially popular at breakfast,
which is huge here at weekends.
It’s a good early-morning stopping-off point for city-bound
business folk during the week, or an early-morning meeting
venue for a genteel start to the business day.
The breakfast menu has to be the best in Adelaide and offers a
great range of options.
At the simplest – and probably healthiest – end of the menu are
dishes such as bircher muesli with grated apple with toasted
almonds, or a chilled melon and citrus salad with Cointreau
syrup and Greek yoghurt – though it’s easy to be tempted by
dishes like the grilled crumpets with caramelised apples and
toasted walnuts.
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Egg dishes, all free range, start with simple scrambled eggs
with pancetta, asparagus and grilled sourdough, and move
through about nine options to a sensational stir-fried blue
swimmer crab omelette.
It’s hardly necessary, but you can bolster these dishes with
everything from hollandaise sauce to extra servings of
asparagus.
Teas and coffees are top class, including jasmine white tea and
spiced chai (Indian-style sweet tea with milk), or even a
fortifying corretto (a short black with a dash of grappa).
There’s also a good list of sparkling wines by the glass for those
special breakfasts.
- Nigel Hopkins
Urban Bistro
160 Fullarton Road, Rose Park, Adelaide
Ph: (08) 8331 2400
Breakfast available Tues–Sun 7.30–11.30am, weekends 8.30–11.30am
About $50 for two, plus the Krug
The Green Grocer
art organic grocery store, deli, bakery and cosy little café,
The Green Grocer is a Melbourne inner-city institution with a
dedicated fan base devoted to its organic produce and
delicious food.
P
The first fully licensed organic café in Australia, The Green
Grocer quickly gained a reputation for its innovative modern
food made with local organic produce and although it may
sound like a relic from the 1970s, this funky little café and
foodstore has a modern aesthetic and atmosphere that sits very
comfortably in the noughties,
The chefs at The Green Grocer pay just as much attention to
the way food tastes as to how it will affect both the environment
and your body and this is reflected in their delicious breakfast,
brunch and lunch menu that embraces modern Australian,
Asian and Meditterranean cuisines.
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Take these breakfast staples for example: two large herb and
fetta pancakes topped with the Big Breakfast of fried organic
bacon and eggs, or switch herb and fetta pancakes for corn
fritters with smoked salmon, relish and sour cream for an even
more indulgent start to the day.
These are breakfasts that will definitely have you skipping lunch
so if you’re not in the mood for such an over-the-top indulgence
you’ll also find home-made porridge with loads of nuts and juicy
sultanas, fresh fruit salad, sweet and savoury muffins and
decadent cakes on the menu, as well as smoothies, fruit juices
and excellent coffee.
The café and garden courtyard are compact so there isn’t much
elbow room for those who like to spread out the newspaper with
their breakfast but the limited tables generally mean service is
quick and efficient.
Unfortunately, the popularity of The Green Grocer means
weekends can be a bit of a crush so if you don’t arrive early you
may have to wait for a table.
While you’re waiting, take the opportunity to re-stock the pantry
with fresh fruit and vegetables, super creamy organic ice-cream
and other dairy products, and The Green Grocer’s pre-cooked
take-home meals.
Cafe Xenos
afe Xenos has been a Sydney ‘institution’ for almost four
decades. Proprietor Peter Xenos recalls working as a young
man in what was then his father’s business back in 1969.
C
Peter’s personal involvement in the day-to-day running of the
cafe restaurant – with the help of sons Tim and Dennis – is part
of the appeal for the cafe’s loyal following on Sydney’s lower
North Shore.
Their Eggs Benedict, one of the best in Sydney, is also part of
the reason for their unwavering reputation. Served with either
smoked salmon or bacon ($14), its generous serving of
Hollandaise sauce is a perfect balance of creamy and tangy that
brings the dish to life (even if your cardiologist disapproves).
As with most organic food cafés you’ll pay a premium for fresh
produce and food but the care with which your food will be
cooked and presented will be worth it.
If Eggs Benedict is not your thing, the menu includes a wide
range of options including scrumptious French toast ($7), fresh
ricotta with strawberries and Turkish pide toast ($8), or a rich
smoked salmon omelette with tomatoes, avocado and hash
browns ($15).
Whether you’re a supporter of organic food or not, you’ll have to
admit there’s something special about the food at this
establishment.
Xenos is also open for lunch or dinner, but is best known for its
weekend breakfast/brunch fare, making Sunday morning
reservations a must – as those in the know, know.
- Justine Costigan
The Green Grocer
217 St Georges Road, North Fitzroy, Melbourne
Ph: (03) 9489 1747
Open 7 days 9am-4pm
About $45 for two for breakfast
- Andrea Plawutsky
Café Xenos
7 Burlington Street, Crows Nest, Sydney
Ph: (02) 9439 1748
Breakfast available Mon–Sat from 7am, Sunday from 8am
About $35–40 for two
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on fertile ground
PHOTO CREDIT: NEWSPIX
rearview
FROM PEEING ON BARLEY TO WARM BATHS FOR TOADS, EARLY-PREGNANCY TESTS
HAVE COME A LONG WAY, RECOUNTS DR GEORGE BIRO.
I
n 1956, Russia invaded Hungary and
Sydney Symphony Orchestra after being
Nicolaides Pathology (SNP) has an
Australian troops in Malaya saw their first
caught with erotic photographs at Mascot
international reputation and employs
action. Robert Menzies’ minister for
airport.
nearly 2000 people.
supply Howard Beale assured Parliament
That same year, in a basement in the
that the nuclear explosion at Maralinga in
Brisbane suburb of Wickham Terrace, Dr
in the last quarter of a century, but so has
South Australia was quite safe.
John Sullivan established a small
pathology, says the company’s CEO and
pathology laboratory. Dr Nick Nicolaides
managing partner Dr Michael Harrison.
And world-famous conductor Sir
Eugene Goossens resigned from the
64_PATHWAY
joined a year later, and now Sullivan
The world has changed exponentially
Lyn Krebs wouldn’t disagree.
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Those were the days: Lyn Krebs would inject
female human urine into the lymph sacs of
male toads.
When she joined the company as a
young Lyn Rouillon back in 1963, days in
the laboratory were always interesting, but
the evening work was a little more unusual.
if not, it was negative. After testing, the
abnormal pregnancies will ensure they still
toads would be given a break of five
play a key role.
Just as Dr Sullivan had done before
her, Mrs Krebs would finish up at the lab
and find her way with a torch to a nearby
creek to hunt male cane toads.
1970s. Antibody-based tests such as
the mainstay of modern pathology. Labs
latex agglutination and radio receptor
such as SNP offer now offer more than
assays eliminated the need for nocturnal
500 tests, some in newer fields like
She’d take the toads in a damp sack
to her mother’s laundry and determine
their sex. The females she took to the
Queensland University physiology lab;
the males to the path lab. For each toad
a bounty was donated to the local Boys’
Brigade, some of whom would help her
at the creek.
weeks before being used again.
All this would come to an end in the
toad hunts and warm toad baths.
These days, automated immunoassay
However, they’re just one weapon in
the armoury of tests that have become
molecular pathology, immunology and
cytogenetics.
pregnancy tests (using serum rather than
urine) yield accurate quantitative results,
Dr Harrison says. Such tests also usually
become positive around day 21 – before
These lead to more precise diagnoses,
and in turn to more specific, tailored
treatment.
It’s little wonder Dr John Sullivan takes
the first missed period.
But the proliferation of simple and
pride in the lab he founded 50 years ago.
After 43 years, Lyn Krebs still works
Such was the complicated nature of
pregnancy testing nearly 50 years ago.
accurate testing kits used at home or in
the GP surgery hasn’t eliminated the need
there. She no longer hunts male cane
No simple home-based urine tests, but
a labour-intensive search for male toads,
which produce sperm when exposed to
human chorionic gonadotrophin (HCG).
for lab-based pregnancy tests. Dr
toads at night with a torch, but there’s
Harrison says their superiority in early or
plenty of other work to do.
A pregnant woman’s placenta
produces large amounts of this peptide
hormone, which passes into the
bloodstream and the urine.
HCG is necessary, especially in the
first trimester, for pregnancy to continue.
But when given to male toads, it
stimulates the testicles to produce sperm
and this is the basis of various bioassays,
including the ‘toad test’.
Try telling this, though, to a suspicious
policeman who finds you rustling around
in the bushes at night.
Back at the lab, staff would keep the
male toads away from the females for a
week to avoid ‘amphibian amours’ leading
to false-positive results.
In winter, when toads normally
hibernate, they would give the cold,
sleepy males a warm bath and stretch
their limbs before starting the test.
Mrs Krebs would take two male toads
and inject a measured volume of female
human urine into the lymph sacs of each
toad’s legs.
After at least six hours, she would
catheterise the toads and check their
urine under a microscope. If she saw
many active sperm, the test was positive;
Animal, mineral, vegetable
ver the centuries, men and women have searched for tests to detect early
pregnancy. About 1350 BCE, an Egyptian papyrus asked women to urinate
over several days on seeds of wheat and barley.
O
If the barley grew, she would have a boy; wheat growing meant a girl, but if
neither grew, she wasn’t pregnant at all.
Apparently this method often worked well.
From the Middle Ages to the eighteenth century, ‘piss prophets’ claimed that
just by looking at urine (or even tasting it) they could diagnose not only pregnancy
but also various diseases.
During the 1920s, scientists identified HCG, found in pregnant women.
Ascheim and Zondek described their (A–Z) test for urinary HCG. They injected
urine into an immature female rat or mouse; if the animal then went on heat, the
test was positive. These tests took at least four days.
Others developed bioassays using toads, rabbits or frogs.
But these tests were still slow, insensitive and meant killing animals to assess
their response microscopically.
By the mid-twentieth century, when SNP was formed, scientists were
developing in vitro tests on cells (immunoassays, rather than bioassays) in which
no animals were killed.
In the twenty-first century, women still want to know as soon as possible
whether they are pregnant.
But some women say they don’t need tests. A friend told us how excited she
was about her very first pregnancy. We politely asked when the baby was due:
“Oh, about nine months from last night.”
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PathWay #11 - Text
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2007
Conference Calendar
2
5
Practical Pathology Seminars
Dermatopathy
2 - 6 May 2007
5 - 8 June 2007
Cancun, Mexico
Las Vegas, USA
www.uscap.org
18
3
The Virology Master Class
Viruses In May
18 - 29 June 2007
3 - 5 May 2007
Adelaide, Australia
Katoomba, Australia
www.sapmea.asn.au/virology2007
jules.rainbow@hotmail.com
JULY 2007
8
MARCH 2007
2
Pathology Update 2007
2 - 4 March 2007
Sydney, Australia
evep@rcpa.edu.au
APRIL 2007
23
Focus 2007
23 - 26 April 2007
Manchester, UK
focus2007@meetingmakers.co.uk
27
CIDM Public Health Symposium
Series 2007
27 April 2007
AACC Annual Meeting
8 - 11 August 2007
San Diego, USA
Miami, USA
http://www.aacc.org/AACC/events/ann_meet/annua
http://www.islh.org/2007/
27
MAY 2007
2
ICPMR Immunology Course
15 - 19 July 2007
l2007/
22
5th Asia Pacific International Academy
of Pathology Congress and Chapter of
Pathologists Annual Scientific Meeting
9th Indo-Pacific Congress on Legal
Medicine and Forensic Sciences
27 - 31 May 2007
Colombo, Sri Lanka
Singapore
inpalms2007@sri.lanka.net
iap2007@ams.edu.sg
JUNE 2007
3
11th Greek Australian International
Legal & Medical Conference
22 - 27 July 2007
AUGUST 2007
16
First World Congress on Pathology
Informatics (WCPI)
16 - 17 August 2007
3 - 9 June 2007
Brisbane, Australia
Crete, Greece
www.pathologyinformatics.org/
jennycrofts@ozemail.com.au
20
Sydney, Australia
judithh@icpmr.wsahs.nsw.gov.au
15
XXth International Symposium on
Technological Innovations in
Laboratory Hematology
3
17th IFCC – FESCC European
Congress of Clinical Chemistry and
Laboratory Medicine
3 - 7 June 2007
The Netherlands
24th World Congress of Pathology and
Laboratory Medicine
20 - 24 August 2007
Kuala Lumpur, Malaysia
acadmed@po.jaring.my
2 - 4 May 2007
Sydney, Australia
david_fulcher@wmi.usyd.edu.au
PATHWAY_67
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postscript
hard act to follow
HE WAS BOLD AND EVEN BRILLIANT, BUT COLOURFUL MEDICAL PIONEER JAMES EDWARD NEILD
HAD HIS FAIR SHARE OF PUBLIC HUMILIATIONS, WRITES WENDY LEWIS.
He also had a penchant for the bizarre
is Sherlock Holmesian reputation as a
forensic pathologist ensured James
Edward Neild was never far from the
public eye.
H
PHOTO CREDIT: MEDICAL HISTORY MUSEUM, UNIVERSITY OF MELBOURNE
– like the sorry saga of the young bride
This founding figure of the AMA was
unperturbed by the publicity that dogged
him in his regular attempts to solve
controversial murders.
Probably his most famous case was
that of Frederick Deeming, whose trial
electrified Melbourne society in a way not
seen since Ned Kelly.
Deeming, who went under several
aliases, was a bigamous cad who
murdered his wife and four children,
buried them under a hearth in Lancashire,
and then jaunted off to Australia. Once
here, he did exactly the same thing to his
new wife.
Forensic pathologist James Neild revelled in
the ‘theatre’ of medicine.
One such victim was the unfortunate
American actor McKean Buchanan.
Neild was acting coroner at the 1892
inquest into Deeming’s last victim and the
courtroom was an entertaining mix of
theatrics and forensics, with both
protagonists not accustomed to sharing
centre stage. In the end, justice was served.
Deeming was committed to stand trial and
was found guilty as a matter of course.
“Let me tell you, Mr B,” Neild wrote in
1856, “that a good deal of your Richard
the Third was violent, boisterous and
unnatural, and a good deal more of it silly
and puerile; that you maltreated
Shakspeare [sic] with a relentless cruelty
enough to make his dust rise in a
whirlwind and choke you…”
Neild was equally at home alienating
actors with his caustic critiques. His
passion for the theatre saw him emerge
as Australia’s leading theatre critic during
the second half of the nineteenth century.
The unfortunate actress playing
Adalgisa in Bellini’s opera Norma also
came in for a beating. Nield declared her
fulsome bosom inappropriate for a virgin
of the temple, a view not necessarily
shared by the theatre management: when
he next took his usual seat, he was
politely asked to leave.
After starting a general practice, he
discovered he could get free passage to
Australia as a ship’s doctor so, being 29
years old and single, off he went.
He began his journalistic assault
writing theatrical reviews under the name
of Christopher Sly, the tinker from The
Taming of the Shrew. He was not averse to
offending fellow journalists and certainly
didn’t mind sticking the knife into actors.
68_PATHWAY
wedding night from ‘sexual excitement’.
The mid to late 1800s were formative
times for medicine. A new kind of
practitioner – the ‘specialist’ – was
emerging and Australian doctors were a
world away from cutting-edge discoveries.
Naive diagnoses were not uncommon
and this was apparent in Neild’s work as a
forensic pathologist.
He was appointed a foundation
clinical lecturer in forensic medicine at the
University of Melbourne in 1865, a post he
held for nearly 40 years. Although not
especially qualified to even assume the
position, Neild became much in demand
as a medical witness and post-mortem
He was considered second to Jack
the Ripper in notoriety and as a result, the
case came to prominence in newspapers
all over the world.
Arriving in Australia in 1853, he had
studied surgery at London’s University
College but never completed the degree.
from Tasmania who sadly died on her
expert. He presided over a number of
Neild’s way with words made him a
worthy editor of the Australian Medical
Journal in 1862, a role he performed
admirably – and with a great deal of
editorial freedom – for 16 years.
He was ahead of his time in publishing
local cases, rather than simply reprints of
overseas material, and covered studies on
a range of topics including hydatids, the
medical uses of ozone, and septicaemia.
triumphant discoveries as well as some
grossly embarrassing misdiagnoses.
In one post-mortem, where a woman’s
throat had been slit, he found a sliver of
crockery under her skin and pronounced
that her death was the result of a freak
accident with a broken plate and not
murder, as had been assumed.
Another, where his interests in theatre
and forensic medicine collided, proved to
be Neild’s biggest faux pas. He was
summoned to the hotel room of a dying
theatrical agent and found the man
stretched out in bed, neck and mouth
covered in blood. Neild diagnosed a burst
blood vessel. Moments after he had gone,
it was discovered that the poor man had
shot himself twice in the chest.
Ah, but the most gifted among us are
but mere mortals.
James Edward Neild made his fair
share of mistakes and raised many
hackles, but he will be fondly remembered
for his literary accomplishments, his sharp
wit and the contributions he made to the
field of medicine in that brave new world
of nineteenth-century Melbourne.
Not just Quality Assurance!
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Virtual Images library
Synovial Fluid
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Case study exercises
Transfusion
Quality Systems Certification Organisation No: 9013
NATA Accredited Proficiency Testing Scheme Provider Number: 14863
www.rcpaqap.com.au
PathWay Autumn 2007 - Issue #11
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