T H E R O YA L C O L L E G E O F PAT H O L O G I S T S O F A U S T R A L A S I A
Spring 2006
Issue #9
WHERE ARE ALL
THE PATHOLOGISTS?
MEDICINE'S ENDANGERED SPECIES
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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
Spring 2006
Issue #9
Wayne Tregaskis
S2i Communications
PUBLISHER
Wayne Tregaskis
EXECUTIVE EDITOR
Dr Debra Graves
COVER STORY
EDITOR
Justine Costigan
Pathology Workforce
ART DIRECTOR
Jodi Webster
ADVERTISING SALES DIRECTOR
Linsday Cullens
PUBLISHING CO-ORDINATOR
Andrea Plawutsky
8
Countdown to crunchtime: PathWay looks at what’s in store for
patients if the current pathology workforce crisis is not
addressed.
HEALTH + MEDICINE
Pathology Training
14
Pathology has never been the easy option but the road to
becoming a pathologist is extremely rewarding.
PathWay is published quarterly for the Royal College
Profile: The Honorary Jane Lomax-Smith
19
4 O’Connell St Sydney 2000
Haematology
24
Tel (02) 9235 2555 Fax (02) 9235 2455
The perfect career for doctors who love both clinical and
laboratory work.
of Pathologists of Australasia (ABN 52 000 173 231)
by S2i Communications, Suite 1201, Level 12,
PrintPOST approved PP60630100114
Rheumatoid Arthritis
28
When your immune system turns against you, the result is chronic
pain.
Leukaemia and Lymphoma
The Royal College of Pathologists of Australasia
Tel: (02) 8356 5858
Email: rcpa@rcpa.edu.au
S2i Communications Pty Ltd
Tel: (02) 9235 2555
Email: wayne@s2i.com.au
PathWay
32
Tony James investigates the substantial advances in treatment
that are making a difference to thousands of lives.
Testicular Cancer
36
It may not be a comfortable subject to talk about, but becoming
familiar with the symptoms of testicular cancer could save your
life. Kelly Fraser reports.
Email: pathway@rcpa.edu.au
http://pathway.rcpa.edu.au
Meanwhile, back at the lab...
40
May Bott and Elaine Murray recall the early days of Sydney’s first
pathology laboratories.
FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF
Postcard from Orange
PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES
There’s more to working as a pathologist in regional Australia
than fresh air and beautiful views.
44
IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE
www.rcpa.edu.au
PATHWAY_1
REGULAR FEATURES
THE PATH TO A
REWARDING CAREER
Letter from RCPA CEO,
Dr Debra Graves
4
PathWay News
6
GP Column
PAGE 14
22
Dr Linda Calabresi argues that
Doctors need to set an example by
living a healthy and balanced life.
PATHWAY LIFESTYLE
Take out a subscription to PathWay
43
Conference Calendar
67
ARTS + CULTURE
Backpage
68
Artists and disease
Don’t Try This At Home: If the idea of
ripping off a band-aid or digging a
splinter out of your finger makes you
wince, look away now.
48
There is no doubt that the dark shadow of illness has played
a role in the production of many great works of art. Dave Hoskin
looks at the link between disease and remarkable achievement.
Ancient Voices
52
Paleo-pathologists can help reveal important clues
to the lives of ancient peoples.
TRAVEL
BALI IS BACK
Bali
56
Despite the troubles Bali has experienced in recent years,
it remains an idyllic island paradise.
PAGE 56
FOOD + WINE
Fortifieds, dessert wines, brandy….
60
Ben Canaider argues the case for these specialised drinks.
Chef Profile
62
Still a boy wonder after many years of success, Vue du Monde’s
Shannon Bennett hasn’t lost his magic touch.
RESTAURANT REVIEWS
PathWay makes the rounds at some of Australia's
most interesting and well-loved restaurants
64
PATHWAY_3
Welcome
to PathWay, issue number 9
ur cover story “Where are all the
pathologists… Medicine’s Endangered
Species” dramatically illustrates our
rationale behind publishing PathWay.
O
Pathology is a critical component of the
whole medical process. Without high
quality pathology, healthcare services will
degenerate and grind to a halt. Yet despite
the critical role pathologists and pathology
play in medicine, very few people
understand what pathology is really all
about.
It is both the ‘backroom’ and arguably,
the ‘backbone’ specialty of medicine, rarely
directly seen by patients or acknowledged
by health administrators and politicians as
the vital medical specialty that it is.
Unfortunately, unless a medical
specialty hits the headlines (like surgical
waiting lists, waiting times in emergency
departments and, more recently, the
problems with mental health in the
community), politicians don’t listen and
funding doesn’t follow.
As a consequence, the College decided
to create its own vehicle to get this
important message out to others in the
medical community, health administrators,
politicians, the media and the general
public.
By increasing awareness of how
important (and fascinating) pathology is,
support from governments for the future of
the profession will follow.
Now in our ninth edition, PathWay has
worked some way towards raising this
profile and understanding, in consort with
our editorial media strategies.
We acknowledge this will not occur
overnight, but slowly and surely the image
of pathologists dealing only with dead
people or automated blood tests is
changing.
The reality is that pathologists are the
doctors that diagnose all known cancers in
4_PATHWAY
the world, they are involved in diagnosing
infectious diseases such as Golden Staph
and influenza, they play an important role in
diagnosing and monitoring diseases such
as diabetes and rheumatoid arthritis, they
play an integral role in blood transfusion
services and more recently they are at the
cutting edge of using genetics in
diagnosing disease.
In fact, more than 70 per cent of all
diagnoses will involve a pathology test.
Further, pathology itself is the specialty
that looks at the underlying cause of all
diseases. As we like to say, “Medicine is
Pathology”.
So why is this critical area of medicine
an ‘endangered species’?
In the last 10 years in Australia, at least
70 training positions were cut out of the
system by stressed health administrators
trying to balance budgets for the short
term. There was no imperative to plan for
the longer term. The same situation exists
in New Zealand, with no increase in the
number of pathology trainee positions in
comparision with 30 years ago.
There are currently 1290 pathologists in
active practice in Australia. Twenty per cent
of these are over the age of 60 and almost
half of these, or a full 130, are over the age
of 65 years.
Currently in Australia we are only able
to produce about 55 new pathologists each
year… quite frightening when you consider
the age profile of pathologists and the fact
that we already have at least 70 vacancies
in the system for qualified pathologists that
cannot be filled.
The situation in New Zealand is even
worse, with a 31 per cent increase in the
number of pathologists or 63 extra
pathologists required to equal the
Australian ratios – which is already
acknowledged as being in crisis. The NZ
age profile is similar to Australia’s.
Indeed the crisis in pathology workforce
is global, so importing appropriately
qualified pathologists to fix the problem is
not a viable option.
Our cover story discusses the
Australian Medical Workforce Advisory
Committee’s 2003 recommendations that
Australia requires an extra 100 training
positions for at least five years, and
concludes that in the three years since the
report, we continue to fall worryingly short
of requirements.
Queensland is the only State
government that has taken the issue even
remotely seriously as they have funded 17
positions. The Commonwealth, as part of
the pathology professions Memorandum of
Understanding for Medicare funding of
Pathology, has funded 10 positions for five
years in the private sector. However the
profession has been requesting funding for
an additional 40 positions for five years – to
no avail.
There are more medical students
wanting to do pathology than there are
training positions, there are plenty of
laboratories that are accredited by the
College for training that are ready and
willing to train – there is just no funding
from governments to provide these extra
positions.
This is not a crisis that is looming – it is
here now. And immediate action is required
now to prevent the crisis from worsening
further.
Dr Debra Graves
CEO, RCPA
Inaugural National Disaster
Victim Identification
Workshop - Sri Lanka
A
ppraisal of responses to managing
the deceased following the 2004
Boxing Day Tsunami indicated that
improvement in Disaster Victim
Identification (DVI) procedures were
required in many affected countries. With
financial support from the Faculty of
Medicine, Nursing and Health Sciences,
Monash University, five members of the
Centre for Human Identification (CHI) at
the Victorian Institute of Forensic
Medicine (VIFM), which is Monash's
Department of Forensic Medicine,
provided a three day workshop in Disaster
Victim Identification in Galle, Sri Lanka
(7-9th July 2006).
The workshop consisted of formal
lectures which detailed the history of
natural and human induced disasters in
Sri Lanka and an account of the handling
of the aftermath of the Tsunami, a oneday practical session, and group
discussions. The workshop functioned
also as a debriefing exercise for the
country's forensic community about
Tsunami related matters.
Workshop activities included using a
mock disaster scenario of a light plane
crash so that participants could work
through the DVI procedure and the final
day of the workshop provided a forum for
the group to concentrate on what could
be done to advance identification
procedures in Sri Lanka.
- Professor Stephen Cordner
Director of the Victorian Institute of Forensic
Medicine
PATHOLOGY
UPDATE 2007
Put this date in your diary now!
PUP 2007
2-4 March 2007
Sydney Convention and
Exhibition Centre, Darling
Harbour, Sydney.
nternational speakers at the update
I
will include A/Prof Dr David
Huntsman from the Genetic
Pathology Evaluation Centre and the
Jack Bell Research Centre,
Vancouver, Canada; Professor Arnold
S Monto, Professor of Epidemiology
at the University of Michigan, USA;
Dr Robert E Petras, National Director
of Gastorintestinal Pathology
Services, AmeriPath Institute of
Gastrointestinal Pathology and
Digestive Disease, USA and A/Prof
Sunil K. Sethi, Department of
Professor Leslie Burnett
Appointed Chair of NPAAC
Pathology, National University
Hospital, Singapore. The Eva Raik
Lecture will be given by the 2006
Australian of the Year, Professor Ian
Frazer, from the Centre for
Immunology and Cancer Research,
rofessor Leslie Burnett has been
appointed the new Chair of NPAAC,
the National Pathology Accreditation
Advisory Council whose role includes
providing advice to the Commonwealth,
the States and the Territories on a range
of accreditation issues.
P
Professor Burnett is the Director of
PaLMS as well as the Clinical Associate
Professor in Pathology at the University of
Sydney and Adjunct Professor in Science
and Technology at the University of
Technology, Sydney. His area of expertise
is Clinical Biochemistry and Laboratory
Genetics and he has received multiple
Awards for Excellence in the area of
Quality management.
6_PATHWAY
University of Queensland.
and are rapidly expanding to include
screening for a variety of preventable
inherited disorders.
Professor Burnett established
Australia's first community genetics
testing program, based at PaLMS and the
Kolling Institute for Medical Research.
These testing programs already include
Tay-Sachs disease and cystic fibrosis,
In the field of health service
management, Prof Burnett has an
international reputation for the
development and implementation of
quality management systems and
business improvement programs. He is
also a member of the Panel of Evaluators
of the Australian Quality Awards.*
* Source PaLMS website at
www.palmslab.com.au/Profiles/burnett.shtml
Plasma
Fractionation
Review
Open Day at
Durham Hall
ustralia’s plasma fractionation
arrangements are currently under
review in order to comply with AustraliaUnited States Free Trade Agreement
commitments. The Review is being
managed by the federal Department of
Health and Ageing and is being
overseen by a steering committee
chaired by Mr Philip Flood, AO.
T
Plasma fractionation is the
separation of blood plasma into a
number of proteins for medical use.
Plasma products are used mainly to
treat trauma patients, provide protection
against infection for a variety of
conditions, and treat haemophilia and
other bleeding disorders.
Hall will be able to view the building’s
A
Under the terms of the Free Trade
Agreement Australia agreed to review its
current contract with CSL Australia, the
sole provider of plasma fractionation
services in Australia.
he RCPA’s beautiful Durham Hall
will join the line-up of architectural
projects and heritage buildings open to
the public during Sydney Open, the
city’s biennial architecture open day.
During the open day, many buildings
not usually open to the public will be
open for display. Visitors to Durham
façade, foyer, library, side verandah,
tea room, council room, upstairs front
rooms and one set of side rooms.
The possibility of off-shore
fractionation services has raised
questions about the future supply of safe
plasma products and whether Australia
should remain self-sufficient in this area.
The review is scheduled to be completed
by Jan 1, 2007.
Sydney Open, 9.30am-5pm,
Sunday November 5, 2006.
Sydney open sells out fast so register
to be on the mailing list by telephoning
02 8239 2288 or emailing
info@hht.net.au (include Sydney open
mailing list in the subject line).
Ccentric
Healthcare Executive Search
Helping Further Your Career
in Pathology
Visit us at www.ccentricgroup.com
Phone: 1300 723 559
PATHWAY_7
COVER STORY
Countdown to
crunch time
THE SHORTAGE OF PATHOLOGISTS IS STARTING TO HAVE AN IMPACT ON
PATIENTS AND IT IS GOING TO GET WORSE. MORE GOVERNMENT
FUNDING AND AN UPGRADING OF PATHOLOGY’S ROLE IN MEDICAL
COURSES ARE DESPERATELY NEEDED, WRITES BIANCA NOGRADY .
8_PATHWAY
So how did it get this bad? Dr Graves says part of the problem is that
pathology is the “backroom” of medicine. “It’s not front of house and
thus for hospital and healthcare administrators and politicians it is not
front of mind”
t’s a pathologist’s worst nightmare.
Somewhere in the steady parade of
slides is one bearing the telltale stamp of
malignancy, yet as it passes in front of
tired, overworked eyes, the warning signs
are missed and the sample is labelled
normal. A cancer goes undiagnosed and a
diagnosis that could save a life is delayed.
Departments are not excessive and
surgical waiting lists are under control.
Unfortunately investing in a workforce for
the future has taken second place in their
priorities. This is very shortsighted as
without pathologists, hospitals and
healthcare systems cannot function,” she
says.
This is a rare, worst-case scenario,
but experts are predicting it could
become more common as a dwindling
pathology workforce is stretched to its
limits. The workforce crisis, which has so
many in the profession dreading the next
five years, is beginning to affect patients,
and it will get worse over time.
About 70 pathology training positions
have been lost in the past decade, Dr
Graves says. The result is that in 2004,
there were at least 40 medical graduates
who applied for training in pathology but
were unable to get positions as there were
simply no jobs available. Given that there
is a global shortage of pathologists, it’s
only a matter of time before these
graduates are snapped up overseas.
I
The future of the pathology workforce
in Australia is looking grim. According to a
2003 report by the Australian Medical
Workforce Advisory Committee (AMWAC),
more than one-third of the 1290 practising
pathologists were over the age of 55 and
nearly 10 per cent or some 130 were over
65. Currently we are only producing
around 50-55 new pathologists per year.
To ensure a viable workforce as the older
generation retired, the committee
recommended creating an extra 100
training positions a year for at least 5
years commencing in 2004.
Another factor is government
restrictions on the numbers of medical
students, which were imposed in the
1990s. There has been a recent
recognition by the Commonwealth
Government of the need to increase
medical student places but the long-term
repercussions of this move are now being
felt across all areas of medicine. To
compound the matter, the shift to
problem-based learning has seen
pathology lose its prominence in the
medical curriculum.
Where once it was taught as a core
subject by pathologists, now it is more
often taught by non-pathologists and as a
small part of the bigger picture.
Awareness of pathology as a career
has suffered from this downgrading and
lack of exposure to mentors.
Former AMWAC chairwoman, Dr
Jeanette Young, says rural areas are
already experiencing shortages of
pathologists, in addition to a dearth of
other medical specialists. Metropolitan
areas are coping, but with the pathology
workforce already very efficient, Dr Young
says there is little fat left to trim.
“At the moment, the pathology
workforce is managing through multiple
strategies to maintain services with their
current numbers, but there probably will
be (effects) if they don’t recruit enough
new people,” she says. “The private
Unfortunately, reality falls far short of
this, says Dr Debra Graves, CEO of the
Royal College of Pathologists of
Australasia. “It’s extremely serious… we’re
in year three, so we should have 300 new
trainees on board,” she says. “We’ve
currently got 39.”
So how did it get this bad? Dr Graves
says part of the problem is that pathology
is the “backroom” of medicine. “It’s not
front of house and thus for hospital and
healthcare administrators and politicians it
is not front of mind”.
“It has been easy for hospital
administrators to target pathology training
positions when they have been trying to
balance their budgets. It is not easy
juggling priorities particularly when there
are political imperatives to make sure
waiting times in the Emergency
PATHWAY_9
“The problem, from what I know about NSW, ACT and Victoria, is that pathology is buried
in hospital administration, which is buried in an administration unit, which is buried within
the department, a long way from the director-general or minister. It makes it very hard for
pathology to speak about its workforce needs.”
sector is also starting to feel the pinch; I
think they are finding it harder to recruit.”
Training costs about $100,000 per
trainee per year and has traditionally been
funded by state health departments.
However, Dr Michael Guerin, chemical
pathologist and medical director of
Symbion Health, says the states have
neglected their responsibilities.
“The simple issue is the fact that the
Federal Government has been paying the
jurisdictions funding for years through
various health arrangements and never
actually bothered to specify that some of
this money should be spent on the
workforce in health,” Dr Guerin says.
Instead, funds have been diverted to
other areas of need within state health,
leaving pathology high and dry. It’s a
short-sighted strategy, he says, because
pathology is a cornerstone of medical
science, and as the population ages and
new tests are developed, demand for
diagnostic services will only increase.
Since AMWAC’s pathology workforce
report was released, some states have
acknowledged the seriousness of the
problem and taken at least preliminary
steps to fix it. One of these is
Queensland. Dr Michael Whiley, director
of Queensland Health Pathology Service,
says that three years ago the situation
was critical in Queensland. There was a
50 per cent vacancy rate in pathology,
and several senior pathologists had
resigned. Then the State Government
came up with funds for eight positions
across the state and across all pathology
specialities, and for 16 pathology registrar
positions.
“We’ve still got a wee way to go in
terms of the right total number of staff…”
Dr Whiley says. “We’ve got 70
The Emil von Behring
scholarship
The global shortage of scientific and medical staff in pathology prompted
international diagnostics manufacturer Dade Behring to look at ways it could relieve
the pressure. So the company created the Emil von Behring scholarship – a global
scholarship fund for students wanting to undertake pathology training. In Australia,
the funds go towards paying the cost of training one chemical pathologist, with
Symbion Health and the Pacific Laboratory Medicine Services (PaLMS) also
contributing and hosting the registrar – a unique arrangement bringing together
industry, public and private pathology.
Erica Flynn, general manager of Dade Behring ANZ, says the fund is only a small
drop in the ocean, “but at least it allows us to get some people into the medical
technology field and into the pathology area that might otherwise not have been able
to do it”.
Professor Leslie Burnett, director of PaLMS, says he was very impressed with the
far-sightedness of Dade Behring in recognising the looming crisis.
10_PATHWAY
pathologists in Queensland and we
probably need about 80.”
However, the record for other states is
poor. The NSW Government has given
seed funding for four registrar positions
for 12 months but has not guaranteed the
money beyond that. Victoria committed
one year of seed funding for six positions
but has failed to extend it. South Australia
has funded two positions, Western
Australia three, ACT one and Tasmania
one.
Dr Whiley attributes the Queensland
Government’s response to the fact that
public pathology services in the state are
united as a single entity. As director of
this entity, he is just two steps away from
the director-general of health, “so the
voice of pathology is heard loud and
clear”.
“The problem, from what I know about
NSW, ACT and Victoria, is that pathology
is buried in hospital administration,
which is buried in an administration unit,
which is buried within the department, a
long way from the director-general or
minister. It makes it very hard for
pathology to speak about its workforce
needs.”
Western Australia has made similar
moves to rationalise public pathology
services. Director-general of WA Health,
Dr Neale Fong, says the state is
undergoing a major health restructure,
including a merger of all public sector
pathology in one entity called PathWest,
which is expected to lead to significant
savings that hopefully can be used to
support more workforce initiatives. While
the state has so far only funded three
registrar positions, Dr Fong says it plans
to fund another 10 trainees over the next
five years.
Pathology groups are also looking to
alternative funding sources. The Federal
Government, via its Memorandum of
Understanding with the Pathology
profession (RCPA, the Australian
Association of Pathology Practices (AAPP)
and the National Coalition of Public
Pathology (NCOPP)), has stepped in with
money for 10 pathology training positions
for five years. The arrangement is an
unusual one in that the money goes to the
private pathology sector to provide the
training for private employees, with the
RCPA setting the criteria for the training.
Registrars must spend at least two years
of training in the public sector but the rest
is in the private sector. The positions are
divided up by state – two go to
Queensland, four to NSW, three to Victoria
and one to WA.
The RCPA has welcomed this
commitment, although it had originally
hoped to get 50 such positions. In fact
the profession had a budget submission
before the Commonwealth for an
additional $13.75 million for an additional
40 position for five years in this year’s
budget. Unfortunately there was no further
money forthcoming. This funding is
urgently needed.
Professor Leslie Burnett, director of
Pacific Laboratory Medicine Services and
clinical professor in pathology at the
University of Sydney, while delighted with
these positions, would like to see the
system being opened up to public sector
organisations as well as private.
“The public pathology sector has a
long and proud tradition of being the
major training ground for registrars
nationwide and we train the workforce for
both the public and private sectors – we
don’t distinguish.”
Dr Guerin says “The College, AAPP,
NCOPP have set up an excellent model
of public-private co-operation, the
Federal Government has been excellent
in funding this pilot project,” he says. “It’s
PATHWAY_11
Workforce statistics
A review of the RCPA database indicates how critical the situation has become: 20% of the practising pathologists
across Australia and New Zealand are over 60 years of age.
In the state of NSW, 44% of general pathologists – the workforce that generally services rural areas – are over the
age of 60.
AUSTRALIAN & NEW
ZEALAND WORKFORCE
Totals
30-45 yrs
46-55 yrs
56-60 yrs
61-65 yrs
(61-65 yrs)
66+ yrs
(66+ yrs)
Total over
60
Total Pathologists
1459
474
488
209
149
10%
139
10%
20%
NSW WORKFORCE
Totals
30-45 yrs
46-55 yrs
56-60 yrs
61-65 yrs
(61-65 yrs)
66+ yrs
(66+ yrs)
Total over
60
Anatomical Pathologists
186
72
48
19
17
9%
30
16%
25%
Chemical Pathologists
22
5
9
4
1
5%
3
14%
18%
Forensic Pathologists
8
2
4
1
0
0%
1
13%
13%
General Pathologists
50
6
15
7
8
16%
14
28%
44%
Genetics
2
0
1
1
0
0%
0
0%
0%
Haematologists
120
39
37
21
11
9%
12
10%
19%
Immunologists
35
15
11
5
1
3%
3
9%
11%
Microbiologists
55
14
24
6
5
9%
6
11%
20%
TOTAL
478
153
149
64
43
9%
69
14%
25%
a model that works, so fund it and let’s
get on with it.”
The diagnostics industry is also
helping out, with international diagnostics
manufacturer Dade Behring contributing a
substantial amount towards a registrar
training position in chemical pathology
(see box).
Even the equally cash-strapped world
of academia is getting involved - the
University of Queensland has provided
funds for one training position.
But such steps do not solve the
underlying problem of pathology fading
into the background of medical curricula,
Dr Whiley says. “The universities are
demolishing their pathology departments
all over the country and that hasn’t helped
because there haven’t been any
pathologists to put into them anyway.”
12_PATHWAY
The other unfortunate effect of
pathology’s invisibility is that medical
students are less aware of the work
involved in diagnostics.
Some universities are bucking the
trend and are working to rebuild
pathology into the clinical problem-based
learning program and looking at having
junior doctors doing residencies in
pathology. Others are starting to employ
pathologists passionate about teaching
medical students pathology. Both are
initiatives the College applauds.
Crystal ball gazers might be excused
for feeling that the future of pathology is
hardly bright. Despite AMWAC’s call to
arms in 2003, so little action had been
taken that chairwoman Dr Young used her
2005 annual report to criticise all parties
for failing to make progress.
Some, such as Professor Burnett,
doubt the situation will be adequately
resolved. “It’s entirely fixable but I’m not
optimistic that governments are so far
listening and understanding as much as
they need to do,” he says. “The RCPA is
doing a sterling job in trying to inform the
governments, but the most likely outcome
is we will have a partial fix and then we’ll
have a crunch.”
“It needs to be very clearly
understood that when the crunch comes,
it will be the governments that have failed
to fund.”
Others, such as Dr Guerin, are more
optimistic that the squeaky wheel will
eventually get the grease. “The only way
you’re going to get rid of me is to shove
money in my mouth,” he says. “We’re
going to keep coming back until we get
funding support for workforce.”
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
RCPA and National Science Week
August 12-20 2006
he RCPA will be promoting pathology during National Science Week this year through the distribution of a
dvd to schools and by touring a condensed version of the College’s successful Blood, Bugs and Bodies
exhibition to museums and conferences around the country. Over 11,000 copies of the pathology video
featuring the story of 12 year skateboarder Toby, who through a series of adventures and mishaps learns more
about the way his body works, has been distributed to science teachers around the country. An introduction to
basic pathology concepts, the film shows how diseases and ‘bugs’ can have an big impact on your health and
lifestyle.
T
At the same time, a condensed version of Blood, Bugs and Bodies will be seen at various museums and
conferences over the next few months. After its successful opening run at the Powerhouse Museum in March
this year, the exhibition has also been displayed at Sydney’s Australian Museum and RACMA conference and
will be seen at Devonport’s Imaginarium Science Centre (Aug 4-25 and September school holidays) and at
Science Week in Campbelltown, Sydney. Planning is in progress for the exhibition to run at the AACB/AIMS
and HSANZ conferences. Additional venues will be added to the touring schedule at a later date.
For more information about The Adventures of Toby and Blood, Bugs and Bodies visit the RCPA website at www.rcpa.edu.au
PATHWAY_13
HEALTH + MEDICINE
THE PATH TO A
REWARDING CAREER
14_PATHWAY
LOUISE MARTIN-CHEW OUTLINES THE
FASCINATING PATH TO BECOMING A PATHOLOGIST.
“It is fascinating as a discipline
minent pathologist Dr John Tonge
recalls how he and other founding
fellows were accepted into the then Royal
College of Pathologists of Australia (set up
in 1956) on the basis of 10 years’ industry
experience.
E
These days, given the growth and
high international standing of the
discipline, becoming a pathologist
requires undertaking strictly regulated
training. Some things, however, have not
changed: the desire to become a
pathologist is driven by reasons that have
attracted graduates since the birth of the
speciality.
Once appointed to a position, the
trainee registers with the RCPA. It is a
requirement that trainees not complete all
of their training in one position (no more
than four of the five years may be
undertaken in the same position).
Anatomical Pathology – the
study of organs and tissues to help in
determining the causes and effects of
particular diseases. An anatomical
pathologist’s findings are fundamental to
medical diagnosis, patient management
and research. Sub specialities include:
•
For Board of Censors Registrar Dr
Wendy Pryor, the specialty offers “an
opportunity to learn a lot in-depth, and a
range of disciplines to choose from”. But
the clincher for her is that pathology
makes you “very much part of the healthcare team for the patient, working closely
with clinicians and impacting strongly on
patient care”.
•
“You can name your location and
hours – locum, work part-time or fulltime,“ Dr Pryor says.
Pathology is a discipline that can only
be learned under an apprenticeship
system. Currently, that requires the
medical graduate, ideally with at least two
years’ experience as an intern and junior
medical officer, to apply for a training
position, either in private practice or in a
government training centre (such as a
hospital) for a minimum of five years.
These positions are advertised on the
RCPA’s website at www.rcpa.edu.au
well in a number of areas with
clinical training and practice.”
Training is in one of eight disciplines.
Dr Ross Boswell, Royal College of
Pathologists of Australasia Chair of the
Board of Censors, describes pathology as
“the scientific underpinning of medicine,
an intellectually challenging and satisfying
discipline”.
The worldwide shortage of
pathologists means there is plenty of
work and a lot of flexibility for medical
graduates interested in specialising in
the field.
and as a study. And it marries
histopathology – microscopic
examination of tissues, taken either
as biopsy samples or resection
specimens, for the purpose of
diagnosis, prognosis and directing
appropriate treatment;
cytology – the study of individual
cells to detect abnormal cells.
Chemical Pathology or
Biochemistry – involves the study
and investigation of the biochemical basis
of disease processes, with particular
emphasis on metabolic diseases, which
include diabetes, bone disease, inborn
errors of metabolism and lipid disorders.
Work covers the common investigations of
electrolyte and diagnostic enzyme
changes and plasma proteins seen in
routine clinical practice, as well as
endocrine testing, tumour markers,
therapeutic drugs and toxicology.
Forensic Pathology – investigating
unexpected deaths, including the analysis
of criminal cases and assisting the police
in a range of investigations.
Genetics
– includes two main
branches – cytogenetics (microscopic
analysis of chromosomal abnormalities)
and molecular genetics (uses DNA
technology to analyse mutations in genes).
It involves tests on chromosomes and
DNA from cells in body fluids and tissues
to diagnose genetic diseases.
Haematology – deals with many
aspects of diseases which affect the
blood, such as anaemia, leukaemia,
lymphoma and clotting or bleeding
disorders. It also encompasses the
subspecialty of transfusion medicine,
which includes blood typing and
compatibility testing and the management
and supply of a large range of blood
products.
Immunology – deals with
immunological tests for allergic reactions,
diagnostic markers for autoimmune
disorders such as lupus, rheumatoid
arthritis, diabetes and thyroid conditions,
and tests to monitor tissue injury due to
inflammation.
Microbiology
– deals with diseases
caused by infectious agents such as
bacteria, viruses, fungi and parasites
through tests on blood, body fluids and
tissue samples. Additional areas involve
control of outbreaks of infectious disease
and dealing with the problems of infections
caused by antibiotic-resistant bacteria.
General Pathology
– covers all
areas of pathology and is a wonderfully
diverse career option. Pathology is the
study of disease or any condition that
limits the quality, length, or enjoyment of
life. From the time a new life is created to
the time it ends pathology is involved.
Pathology touches every facet of medicine
and, therefore, society.
PATHWAY_15
VOX POPS OF PATHOLOGY
TRAINEES
Sophie Otto
4th year trainee, anatomical pathology
Institute of Medical and Veterinary Science, SA
Starting training in Anatomical Pathology felt like beginning my medical
degree all over again. The training program has proven to be challenging and
incredibly interesting. Nothing in clinical medicine properly prepares you for
this career path. I’d been a GP for 16 years and, with a colleague, also
operated a surgical assisting service so becoming a pathologist was a real
“sea change” for me. I wanted to do something new and was fascinated by
the problem-solving demands of this course. I particularly enjoy using
autopsy technique, as well as macroscopy and microscopy, in order to make
a diagnosis. I had the good fortune to pass my Part 1 exam last year, and this
year, having completed three and half years of training, hope to sit the
Postmortem Exam, and also complete my Case Book, both required
assessment elements in Anatomical Pathology.
Subject areas overlap within the
various disciplines. Each strand also
shares three major hurdles. The first is the
Basic Pathological Science exam that
every trainee must pass or gain exemption
from. This may be taken by a final-year
medical student or before commencement
of training.
Then, for each of the eight training
streams there is a part one examination
taken after about three years and a part
two exam taken in the final year. The part
two exam is a combination of a written
exam (essay questions, short answer
questions and some multiple choice),
practical and oral components.
These exams are designed to ensure
that people who pass and become Fellows
of the College are able to demonstrate
their knowledge of pathology in spoken
and written form to their colleagues.
While five years is the minimum time
taken, many trainees choose to spend
longer in this process, and not everyone
passes on the first attempt. However,
completion rates are high in comparison
with other disciplines.
16_PATHWAY
Pathology offers lifestyle advantages in that it may allow for
work/life balance. It is fascinating as a discipline and as a study.
And it marries well in a number of areas with clinical training and
practice.
Dr Pryor suggests that once people
get a taste for pathology, “they want more.
Essentially, once trainees are accepted, we
don’t have many dropouts.” Last year,
85.7 per cent of trainees who undertook
their part two examination passed.
The discipline, rather than the place of
study, determines the content of the
course (so those keen to pursue infectious
diseases do not necessarily need to head
for tropical areas). Most training is
undertaken in major city centres rather
than remote parts of Australia, and
pathologists working in smaller centres
tend to be general pathologists able to
accommodate the broader needs of the
community.
Joint qualifications are also available
with the Royal Australasian College of
Physicians, ie clinical haematology, clinical
immunology, microbiology with infectious
diseases or chemical pathology with
endocrinology.
Some high-profile pathologists work at
an international level on public health and
preventative policies. While this is not a
common path for pathologists, as a
discipline pathology does accommodate
those with an interest in management
systems.
Pathology also offers lifestyle
advantages in that it may allow for
work/life balance. But most importantly, as
Dr Boswell notes: “It is fascinating as a
discipline and as a study. And it marries
well in a number of areas with clinical
training and practice.”
High completion rates from initial
trainee to RCPA Fellow are testimony to its
inherent satisfactions.
Daman Languth
Completed training December 2005, immunology
Royal Brisbane Hospital
Desmond Chih
3rd year trainee, infectious
diseases and microbiology
Royal Darwin Hospital
I’m originally from Perth and
came to Darwin to start my
microbiology training.
I couldn’t resist the opportunity
to be exposed to the usual and
unusual pathogens up in the
Top End and had heard many
good reports in starting
laboratory training here. In many
ways, the training in Infectious
Diseases and Microbiology
complement each other and I
have decided to pursue
Pathology (Microbiology)
training as well. The
combination of both clinical and
laboratory work suits me and I
believe will create more
opportunities down the track.
I actually started rheumatology/physicians
training, then changed to clinical immunology
before beginning immunopathology. I had had limited
exposure to the field in Brisbane and it was only after I moved
to Royal Perth Hospital (after my first two years of advanced
training) that I decided upon immunopathology. I spent two
years in Perth and was lucky enough to train with some
wonderful pathologists there and in Brisbane; Richard Wong,
Dom Mallon and Peter Hollingsworth. Immunology is one of
the smaller Disciplines so you need to seek out the people
who can help you. It’s a good idea to move around hospitals
and cities to get a broad spectrum of training and experience.
In Perth I worked in HIV research and I’m now focussed on
auto-immune testing.
Fiona MacLean
Completed training July 2006, anatomical pathology
Douglass Hanly Moir, Sydney
I trained to be a physiotherapist because although I was interested in medicine I thought a medical degree would take too
long. After a few years as a physio I decided I did really want to become a doctor after all. Once I finished medical school I
was thinking about my options and pathology was one of the areas I was interested in. Pathology was not the easy option, it
has been much more work than I anticipated and I was surprised at how much there was to learn. It really showed me what
my limitations were. After being a competent resident in a hospital, starting pathology training was like going back to school
– I didn’t know how to do anything! Pathology is very mentally stimulating. There are so many variations, no problem is
exactly the same and you are challenged every single day. I have had quite a mixed training experience including spending
time in a number of public hospitals as well as in a private lab. This allowed me to compare my experiences working in
different settings, which has been important recently as I considered where I wanted to commence working as a newly
qualified pathologist. I chose to work at the private lab where I had spent some time training as I found the experience quite
positive, including plenty of opportunity to learn how to report cases, a wide variety of material to access and staff who were
easy to approach and enthusiastic to teach me. As a result I am looking forward to starting my career in that setting.
PATHWAY_17
Pathologists do it
With culture and sensitivity
Pathology - The study of disease, is a career which offers a number
of choices within the specialty including:
Anatomical Pathology (leading to Forensics)
Chemical Pathology
Genetics
General Pathology
Haematology
Immunology and
Microbiology
The RCPA (Royal College of Pathologists of Australasia) accredits
laboratories and pathology training, approves supervised training, and
conducts examinations leading to certification as a qualified
pathologist and Fellow of the College (FRCPA).
The College accepts applications from registered medical
practitioners with a minimum of one year’s post graduate experience.
Training in pathology takes five years.
Applicants must be employed in an accredited laboratory before
seeking registration with the College. Laboratories are accredited for
training in Australia, New Zealand, Hong Kong, Singapore, Malaysia
and Saudi Arabia.
The Royal College of Pathologists of Australasia
1 9 5 6 - CELEBRAT ING 50 YEAR S - 2006
16_PATHWAY
For more information on your exciting career in pathology visit the
College website: www.rcpa.edu.au or Tel: (02) 8356 5858.
PROFILE
DOCTOR IN THE HOUSE
WHERE ONCE SHE PRACTISED PATHOLOGY, JANE LOMAX-SMITH NOW PRACTISES POLITICS. BUT
SKILLS FROM HER PREVIOUS LIFE HAVE STOOD HER IN GOOD STEAD. THE SOUTH AUSTRALIAN
GOVERNMENT MINISTER TALKS TO PAM RACHOOTIN .
PHOTOGRAPHER: BRETT HARTWIG
he first thing I learned about Jane
Lomax-Smith was that there were few
times she was not juggling three things at
once. Presumably, any breathers she
takes are planned weeks in advance.
T
Over a cup of tea slotted in before
parliamentary question time, however, the
mood is surprisingly relaxed. The scene is
her large ministerial chambers within the
otherwise cramped South Australian
and set up her own pathology laboratory
Parliament House.
in Adelaide.
The Minister for Education and
Candid, thoughtful and articulate, she
Children’s Services, for Tourism and for
holds a PhD from the University of
the City of Adelaide has quite a CV. A UK
Adelaide for her work on the kidney
and Australian-trained anatomical
disease IgA nephropathy and liver
pathologist, she has been a lecturer and
disease, and has written numerous
researcher (including a stint at Harvard)
scientific publications.
PATHWAY_19
“Medicine is a really good skill
because it teaches you about
judgment… judging people…
people going into politics can
be gullible. I think that I have a
very honed skill in picking
porky pies.
“Lecturing was really significant in terms of public speaking. When
you had to talk to 100 fidgeting, scratching medical students, you
learned how to read the audience and change pace and direction.
You get a slightly theatrical bent if you are going to survive
(teaching) a basic pathology course.”
intellectual area, much more intellectual
than most of the other bits of medicine in
that day.”
Although she chose to do pathology
training from the start of her career, she
was also offered a job as a surgical
trainee by a vascular surgeon. She says
she “seemed to be capable of feeling
pulses, which a lot of housemen and
Her contribution to medicine and
science has been matched by her
dedication to community service. She
served five years as a councillor in local
government for Adelaide City from 1991
before being elected as Lord Mayor, a
position she held from 1997 to 2000. She
was elected to State Parliament as the
Labor member for Adelaide in 2002 and,
typically, began ministerial duties
immediately. She is married, with two
sons aged 16 and 18.
Dr Lomax-Smith comes from a
working-class background. Born in 1950,
20_PATHWAY
she grew up in the East End of London.
Her mother was a hairdresser and her
father a carpenter.
registrars weren’t capable of feeling”.
“One of my first jobs was in the
hairdresser’s shop, handing out hair rollers
and perm papers,” she says. She loves
the smell of perms, “so evocative of that
era”. I couldn’t help but wonder if early
exposure to pungent vapours helped
prepare her for later work on formalinpreserved specimens.
outpatient clinic. But she did not think she
She says she “always had a morbid
curiosity, and even as a (medical) student
was amazed by pathology. It was an
During her first year of pathology, she
worked once a week in a surgical
had the right personality for surgery and
didn’t like night work, so it was never an
option, despite her enjoyment of the
clinical work.
Asked whether her practice of
pathology helped prepare her for the
practice of politics, she says: “(Each of
the steps in) my really bizarre career path
has actually given me skills that have
been very useful.
“Pathology is generally also useful in that a lot of politics is about big policies, big
announcements, whereas being a pathologist, you always want to know why… what is
the underlying problem? Too often people devise a policy or a strategy without ever
asking themselves what the underlying problem is.”
“Medicine is a really good skill
because it teaches you about judgment
… judging people… people going into
politics can be gullible. I think that I have
a very honed skill in picking porky pies.
“Local government was very useful
because it taught me about process,
governance and everything from conflicts
of interest to … management areas like
strategic planning and human resources
that I wouldn’t otherwise have known
about.
“Lecturing was really significant in
terms of public speaking. When you had
to talk to 100 fidgeting, scratching
medical students, you learned how to
read the audience and change pace and
direction. You get a slightly theatrical bent
if you are going to survive (teaching) a
basic pathology course.”
She regards the old-fashioned
mortuary presentations as theatrical. “It
was all performance skills and about
pacing the information a bit at a time to
keep them on the edge of their seats.”
Dr Lomax-Smith regards science, and
especially an understanding of statistics,
as essential in politics. She gives her staff
her old statistics textbook to read
because, “I get enraged when people tell
me numbers mean something that they
don’t.” She values science for providing
an analytic approach to problem-solving.
“Pathology is generally also useful in
that a lot of politics is about big policies,
big announcements, whereas being a
pathologist, you always want to know
why … what is the underlying problem?
Too often people devise a policy or a
strategy without ever asking themselves
what the underlying problem is.”
She describes herself as a risk taker.
“I always want to know I can do
something, and once I prove it, I want to
do something else. In most professions
you have peaked by the age of 50 and
tend to learn less as time goes on.”
She has kept challenging herself
intellectually by switching careers and
starting again at the bottom of the
learning curve, not that she ever seems to
stay at the bottom for long.
way to everyone. She describes herself as
“fairly tough”.
Her most satisfying portfolio is
Education, she says, because of its
impact on the community and ability to
alter “everything from children’s
opportunity and family stability through to
the economic viability that underpins any
industry development”. She believes that
“one of the challenges is to match low
population growth with high skill needs
and low unemployment”.
She reads widely (“I drift into another
orbit reading”) and says one of the great
privileges of her current role is the
opportunity to meet the guests invited to
Adelaide’s Writers’ Week and the Festival
of Ideas.
Although she has an academic
background, including Latin, she believes
in flexibility in order to keep less
academic children engaged.
One of the issues she is particularly
interested in is how to make sure every
child gets to the stage of choosing a
career in life. She feels that “the worst
brain drain isn’t teenagers moving to
Sydney; it’s teenagers not reaching the
stage they can make choices (about
careers).”
She is also focusing on pre-school
experiences, the 0 to 5 age group,
especially investing in early childhood
development centres as one-stop shops
with early intervention services and the
capacity to facilitate good family
interactions during the crucial formative
years.
Asked what disease parliamentary
debate might most resemble, she is
understandably reluctant to think of it in
those terms, although tinnitus comes to
mind.
“It is more like a playground at
recess,” she says. “I look at the behaviour
around me and they remind me of my
boys at their worst … except that my
boys will grow up and, I hope, calm
down.”
So is it easier to be a woman in
medicine or politics? Dr Lomax-Smith
says she found pathology to be
egalitarian and characterised most men in
the field as “very sensitive individuals”.
“Politics can be abrasive,” but it is that
As for the workforce crisis in
pathology, Dr Lomax-Smith believes that
it is part of a greater crisis in science. She
is concerned about the “hullabaloo and
hysteria about autopsies and retained
body parts (that) is destroying the
appreciation of pathology as the only
natural audit. It is in the context of antiintellectual pressures from a whole range
of community views.”
As far as returning to a career in
pathology goes, she suspects she would
be “too rusty to go back now”, after a
gap of eight years. “The challenge for
histopathology, and the thing that
concerns me, is that if children have
never dissected an animal at school, and
if medical students know virtually no
anatomy or only learn on a need-to-know
basis, a lot… has been lost.
“Because, to me, (every single case
in) pathology is always a challenge, an
intellectual puzzle, and it is hard to
imagine that you can enjoy the craft
unless you have been involved in the
gross anatomy of it all. If you can’t
understand pathology, you can’t
understand treatment.”
She misses “the instant gratification of
pathology, the joy of finishing something,
the buzz of looking at a pile of signed
reports going out, or a completed autopsy
report. Because in politics nothing ever
gets finished, it is always a work in
progress. You are always nibbling at the
edges and pushing things along slowly,
without being able to say at the end of
the day, well, today I did something. It
may take months before anything really
happens.”
PATHWAY_21
GP COLUMN
Wanted: shining examples of vitality
IT’S NOT ENOUGH FOR DOCTORS TO MERELY TALK ABOUT HEALTHY LIFESTYLES – YOU NEED TO
HAVE ONE, WRITES LINDA CALABRESI .
The backlash was swift and pointed.
The hapless researcher was pilloried and
accused of being the “health police”, but
was he right? To what extent are we
obliged to practise what we preach in
order to be effective doctors?
More importantly, what are patients’
expectations regarding this issue?
One would have to predict a crisis of
credibility if a doctor was trying to sell the
benefits of a healthy diet and exercise
while personally having a body mass
index of 32!! Such anomalies do not go
unnoticed.
Dr Calabresi is a practising GP and
Medical Editor of the Medical Observer
ave a look around at the next medical
H
conference you attend. Check out
your colleagues as they absorb the latest
pearls of wisdom from some enthusiastic
speaker.
Let’s face it. As a group we’re not
exactly paragons of good health and
vitality, are we? With a few exceptions, we
can hardly be held up as shining
examples of healthy lifestyle choices and
perfect work/life balance, serving as an
inspiration to the unhealthy and the
unmotivated.
Recently a US researcher faced a
barrage of criticism after suggesting that
doctors could better serve their patients
by being the fittest and leanest human
beings in the population. In short we need
to become ideal role models.
What’s more, he went on to say that if
we didn’t, we would be reinforcing the
idea that the healthy aspirations we
advise for our patients are unattainable.
22_PATHWAY
A country GP friend had lived and
practised in the same small town for many
years. On attending the local show (as
you do), he thought he’d indulge in a
“Pluto pup” (aka heart attack on a stick).
You’d think such a minor transgression
would be overlooked in the spirit of the
occasion and given the fact he was
relatively young, fit and slim.
No way. He’d barely taken a bite
before the heckling started: “That’s not
good for you, you know, doc,” “Doesn’t
look like health food to me, doc,” and
even more pointedly, “That’ll kill you, you
know, doc.” The pressure was
overwhelming. He wound up throwing half
of it away!
The reality is, like it or not, our own
health and lifestyle will come under
scrutiny when we put ourselves up as
serious advocates for health.
And it’s not just the obvious as in
smoking, drinking, eating and exercise.
It’s also all those other aspects of
preventative health that we are so quick to
advise for our patients when we are in our
professional mode.
Do we get our cholesterol, blood
pressure, blood sugar level and so on
checked regularly? What about
mammograms and pap smears? Do we
practise stress management? Do we get
suspicious symptoms checked out early?
Once again, speaking generally, I
suspect our report card might include
“could try harder”. Even for doctors, the
gulf between knowing and doing is often
very wide.
Ignorance certainly isn’t the culprit,
but other factors such as time, motivation
and perhaps an ostrich mentality are likely
to be involved.
The accepted wisdom that all doctors
should have their own GP would logically
go a long way to solving or at least
managing this problem of substandard
self-care.
However, in my experience, doctors
who have sufficient self-awareness to
recognise the need to hand over
management of their own health care to
another doctor aren’t the ones with a
problem.
It’s the rest of us, myself included,
who tend to take shortcuts with their own
health, who never get around to getting
that fasting blood test, whose choice of
antibiotic can vary according to what’s in
the sample cupboard.
We are the ones who are going to
have to rise to the challenge as primary
care shifts from being illness-based to
being increasingly concerned with lifestyle
and preventative health.
It will only become more obvious to
our patients and the public at large how
well we follow our own advice. We all
know medicine is a life, not a job. We
don’t stop being doctors when we close
the surgery door. Our credibility is on the
line here.
In short, we will need to start looking
after ourselves as well as we try to look
after our patients.
There go the Tim Tams.
HEALTH + MEDICINE
Package deal
HAEMATOLOGY IS THE PERFECT CAREER FOR DOCTORS WHO CAN’T
CHOOSE BETWEEN DETECTIVE STORIES AND HOSPITAL BEDSIDE
DRAMAS, WRITE JENNI HARMAN AND MICHIKO SMITH .
PHOTOGRAPHER: EAMON GALLAGHER AND BRETT HARTWIG
even-year-old “Will” just wanted to
kick a ball around with his mates, but
since starting treatment with the anticlotting drug warfarin, he had been
sidelined from ball games, tree-climbing
and all pursuits that might risk a potentially
disastrous bump.
within a blood vessel. In Will’s case,
Will had been diagnosed with a
deficiency of protein S, a naturally
occurring anticoagulant necessary to
prevent abnormal blood clotting occurring
opposite risk of fatal bleeding – perhaps
Will’s blood level of protein S was in fact
acceptable to a sedate adult, but
normal for his age, and was low only
extremely frustrating to a 2018 World Cup
relative to standards derived from studies
hopeful.
in adults.
S
24_PATHWAY
Even more frightening for Will and his
insufficient levels explained the worrying
parents, he was still considered to be at
stroke-like symptoms he had been
risk of another stroke when referred to
showing.
Professor Paul Monagle, paediatric
Unfortunately, the standard
anticoagulant treatment carries the
haematologist at the Royal Children’s
Hospital, Melbourne. On careful reanalysis, Professor Monagle found that
“Not a week goes by where you are not faced with a patient with a
new disease you haven’t previously treated,”
Professor Monagle’s investigation led
to the discovery that Will’s neurological
episode hadn’t been a stroke at all, but a
treatable seizure. With warfarin no longer
necessary, Will is now catching up on two
years’ climbing and kicking and generally
getting his knees as scabby as the next
kid’s.
For other children, strokes and oncerare vascular diseases are a reality. The
Royal Children’s Hospital sees an average
of one child every week with thrombosis
(clotting accidents) and at least one each
fortnight with a stroke.
As improving medical care means that
more children are surviving once-fatal
primary illnesses, blood clots from central
venous catheters inserted into the chest
are becoming more common. For
pathologists, this change has opened up
new areas of investigation.
Professor Monagle arrived at a career
in thrombosis research via training in
paediatrics, during which he became
interested in childhood cancer and
decided to put in a year in a haematology
laboratory as part of the groundwork for a
job in oncology. To his surprise, he
thoroughly enjoyed the “detective work”
he found himself engaged in and decided
to switch to paediatric haematology.
“Not a week goes by where you are
not faced with a patient with a new
disease you haven’t previously treated,”
he says.
Professor Monagle now heads the
department of pathology at the University
of Melbourne, where he leads a research
team investigating developmental
haemostasis – the way the complex
biochemistry of blood clotting changes
throughout childhood – a new
understanding that has led to the
adjustment of laboratory testing
procedures to ensure misunderstandings
such as in Will’s case do not happen in
future.
What is exciting about haematology,
Professor Monagle says, is the chance to
be involved in all stages of a patient’s
“Research into thrombosis in children
is fascinating because we have such little
background knowledge,” Professor
Monagle says.
“Although all the same coagulant
molecules are present in children and
adults, they are present in different
quantities. This means that the entire
mechanism by which clots are formed is
different in children compared to adults.
The medical consequence of this is that
anticoagulant drugs that were effective in
adults may not be similarly effective in
children.”
As this understanding advances,
tailored treatment is replacing the former
“one size (adult size, that is) fits all”
approach.
“How you devise the treatment plan
for a three-year-old is completely different
from a treatment plan for a 10-year-old,”
Professor Monagle explains, citing this as
one of the aspects of paediatric
haematology that keeps the job both
challenging and interesting.
With better care, better
anticoagulation management and better
education for the children’s families,
complications and recurrences of
thrombosis are now extremely rare.
Professor Paul Monagle, paediatric haematologist at the Royal Children’s Hospital, Melbourne
PATHWAY_25
Professor Tim Hughes, director of
haematology research at South
Australia’s Institute of Medical and
Veterinary Science
“Haematology is rare
among medical
professions, allowing
you to couple
fundamental research
with clinical practice.”
care, avoiding the compartmentalisation
imposed by other medical specialities and
enabling a “multilayered” approach.
“As a clinician, you have the
opportunity to follow a patient right
through from presenting problem and
diagnosis to treatment. This allows the
clinician to devise the best treatment,
often along with consultants from other
specialties, and follow through with the
patient.
“Diagnosis and treatment of clotting
disorders requires paediatric
haematologists to work with consultants
from many different specialties. The
collaboration with consultants of various
fields adds to the breadth and variety of
work a paediatric haematologist faces on a
daily basis.”
This breadth of focus is also what
drives Professor Tim Hughes, director of
haematology research at South Australia’s
Institute of Medical and Veterinary Science.
“The attraction of haematology for me
was the capacity to continue an active
clinical practice and delve into the
molecular and cellular biology of a disease.
“I can see a patient with leukaemia,
take their blood or bone marrow cells,
follow through to the lab and study these
cells in culture. And then take this
improved understanding of the leukaemia
back to the patient to devise the best
treatment plan,” he says.
Becoming a
haematologist
M
edical graduates who have completed
their internship in a hospital are eligible
to apply for a training position in
haematology. The minimum time for
specialist training is five years, in a registrar
position accredited by the Royal College of
Pathologists of Australasia.
Trainees can choose either to train solely
for the RCPA qualification or, after qualifying
as a Fellow of the RCPA, train for a dual
fellowship with both the RCPA and the Royal
Australasian College of Physicians (RACP)
26_PATHWAY
“Haematology is rare
among medical professions,
allowing you to couple
fundamental research with
clinical practice.”
Professor Hughes moved
into haematology in the late
1980s, at a time when
researchers were pinpointing
the precise structure and
actions of the aberrant enzyme
responsible for malignant
overproduction of white blood
cells in patients with chronic
myeloid leukaemia (CML).
The CML story highlights
the interaction between
laboratory and clinical
medicine that so fascinates
haematologists. In the 1960s it was
understood that this usually fatal disease
was caused by a chromosomal
abnormality and by the 1970s, improved
genetic research techniques revealed that
this abnormality involved the fusion of two
genes.
The ’80s saw the protein product of
this cancer-causing double gene (known
as BCR–ABL) identified as an altered,
overactive form of the tyrosine kinase
enzyme. During the ’90s researchers
focused on finding molecules shaped to
lock into the abnormal enzyme and block
its action. By the late 1990s they
succeeded with the enzyme inhibitor
imatinib mesylate (Glivec), a treatment
considered to have revolutionised the
management of CML.
“It is a perfect example of
understanding the fundamental
mechanism of a disease and following it
through to therapy. There is rarely a
disease where you can follow through
from cause to therapy as directly as for
CML,” Professor Hughes says.
“The risk of progression from chronic
to acute leukaemia before the availability
of imatinib was about 15 per cent per
year. The risk for patients on imatinib
therapy was about 3 to 4 per cent for the
first few years of therapy and has now
fallen to less than 1 per cent. Based on
this, we can project survival of better than
15 to 20 years for most patients –
compared with only four to five years
before imatinib,” Professor Hughes
explains.
“There are now over 1,000 patients
living full and productive lives on
continuous imatinib therapy. As well as
having a dramatic effect on survival, the
quality of life for patients on imatinib is
generally excellent. The previous best
therapy, interferon, was associated with
major side effects which limited recipients’
quality of life.”
The chase is not over yet, though.
Lack of response to treatment in some
patients and the development of
resistance by the leukaemic cells led to
the development of a new generation of
these drugs, now undergoing clinical
trials. A mutation recently identified by
Professor Hughes’ research group
produces a CML-inducing protein that is
resistant to all available enzyme inhibitors.
“Resistance can occur when a small
population of the CML cells carry a
mutation in the BCR-ABL gene fusion,
which is not inactivated by imatinib. As
you continue to treat with imatinib you
‘select’ for more resistant cells as the
susceptible cells die off.
“We were able to identify a specific
type of mutation (called ‘p-loop’) which
was associated with a particularly poor
prognosis. Based on this knowledge, we
have been able to rescue patients who
develop these p-loop mutations with a
donor stem cell transplant before they
have developed advanced disease. This
finding has now been confirmed in French
and Italian studies, and has changed the
way these patients are treated
internationally.”
Given that imatinib acts only against
leukaemic cells already in the circulation,
Professor Hughes and his group are now
turning to their precursors, trying to
discover better ways to target leukaemic
stem cells.
Professor Hughes says the key to
good research is to find great
collaborators.
“Australian haematologists are well
known internationally for their capacity to
conduct high-quality clinical research and
combine different fields of science
through collaboration. The Australasian
Leukaemia and Lymphoma Group is
recognised in particular, because the
group’s haematologists and scientists
build such strong collaborations.”
The case for cases
esearch into bleeding disorders, and the evolution of haematology as a
distinct discipline, has advanced through careful case-by-case
observations by clinicians fascinated with the diversity of medical outcomes.
The present-day catalogue of coagulation and anticoagulant factors was
pieced together largely through the detailed study of individual patients.
R
Haematology is still suited to those who like to follow an individual’s case
story right through – doctors for whom puzzling over an idiosyncratic response
to standard treatment is what makes medicine fascinating, rather than seeing
those cases as exasperating aberrations in an otherwise tidy array of textbook
outcomes.
Some argue we need to ensure that this type of thinking isn’t lost in an era
where large, randomised, controlled clinical trials and meta-analyses
(statistical analysis of data from multiple trials) are sometimes seen as the only
respectable evidence.
As UK haematologist Paul Giangrande points out: “It can be difficult in this
intellectual climate to appreciate that humble case reports, usually banished to
the last pages of modern journals, have often been the source of great
advances in the past. In particular, many of the advances in coagulation
medicine have come from case reports from physicians who have written
about patients encountered in their busy everyday practice, patients in whom
they recognised something special or unusual, and from whom they have
learnt important clinical and scientific lessons.”
Source: Paul L. F. Giangrande. Six characters in search of an author: the history of the
nomenclature of coagulation factors. British Journal of Haematology 2003; 121: 703–712.
One area in which Australian
haematology enjoys a position at the
forefront of research is multiple myeloma,
another white blood cell malignancy. In
multiple myeloma, abnormal plasma cells
crowd the bone marrow and block the
production of normal blood cells,
suppressing the immune system and
causing kidney failure and painful bone
damage. About 1200 Australians are
diagnosed with multiple myeloma every
year, typically aged in their early 60s.
The current standard treatment for
patients under 65 is stem cell transplant
using the patient’s own cells harvested
from the blood. This is usually attempted
after three to six months’ treatment trying
to reduce the tumour load and prevent
stem cell contamination with malignant
plasma cells. Some patients undergo a
second transplant following relapse of the
disease some months after the first.
However, newer approaches that target
the malignant cells might change this
practice in the near future.
“There have been tremendous
improvements in drugs to treat multiple
myeloma,” says Professor Douglas
Joshua, head of clinical haematology at
the Sydney Cancer Centre.
Targeted treatments available in North
America and now undergoing clinical trials
in Australia include bortezomib, a drug
that kills cancer cells by inhibiting a
protease enzyme. Thalidomide’s
reputation has also enjoyed a recent
rehabilitation following the discovery that,
when combined with other cancer
treatments, it is an effective drug even in
patients who have relapsed following
other treatments.
According to Professor Joshua,
haematology is a career choice that will
ensure a young doctor a part in the next
generation of medical breakthroughs.
“If you want to be at the forefront of
development of new techniques, you want
to be in haematology,” he advises.
“Haematology is very exciting
because it encompasses both laboratory
science and clinical practice. If you want
the total package of laboratory research
and clinical practice, then you should
specialise in haematology.”
PATHWAY_27
HEALTH + MEDICINE
Joints under attack
AT EVERY MOMENT OF EVERY DAY YOUR IMMUNE SYSTEM IS PROTECTING YOU, BUT WEAPONS
CAN HAVE TWO EDGES, AND IF TURNED AGAINST YOU AS IN RHEUMATOID ARTHRITIS, THE
POWER OF YOUR OWN IMMUNE SYSTEM CAN BE DEVASTATING, WRITES MATT JOHNSON .
PHOTOGRAPHER: BRETT HARTWIG
28_PATHWAY
About 1 per cent of the population will be affected, with the onset
occurring most often between the ages of 25 and 50 and women two
to three times more likely to develop the disease than men.
rthritis is Australia’s leading cause of
disability and chronic pain, affecting
3.4 million people and limiting the lives of
four in five sufferers. Counter to general
opinion, it is not necessarily an old
person’s disease: more than half of those
affected are under 65, and it accounts for
nearly 1.8 million days of reduced activity
and about 213,000 days off work and
school each year.
A
There are more than 100 different
kinds of arthritis, but by far the two most
common are osteoarthritis and
rheumatoid arthritis. The term “arthritis’’
simply means inflammation of a joint. The
pain, swelling or stiffness associated with
the inflammation may be short-term as a
result of injury, but what most people
mean when they say “arthritis” is the
chronic form of osteoarthritis, in which
wear and tear on a joint damages the
protective cartilage that covers the ends
of the bones.
Rheumatoid arthritis, conversely, can
strike suddenly, at virtually any age and is
not necessarily preceded by injury or
excessive wear. It is the result of an attack
by the immune system on the joint itself,
and the effects can be devastating. The
adverse immune response may not even
be confined to the joints; evidence has
emerged that organs such as the heart,
lungs and eyes may also be affected.
Virtually all the joints in the limbs are
surrounded by a capsule of thin tissue,
the inner lining of which secretes fluid to
lubricate and protect the cartilagecovered bone ends as they rub against
each other. Like all other cells in the body,
these synovial tissue cells carry an
external marker that identifies them as
friendly to your immune system.
In rheumatoid arthritis these cells lose
their friendly status and become subject
to attack from the immune system.
Antibodies produced by the attack
continue to drive the response and
lymphocytes, immune system cells,
infiltrate the synovial tissue and further
inflame the reaction.
Immunopathologist and clinical
immunologist Professor Paul Gatenby,
from the Australian National University, is
one of thousands of scientists trying to
understand the disease.
“We firmly believe rheumatoid arthritis
is initiated by an auto-immune response
and that the immune system then
participates in the disease, but we don’t
know what the auto-antigen (the
substance triggering the immune
response) is,” he says.
Left unchecked, the normally delicate
synovial capsule starts to thicken and
develop folds as it is colonised by more
immune system cells and the synovial
cells themselves enlarge. By now the
inflamed lining of the joints is starting to
damage and erode not only the cartilage
but also the bone beneath it and
ligaments securing the joint.
“The inflammatory cascade that
occurs in rheumatoid arthritis literally
destroys the joint,” Professor Gatenby
says. “It’s a particularly severe form of
arthritis, and if not controlled properly the
joint becomes deformed by the muscle
forces acting on it.”
The onset of rheumatoid arthritis is
often insidious: the pain is usually slight
and may resolve several times before
becoming established. The problem
usually appears in both limbs at once and
most often the small joints of the hands
and feet are the first affected. Aside from
swelling and pain in the joints, sufferers
also usually complain of morning
stiffness, persistent fatigue and muscle
weakness.
What triggers the change in the cells
of the joint lining is not known. A genetic
predisposition has been identified and
tracked down to a specific gene, but it is
unlikely to cause the disease, only make
certain individuals more susceptible.
Environmental factors are suspected to
play a role, but none has proved
conclusive.
About 1 per cent of the population
will be affected, with the onset occurring
most often between the ages of 25 and
50 and women two to three times more
likely to develop the disease than men.
Until the cause is identified, the disease
cannot be prevented or a cure developed,
but a change in the way it is managed
and the advent of a new generation of
drugs have dramatically altered the
outlook for patients over the past few
years. In the absence of the causative
antigen, however, the problem is accurate
diagnosis.
“Rheumatoid arthritis is still a
common disease with a lot of disability
associated with it, but we now know that
if we pick it up early, there’s a great deal
that can be done,” says Dr David Gillis,
immunopathologist at the Institute of
Medical and Veterinary Science in South
Australia.
“But until we identify the antigen, or
antigens, that cause the disease, we don’t
have a test that conclusively identifies if
the disease is present or not, and that
means we don’t know who will respond to
the drugs and if the side effects of those
drugs are worth the risks,” he says.
“The big problem facing doctors is the
patient complaining of arthritic pain that’s
been there for, say, six weeks. Is this early
rheumatoid arthritis that needs aggressive
treatment, or will it go away by itself?”
The urgency becomes apparent when
it is realised that 90 per cent of the bone
damage due to rheumatoid arthritis
occurs in the first two years of the
disease.
The most common pathology test
sought by doctors suspecting rheumatoid
arthritis is a blood test for rheumatoid
factor, an immunologic marker that is
found in small amounts in a range of
acute and chronic diseases.
Unfortunately, it is also found in about
5 per cent of healthy elderly people, and
while very high levels of rheumatoid factor
PATHWAY_29
“The big problem facing doctors is the patient complaining of arthritic pain that’s been
there for, say, six weeks. Is this early rheumatoid arthritis that needs aggressive
treatment, or will it go away by itself?”
are usually associated with rheumatoid
arthritis, up to 25 per cent of rheumatoid
arthritis patients test negative for this
factor.
“We’re crying out for a better test,”
says Dr Gillis, “It’s bad enough that 25 per
cent of rheumatoid arthritis patients test
negative, but considering how important it
is to pick the disease early, what’s worse
is that rheumatoid factor is positive in only
25 per cent of early rheumatoid arthritis
patients.”
A recently developed antibody test
promises more accuracy but is still far
from conclusive.
The new anti-CCP test was developed
from two earlier tests that did not become
widespread in clinical practice because of
technical difficulties. Anti-perinuclear
factor (APF) and anti-keratin antibodies
(AKA) tests had a specificity of up to 70
per cent for rheumatoid arthritis, and
although they proved technically
problematical, they provided evidence that
APF and AKA were targeting particular
proteins in the inflammatory response.
A simpler test was then able to be
developed to detect the presence of the
antibodies against these proteins. The test
for anti-CCP is not as widely available as
that for rheumatoid factor.
“Anti-CCP can help confirm the
diagnosis, but it also appears to indicate
how severe the disease may become,
which in turn indicates that the patient is
at increased risk for damage to the joints,”
Dr Gillis says.
For Dr Gillis and Professor Gatenby,
the pathology tests are valuable tools, but
they are simply pieces in the diagnostic
puzzle.
“In the absence of knowing the
antigen, there’s no perfect test,’’ Professor
Gatenby says. Other diseases can cause
a rheumatoid factor positive result, and
the entire clinical picture needs to be
known.
Dr Gillis says: “The pathology tests
help us distinguish between the forms of
arthritis and are therefore very important,
but only in the context of a detailed
clinical examination and full patient
history.”
The frustration at not being able to
confirm the disease is heightened by
recent developments in understanding
and in new drugs with which to treat it.
“Rheumatoid arthritis has undergone a
significant revolution recently,’’ Professor
Gatenby says. ‘’First was the realisation
that there is a necessity in this disease to
control the inflammation more aggressively
– to control what is causing the damage. It
was routine practice for 20 years to start
by treating the symptoms conservatively
and only then move to more powerful
drugs when this failed,” he says.
“But studies made it clear we had to
move more rapidly. We were starting at
the wrong end. Now we aim to control the
inflammation quickly to reduce the joint
damage. This has led to fewer people
requiring joint replacements.”
The traditional treatment approach for
rheumatoid arthritis started with
nonsteroidal anti-inflammatory drugs
(NSAIDs) to control pain and stiffness. By
removing the pain barrier to exercise,
NSAIDS allowed the patient to maintain
some mobility, and slow-acting antirheumatic drugs (SAARDs) such as
methotrexate were introduced later in the
disease process.
Dr David Gillis, immunopathologist at the Institute of Medical and
Veterinary Science in South Australia
30_PATHWAY
This approach was used because
rheumatoid arthritis was thought to be a
benign disease controllable by NSAIDs,
and the SAARDs were considered too
toxic for regular use.
It is now recognised that rheumatoid
arthritis causes significant disease and
mortality and that NSAIDs do not prevent
the progression of the disease. It is also
understood that the slow-acting antirheumatic drugs are no more toxic than
many NSAIDs and so most physicians are
using SAARDs earlier.
Involvement in joint sites in established rheumatoid arthritis
Temporomandibular 30%
Cervical spine 40%
Crico-arytenoid 50%
Acromioclavicular 50%
An indication of the change in thinking
is the shift in terminology that has seen
the phrase ‘’slow-acting anti-rheumatic
drug’’ replace the previous description of
these drugs: ‘’disease-modifying antirheumatic drugs’’. It is now recognised
that many of these drugs do little to
modify the course of the disease except
to slow down the rate of new joint
lesions.
Shoulder 30%
Sternoclavicular 30%
Elbow 50%
Hip 50%
Wrist 80% (early)
Metacarpophalangeal,
proximal interphalangeal 90% (early)
The change has been prompted by a
new generation of drugs that actually
control the disease. The biological
response modifiers control the production
and effect of tumor necrosis factor and
interleukin 1, two powerful inflammatory
agents.
Professor Gatenby says these drugs
work extraordinarily well: “It’s rash to talk
about a cure as no one’s been on these
drugs for longer than a decade, but they
produce an extremely good outcome in
75 per cent of patients.
“They are spectacularly effective, but
they’re also spectacularly expensive, so
when they became available it was set up
so that patients only got them by failing to
respond to vigorous doses of the other
drugs,” he says.
The high cost of the drugs and the
strict prescription regime have had an
unexpected side effect: “By insisting
patients are first treated with SAARDs, it’s
made sure that people are treated with
sufficient doses.
"The spin-off has raised the quality of
the standard therapy, and we’ve found we
were undertreating people and weighing
the side effects too heavily. As a result,
we’ve found the use of the biologics is
lower than predicted and we’ve got better
treatment with standard drugs.”
Professor Gatenby expects drug
developments will continue. “The
biologicals are genetically engineered,
which is why they’re so expensive. If the
drug companies can mimic the drugs’
action with small molecules that can be
chemically synthesised, they will be much
cheaper.
Knee 80%
Ankle, subtalar 80%
Metatarsophalangeal 90% (early)
“Secondly, there are other targets,
other receptors or mediators, so I expect
there‘ll be a gradual expansion of these
families of medications and the newer
ones may be more effective and carry
fewer side effects.”
The side effects of all the drugs now
used to treat rheumatoid arthritis can be
serious, and patients need to be carefully
monitored, with sometimes monthly blood
tests. The biologicals profoundly suppress
the immune system, so patients are more
susceptible to infection, while the SAARDs
can affect the liver in the long term.
Pathologists also play a role in
monitoring long-term complications of the
disease outside the joints.
“There’s certainly a link between the
inflammation of rheumatoid arthritis and
the inflammation process that contributes
to coronary artery disease, and we now
follow the lipid (cholesterol) levels of
rheumatoid arthritis patients very closely
and treat them if necessary,” Dr Gillis says.
It’s the necessarily close relationship
between the rheumatologist, local doctor,
pathologist and radiographer that leads
Professor Gatenby to remark that
rheumatoid arthritis is a disease where
attention to detail is very important.
“The people who do best have a firm
partnership between themselves and their
medical team,” he says. “Treatment is a
trade-off between relief versus toxicity,
and regularly assessing the efficacy of the
therapy is vital.
“Patients need to see someone who
understands the disease and the
treatment options and who is current with
these new therapies, who can make sure
their treatment is the best available and
who can help them monitor and control
the side effects.”
Meanwhile, not far removed, the
search for the ultimate cause will continue.
Is it a single antigen or a combination?
The genetic susceptibility makes Professor
Gatenby suspect a single antigen is more
likely, but it could still be something
derived from the environment that mimics
some biological antigen. Until it is found
the uncertainty over the diagnosis and
treatment will remain.
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
PATHWAY_31
HEALTH + MEDICINE
Blood cancers:
reasons for hope
SUBSTANTIAL ADVANCES IN TREATMENT FOR DISEASES SUCH AS LYMPHOMA AND
LEUKAEMIA ARE MAKING A DIFFERENCE TO THOUSANDS OF LIVES, WRITES TONY JAMES .
PHOTOGRAPHER: MALCOLM FAIRCLOUGH
lood cancers are a complex group of
diseases with outlooks ranging from
slow progression of an illness that poses
little threat to rapidly progressing, highrisk disorders. The good news is that real
advances in treatment have been
achieved in the past few decades, and
patients are benefiting from the genetic
revolution.
B
Pathologist and physician Dr David
Joske, the head of clinical haematology at
Sir Charles Gairdner Hospital in Perth,
says it is an exciting time.
“Not only are new treatments more
effective, but they are also easier for
patients, targeted closely at the disease
process and having few side effects.”
Of the blood cancers, leukaemia is a
cancer of white blood cells and their
precursors that arises in bone marrow.
Lymphoma is a cancer of cells of the
immune system that are lodged mainly in
lymph nodes and other lymphoid tissue,
for example in the lining of the gut. In
both cases, malignant cells can spill into
circulating blood, but this is not reliable
enough for diagnosis.
as fever, sweats, weight loss, tiredness
and itching,” Dr Joske says. “If someone
has a swollen lymph node that persists for
four weeks or more, and especially if they
are also unwell, then the possibility of
lymphoma needs to be considered.”
Leukaemia causes widespread
disruption to the normal function of bone
marrow in producing the cellular
components of blood. “Negative”
symptoms of leukaemia result from
deficits in white cells (for example,
infection), red cells (for example, anaemia
and fatigue) and platelets (excessive
bleeding). “Positive” symptoms can
resemble those of lymphoma and include
weight loss, night sweats and fever.
Diagnosis of lymphoma requires a
biopsy of the lump. In leukaemia, the
number of white blood cells in the
circulation can be normal, elevated or
decreased, and a bone marrow biopsy is
essential to make the diagnosis.
Myeloma is a distinct type of tumour
in which antibody-producing cells
proliferate in bone marrow and release
abnormal proteins into circulation.
In myeloma, problems such as renal
dysfunction can be caused by the
abnormal protein products of malignant
lymphocytes, and proliferation of the cells
in marrow can cause bone fractures and
pain. The first step in diagnosis is to
identify the circulating proteins, followed
by bone marrow biopsy and other tests.
“Lymphoma usually presents as a
lump, typically in the lymph nodes such
as those in the neck, armpit or groin, with
or without constitutional symptoms such
Imatinib (Glivec) is the outstanding
example of how scientific advances can
transform the treatment of some cancers,
Dr Joske says. In 1960 an abnormal
32_PATHWAY
chromosome was first identified in
patients with chronic myeloid leukaemia
(CML) and labelled the Philadelphia
chromosome.
Subsequent research showed it
resulted from the creation of a novel gene
called BCR-ABL that specifies the
production of an abnormal tyrosine kinase
enzyme. The enzyme is the underlying
cause of the disease and is very
specifically targeted by imatinib.
“Imatinib was the first true ‘magic
bullet’ in cancer treatment,” Dr Joske
says. It directly attacks the biological
abnormality, kills CML cells but has
almost no effect on other tissues and
causes few side effects.
“Five-year results presented recently
show that more than 90 per cent of
patients appear to have complete
disappearance of their leukaemic cells,”
he says. “Trials are now investigating the
feasibility of stopping treatment to see if
they are, in fact, cured, and new
treatments are being developed for the
small subset of patients whose disease is
resistant to imatinib.”
Another advance is rituximab
(MabThera), which binds to the CD20
antigen found on the surface of abnormal
lymphocyte cells in more than 95 per cent
of patients with B-cell non-Hodgkin’s
lymphomas. Response rates are
favourable, and the incidence of serious
side effects is low.
Clinical professor Dominic Spagnolo (left),
a consultant anatomical pathologist with a
special interest in lymphomas at PathWest
Laboratory Medicine in Perth with
Pathologist and Physician Dr David Joske
(right), the head of clinical haematology at
Sir Charles Gairdner Hospital in Perth
“We have a high degree of interaction with other specialists and take a truly multidisciplinary
approach to the diagnosis and management of patients,” Professor Spagnolo says.
When microscopes and basic stains
were their only tools, pathologists used to
concentrate on the superficial appearance
of cells to diagnose blood cancers. Today,
a far more sophisticated set of tools is
available.
Clinical Professor Dominic Spagnolo, a
consultant anatomical pathologist with a
special interest in lymphomas at PathWest
Laboratory Medicine in Perth, works
closely with haematologists such as David
Joske in defining the exact type of cancer,
its characteristics, the outlook for the
patient and the best treatment.
“We have a high degree of interaction
with other specialists and take a truly
multidisciplinary approach to the
diagnosis and management of patients,”
Professor Spagnolo says.
“For example, when an enlarged
lymph node suggestive of lymphoma is
removed by a surgeon, we examine cells
microscopically, test for cell surface
markers and analyse the DNA. This
defines the precise biological features of
the tumour, and we work with
haematologists and others to formulate
the diagnosis and thus develop the best
approach to treatment.”
The massive expansion in
understanding of blood cancers will pose
new challenges for pathologists in this
increasingly specialised discipline. New
knowledge is prompting revision of
outdated disease classification systems,
and laboratories will be forced to move
rapidly to keep up and provide accurate
information.
An Australian Blood Cancer Registry is
being developed and will provide more
comprehensive and reliable data on the
effect of these diseases on society.
“It will help clinicians to understand
the burden of disease and the outcomes
at a population level,” Dr Joske says.
“Consumers will be able to lobby in an
informed way for further support. The
information will help governments in
allocating health-care resources, and to
see whether clinical practice guidelines
are appropriate and are being
implemented.
“It will provide very important
information on epidemiology. For example,
the incidence of lymphoma has doubled in
the last 20 years. We still don’t know why,
although environmental influences ranging
from lifestyle to pesticides and ultraviolet
light exposure have been suggested.”
Professor Spagnolo stresses that
accurate diagnostic information, the
province of pathologists, will be essential
in ensuring the data have real meaning,
particularly when other researchers are
using the diagnostic information to draw
conclusions.
PATHWAY_33
LEUKAEMIA IN CHILDREN:
A SUCCESS STORY
wenty years ago a diagnosis of
leukaemia in a child was most often a
death sentence, with cure rates no higher
than 30 per cent. Today about 80 per cent
are cured as a result of the sustained
research that has led to better treatment.
T
Dr Catherine Cole, a paediatric
haematologist and oncologist and the
director of laboratory haematology at
Princess Margaret Hospital for Children in
Perth, says leukaemia accounts for about
25 per cent of childhood cancers. Of that
25 per cent, about 85 per cent are the
high-risk and rapidly progressive acute
lymphoblastic leukaemias (ALL). Her unit
treats about 15 new ALL cases a year.
Leukaemia treatment is tailored to
each patient and adjusted according to
the response at each stage of therapy.
The complete course of treatment
typically extends over two years in girls
and three years in boys.
The first month’s treatment targets the
cancer itself, and the response can be
assessed in the first one or two weeks.
Even in this early stage it is possible to
identify markers that suggest a good
prognosis, in which case some aspects of
treatment can be scaled back, or more
resistant disease that might benefit from
more intensive therapy.
The next phase aims to prevent the
spread of the leukaemia cells into the
brain and spinal cord. Radiotherapy was
once used, but chemotherapy
administered into the fluid surrounding the
spinal cord is now the treatment of
choice, as it has significantly fewer
adverse effects. A second phase of
chemotherapy, termed reintensification, is
aimed at further reducing the number of
diseased cells.
These first stages require an extended
time in hospital and lead to wellrecognised side effects such as hair loss.
But children can resume almost normal
34_PATHWAY
lives as they move into an
extended period of
maintenance therapy,
requiring a single monthly
intravenous chemotherapy
treatment supplemented by
oral medication.
“We are extremely
conscious of the psychological
effects of the disease and its
treatment on our patients and
their families,” Dr Cole says.
“Paediatric oncology is very
good at providing
multidisciplinary care that
involves social workers,
psychologists, teachers and
other disciplines as well as
medical services. The highest
incidence of ALL is in
preschoolers, and we know
that many can’t remember much
about their illness or its treatment
when they are older.”
Dr Catherine Cole, a paediatric haematologist and
oncologist and the director of laboratory haematology at
Princess Margaret Hospital for Children in Perth
Refinement to chemotherapy
protocols so they kill cancer cells
more effectively is one element of
the advances in leukaemia treatment.
Other advances include treatments that
are better tolerated, causing fewer side
effects at the time and less likelihood of
future problems such as infertility. Better
supportive treatment, for example to
control infection when patients’ immune
systems are suppressed, has also helped.
Although childhood leukaemia attracts
considerable attention because of its
particular poignancy, it fortunately remains
relatively rare. This means that individual
treatment centres would have difficulty
recruiting sufficient patients for meaningful
studies, so national and international cooperation is essential.
The Princess Margaret oncology unit
was the first non-American institution to
join the US-based Children’s Oncology
Group. Established more than 50 years
ago, the group now enrols about 2,000
patients a year into its clinical trial
programs.
As a paediatric and adolescent
oncologist and haematologist, Dr Cole
has a special interest in patients who can
fall into a poorly defined area between
paediatric and adult services. Her young
patients tend to have a greater capacity to
tolerate intensive cancer treatment than
older adults, and there is a risk that older
adolescents or young adults will miss out
on optimal treatment.
“We now have evidence that young
adults with leukaemia can do twice as
well when they are treated with
‘paediatric’ rather than ‘adult’ protocols,”
she says.
BONE MARROW TRANSPLANTATION
ubstantial advances have also been
made in bone marrow transplantation,
a key part of treating certain blood
cancers. About 1,200 transplants are
conducted each year in Australia, of
which two-thirds use the patient’s own
cells and one-third use donor cells.
S
subjected to chemotherapy or
radiotherapy. This effectively provides the
patient with a new immune system to
attack abnormal cells, although there is
some risk of the graft attacking normal
tissue.
Autologous transplantation typically
involves obtaining bone marrow cells from
the patient prior to chemotherapy and/or
radiotherapy. Temporarily “banking” the
stem cells allows the patient to receive
high-dose treatment that is more effective
in killing cancer cells but destroys marrow
cells. Stem cells are then returned to
repopulate the marrow and restore normal
blood cell formation.
The advent of recombinant G-CSF
(granulocyte colony stimulating factor) –
largely a product of Australian research
led by pathologist Professor Donald
Metcalfe – has removed the need to
surgically extract bone marrow from
donors. Instead, four injections of G-CSF
are used to stimulate the proliferation of
stem cells in marrow and their liberation
into circulating blood.
In allogeneic transplants, stem cells
from a donor, matched as closely as
possible to the recipient, are transplanted
after the patient’s own marrow is
The circulating stem cells are then
extracted in a procedure that is no more
taxing than a normal blood donation,
except that it takes three or four hours.
The Australian Bone Marrow Donor
Registry (www.abmdr.org.au) lists people
willing to be considered as stem cell
donors. Potential donors must be aged
between 18 and 40, meet the usual
requirements for blood donation and be
prepared to donate on behalf of patients
anywhere in the world.
After registering with the Australian
Red Cross Blood Service, donors provide
a blood sample for tissue typing, and their
details are entered onto an international
database of more than 10 million people.
About 1,000 Australians are asked to
donate stem cells each year.
The Australasian Bone Marrow
Transplant Recipient Registry records
virtually all transplants conducted in
Australia since 1992 and New Zealand
since 1998 and contains data on about
11,000 procedures.
BLOOD CANCERS – A QUICK GUIDE
Source: Leukaemia Foundation, www.leukaemia.org.au
NEW CASES IN
AUSTRALIA PER YEAR
PEAK AGE OF
INCIDENCE
MOST COMMON COURSE
OF DISEASE
Leukaemia
Acute lymphoblastic leukaemia (ALL)
300
Children 0-14 years
(60% of all cases)
Progresses quickly
Chronic lymphocytic leukaemia (CLL)
700
> 60 years (80% of cases),
rare <40 years
Progresses slowly, not all cases require
treatment
Acute myeloid leukaemia (AML)
700
> 60 years
Progresses quickly
Chronic myeloid leukaemia (CML)
250
> 50 years
Develops gradually, but chronic phase can
progress to accelerated and blast phases
requiring intensive treatment
3,500
> 50 years
Highly variable: many different types
400
15-30 years
Variable; most are curable
> 60 years (80% of cases)
Variable in early stages, but often
progresses to serious disease
Lymphoma
B-cell or T-cell (non-Hodgkin’s) lymphoma
Hodgkin’s lymphoma
Myeloma
1,100
PATHWAY_35
HEALTH + MEDICINE
a dangerous silence
TESTICULAR CANCER IS ONE OF THE MOST CURABLE OF ALL CANCERS,
BUT MEN WORRIED ABOUT A LUMP ARE OFTEN EXTREMELY STUBBORN
ABOUT SEEING A DOCTOR, WRITES KELLY FRASER .
en can be stoic and stubborn about
diameter while patients stalled, hoping the
develop and only 15 per cent thought it
going to the doctor, particularly
problem would somehow disappear.
could be cured.
M
when they are worried about a lump in
“It’s absolutely incredible,” he says.
The good news is that testicular
their private parts. It is often partners who
“Men are self-conscious about testicular
cancer, affecting the egg-shaped glands
will notice the lump or a change in the
examination. One of the things that
that produce semen and sex hormones in
size of their man’s testicle and browbeat
society needs to promote is awareness of
men, is one of the most curable of all
them into action.
testicular cancer in men. There’s an
cancers.
Brett Delahunt, professor of pathology
enormous ignorance out there.”
Lack of public knowledge about the
and molecular medicine at the University
A study he carried out in 1994
of Otago’s Wellington School of Medicine
involving about 500 New Zealand men
it is relatively rare, with an estimated
in New Zealand, has seen tumours that
with a mean age of 39 found 70 per cent
incidence of six in every 100,000 men.
have grown up to 12 centimetres in
were unaware that testicular cancer could
But greater awareness is needed because
36_PATHWAY
disease is partly explained by the fact that
In Australia there were 578 cases and 19 deaths relating to testicular
cancer in 2000. Awareness is important because the earlier the
cancer is diagnosed, the better the prognosis.
the rate is steadily increasing and the
number of men diagnosed has grown by
34 per cent in the past decade. In men
aged 15 to 35, it is one of the most
common cancers.
Fortunately the survival rate is also
rising as methods of treatment improve.
Five-year relative survival is about 93
per cent for all age groups under 60.
New Zealand figures show there were
124 men diagnosed with testicular cancer
in 1996, while in 1997 six people died of
the disease. It is projected that in 2011
163 men will be diagnosed with
the cancer but only three will
die, because of a higher cure
rate due to earlier diagnosis
and improved treatment,
including new chemotherapy
drugs.
Wellington Hospital urologist Richard
Robinson, who works closely with
Professor Delahunt, says GPs may see
only one or two cases of testicular cancer
in their career, but they are usually alert to
the warning signs. Referrals are treated as
a high priority because the patient needs
to be assessed and treated promptly.
The urologist will order blood tests
that can reveal elevated levels of proteins
in the blood that suggest cancer is
present. For this reason they are called
tumour markers. Testicular tumours are
one of the few that
produce these
chemicals.
While most cancers are diagnosed
through a biopsy that removes a small
piece of tissue from the tumour, this is not
usually done with testicular cancer
because cutting through the outer layer of
the testicle would risk spreading the
cancerous cells to other parts of the body.
“In most normal circumstances, there
is no biopsy prior to (testicle) removal,”
Professor Delahunt says.
In Australia there were 578
cases and 19 deaths relating to
testicular cancer in 2000. Awareness
is important because the earlier the
cancer is diagnosed, the better the
prognosis.
The testicle is removed through the
groin, not the scrotum. An incision is
made above the pubic bone and the
testicle is pulled out by the spermatic
cord, which is also removed because
it contains blood and lymph vessels
that can act as a pathway allowing the
cancer to spread. Cutting into the scrotum
would also risk dispersing the tumour
cells, causing the cancer to advance from
stage I to stage IV.
“If you catch a testicular
cancer when it’s a small
nodule, then the outcome
is much better than if it’s
huge. It’s one of the most
treatable cancers of all;
even if it has spread it’s
treatable,” says Professor
Delahunt, who specialises
in urologic pathology.
Symptoms include a
usually painless lump in
the testicle, or a change
in its size or shape. About
a third of patients report a
dragging, heavy sensation
and dull ache in their lower
abdomen or groin. A number of
non-cancerous conditions can
produce similar symptoms, but men
should always see their GP, who will refer
them to a urologist, if they are concerned.
Other factors can cause tumour
markers to rise, such as liver or blood
disease, and it is possible to have
testicular cancer and not have elevated
markers. An ultrasound is often carried
out to check for a mass in the testicle.
But, a diagnosis of testicular cancer is not
conclusive until after the testicle has been
removed in an operation called an
orchidectomy and examined by a
pathologist.
The removal of one testicle
does not usually affect the
patient’s ability to have a
normal sex life, but it may
reduce fertility. Mr Robinson
says urologists will discuss the
need to bank sperm with a
patient when decisions about
follow-up treatment, such as
chemotherapy, are made.
This image of an advanced tumour may be
horrifying, but the good news for men is that if
it is caught early enough, testicular cancer is
one of the most curable of all cancers.
Men can have an artificial
testicle placed in the scrotum,
but Mr Robinson usually
discourages this because of the
hardness of the solid silicon implants
used. “But that’s a personal preference,”
he says.
PATHWAY_37
Professor Brett Delahunt, a
specialist in urologic pathology,
as portrayed in caricature by
one of his favourite artists.
process takes into account the size of the
primary tumour and whether it has
spread.
Advanced testicular cancer can invade
the lymph nodes around the major blood
vessels that lead in and out of the heart.
Doctors use CT scans of the abdomen
and chest to determine whether the
cancer has spread into this region or to
the lungs.
Professor Delahunt says the
pathologist and urologist will meet to
discuss the case. “We have a urology
meeting where we look at the slides
together and tell (the urologist) what the
diagnosis is and we talk about the staging
of the patient,” Professor Delahunt says.
Mr Robinson says the professional
relationship between a urologist and
pathologist is very important.
There are many different
varieties of testicular tumours.
Most cancers start in the cells
that make sperm, called germ
cells. Seminona is the most
common type of germ cell
tumour, accounting for about
40 per cent of cases.
After the testicle is removed it is
immediately assessed by a pathologist,
who will cut it in half and examine it
before dividing it into sections to
determine what type of tumour it is.
There are many different varieties of
testicular tumours. Most cancers start in
the cells that make sperm, called germ
cells. Seminona is the most common type
of germ cell tumour, accounting for about
40 per cent of cases.
Non-seminoma tumours are more
common in younger men, usually aged in
their 20s, and they include teratoma,
embryonal carcinoma and
choriocarcinoma. They tend to be more
aggressive and more likely to spread, but
they respond well to chemotherapy.
Sometimes the cancer is a mixture of
different types. There are also non-germ
cell tumours, but these make up only
about 5 per cent of cases.
Along with identifying the type of
cancer affecting a patient, determining
what stage the cancer is at is a vital part
of the pathologist’s role. This complex
38_PATHWAY
“We would review all of these patients
with a pathologist. Most urologists would
be very reliant on the pathologist because
their histological diagnosis is a critical part
of the whole treatment.”
Information from blood tests, scans
and the pathology of the tumour is used
to make decisions on how the patient will
be treated after surgery. For some
patients whose cancer is limited to the
testicle, its removal is all that is required,
although there will be continuing follow-up
and surveillance with blood tests, chest Xrays and CT scans.
Blood tests after an orchidectomy are
used to compare levels of tumour markers
with baseline results before surgery. If the
markers are still present, it suggests the
cancer has spread. If the tumour markers
fall after the operation but then slowly
creep up again, it suggests the cancer is
growing somewhere else in the body.
For those with seminonas,
radiotherapy is the treatment of choice if
the tumour has spread. For nonseminoma tumours, chemotherapy may
be required along with surgery.
“The prognosis is very good, and it’s
because a lot of tumours are cured by
surgery, and the ones that aren’t cured by
Professor Delahunt says cancer lobby groups and health authorities should
promote the message that men should practise self-examination and if they
notice any changes, they should see a doctor.
surgery are usually cured by radiotherapy
and chemotherapy,” Professor Delahunt
says.
If the cancer has spread to the lymph
glands in the abdomen into which the
testicles drain, they may need to be
removed in an operation called a
retroperitoneal lymph node dissection. A
pathologist will examine the nodes to
determine whether they contain cancer
cells.
In some cases cancer can recur and
further treatment is required. A small
number (two or three per cent) of men
who have had cancer in one testicle later
develop it in the other. Some tumours of
the testicle are benign, but most are not.
It is unclear why the incidence of
testicular cancer is increasing, although
changes in diet and lifestyle are likely to
be factors. There are clear ethnic
differences in the incidence of testicular
cancer, Professor Delahunt says.
whether surgery was done. A family
World Health Organisation figures
show that Europe has the highest rate, at
eight to 10 per 100,000 men. In Asia the
figure is two per 100,000, but in New
Zealand Maori it is much more common,
with a rate of seven per 100,000.
also factors.
Another risk factor is a history of
undescended testicles – remaining in the
lower abdomen rather than in the scrotum
- as a baby. Men in this category have a
three to fivefold increase in the rate of
seminona tumours, not only in the testicle
that was undescended but also in the
normal one, suggesting that the increased
risk is due to whatever caused the original
problem.
notice any changes, they should see a
history of the disease and low fertility are
Professor Delahunt says cancer lobby
groups and health authorities should
promote the message that men should
practise self-examination and if they
The association between testicular
cancer and undescended testicles
(cryptorchidism) remains regardless of
doctor.
“People are often too embarrassed to
talk about this with their doctor. It’s an
awareness that once you’ve determined
there’s an abnormality, do something
about it, don’t wait until a lump is 10
centimetres across.”
GPs NOTE: This article is available for
patients at http://pathway.rcpa.edu.au
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PATHWAY_39
HEALTH + MEDICINE
Meanwhile,
back at the lab …
WENDY LEWIS TAKES A LOOK AT THE EARLY DAYS OF ONE OF SYDNEY’S FIRST
PATHOLOGY LABORATORIES.
PHOTOGRAPHER: JAMES ALCOCK
onsider the typical pathology lab of
C
2006. It’s possibly part of a
multinational company with central and
regional offices. It comes with high-level
management, 24/7 activity, electronic
downloading of results and a mindboggling array of other value-adding
services.
All the key buzzwords and phrases are
there: process flow, resource scheduling,
equipment utilisation. When it comes to
getting the laboratory functioning as
effectively as possible, consultants can be
brought in to analyse the physical layout
of the space. It’s likely they’ll build a
simulation model of the lab operation, or
create a detailed process map so that
management and staff can better
understand what goes on.
Now imagine the same lab 20 years
ago… 40... 60… how about 80 years
ago? For it was almost 80 years ago,
1928 to be precise, that a formidable
woman by the name of Dr Eva Shipton
set up a private pathology practice in
Sydney in partnership with Dr Cyril
Shearman; a practice that has since
evolved into Sydney Diagnostic Services.
In the mid-1940s, May Bott and Elaine
Murray were among the first women to
work in the Shipton/Shearman practice,
which was one of Sydney’s earliest
pathology laboratories.
40_PATHWAY
This enterprise was located in the
BMA (now AMA) building in Macquarie
Street, down towards the Circular Quay
end of town, a part of Sydney where, in
those days, reputable doctors rented the
most expensive consulting rooms they
could manage.
Shipton was one of the pioneers of
pathology in Sydney and had an
outstanding medical career. She was the
first woman to become a resident doctor
at Sydney Hospital, in 1925. She worked
tirelessly visiting hospitals, insisting on
seeing every one of her patients.
Through this, she gained a reputation
as one of Sydney’s first “consulting
pathologists”. She was the first to employ
science graduates in her laboratory and
was the first in Sydney to use blood
groups in determining paternity suits. She
worked at Royal South Sydney Hospital
from 1930 to 1946 and was honorary
consultant at St Margaret's Hospital for
Women from 1932 to 1974 and at Mater
Misericordiae, North Sydney, from 1936 to
1946.
nonsense woman who insisted that her
staff “look professional”. She wore
beautiful, tailor-made calf-length skirts
and fashionable wide-brimmed hats.
Her trademark long hair was always
twisted up in an enormous bun. “Don’t
whistle,” cheeky colleagues whispered,
“or the birds will fly out!”
Shipton famously said: “Medicine is
my life and my major interest. I have been
too busy to marry, I have no friends and I
sometimes cannot find time even to
smile…” And from her list of
achievements, it seems she wasn’t joking.
Back in the 1940s, when Bott and
Murray were working for Shipton,
pathology in Australia was in its formative
years. The two young science graduates
from the University of Sydney carried out
their work in a smallish room, about four
metres by five metres. They sat with two
microscopes, silhouetted against giant
bay windows.
She regularly lectured medical
students up until her early 70s and earned
a Commander of the Order of the British
Empire (CBE) at the age of 73 for her
services to medical science.
Apart from those two well-used
microscopes, there was little other
equipment to speak of. There were just
the two of them, plus a messenger who
washed up the test tubes and delivered
reports around Sydney. In those days
there weren’t many private pathology
labs.
Not surprisingly, Shipton made a
definite impression on all who knew her.
Bott and Murray remember her as a no-
One small room off the main
workspace functioned as a storeroom and
kitchen, an arrangement that would give
In the mid-1940s, May Bott and Elaine Murray were
among the first women to work in the
Shipton/Shearman practice, which was one of
Sydney’s earliest pathology laboratories.
today’s occupational health and safety
a steady hand, good colour perception
officers apoplexy! This little alcove was
and astute attention to detail.
where you made your cup of tea, where the
test tubes were washed and where all
kinds of dangerous chemicals were stored.
Looking back, Murray is amazed that “the
centrifuge didn’t blow up!”
The two young women would work
steadily until their tasks were done for the
day, with no real lunch or tea breaks.
Much of their work was just the same as
today – making up agar, checking basal
metabolic rate, testing for calcium, faecal
fat, urea concentration – but the
methodology was, to all accounts and
purposes, “primitive”.
Of course, this was way before the
Tests for haemoglobin and blood
Certainly testing has undergone
massive changes, but Bott and Murray
think the one procedure that hasn’t
sugar were based on perception of colour
changed that much is cutting and staining
comparison. Murray recalls testing for
tissue sections. While some aspects of
protein involved fasting, giving the patient
this process may be computerised now,
broth – good old Bovril! – and then
fundamentally, the process has stood the
checking for the presence of hydrochloric
test of time.
acid.
Another testing method involved
Technological changes in the lab
would have to be considered the biggest
nothing more sophisticated than a canvas
shift in pathology over the past few
bag. You would get the patient to breathe
decades, with automation being an
into the aforementioned bag and then
important part of pathological analysis. It
proceed to check the contents for CO2
must be stressed that even with
levels.
automation, areas such as Anatomical
Testing for blood sugar was another
Pathology and Microbiology are still very
information age. Nothing was automated;
procedure that needed good judgement,
labour intensive and all areas of pathology
computers were in the early stages of
with just a bit of luck thrown in. What was
still require significant input from
development (prototype machines such as
required was a clear solution of blood with
pathologists and scientists.
ENIAC) and the incredible range of
the sugar in it. This involved sucking up
applications for new technology was
the liquid with a pipette. If you sucked up
advantages over hands-on methodology.
largely unrealised. This meant that testing
a little too vigorously, you would stir up
It leads to standardisation and greater
was more or less subjective. The major
the solids and – bad luck! – you’d have to
accuracy and can also integrate different
requirements for any kind of analysis were
start all over again.
functions in one operation.
Automation has certain clear
PATHWAY_41
Above: Dr Eva Shipton on page 2 of The Australian, January 1974; having received a
CBE at the age of 73 in recognition of her pioneering work in pathology.
Top right: May Bott (nee Davies) in a graduation photo from 1945. She commenced
working for Dr Shipton that same year.
Right: Elaine Murray (back row, left) in “a bevy of happy students of Sydney
University” receiving their degrees in The Sun, Saturday June 17, 1944.
Bott recalls being amazed that
This, in turn, has a flow-on that is both
was back when a week’s rent for a house
equipment that once analysed a sample
positive and negative. Doctors and
can now print out results and spew out an
patients are rewarded with results that
invoice as well. Electronic downloading
they previously would have had to wait
many other businesses, need to keep up
via various software programs is another
days for. But requesting doctors may not
with new customer demands. Many of the
major advance, resulting in speedier
have as close a relationship with their
larger labs offer a much broader range of
access to results.
patholgists. It is very important for this
services than would have been
relationship to be fostered to ensure high
conceivable a few decades ago, including
quality pathology services. Communication
clinical trials and services for corporate
skills are more important than ever.
clients such as insurance claim-related
Of course, anyone working in a field
that has undergone massive change must
come face to face with some bad as well
as the good. Rapid turnaround time
radically alters, perhaps even distances,
the doctor/patient relationship.
When Eva Shipton ran her practice,
These days, routine laboratory safety
practices go without saying. Health and
safety regulations are far more stringent
in Sydney would be about 30 shillings.
Pathology laboratories today, like so
testing, water testing and environmental
testing.
Eva Shipton would probably be
than 60 years ago. You wouldn’t be seen
astounded at the developments in
eating a sandwich in the lab… and you
pathology in Australia over the past 80
she would insist on seeing each of her
wouldn’t be caught storing ether
years. And most certainly she would be
patients. These days this is just not
alongside the tea bags either!
pleased. The technology is ever changing,
humanly possible. Changes in how
Your salary would be greater too.
the work environment and conditions are
pathology laboratories operate have
Murray recalls a salary of £4 while her
completely different, but pathology is still
resulted in bigger labs, some with 24
husband, a new graduate engineer, was
one of the most important fields of
hour-a-day, 365 day-a-year operations.
on £7 15d. Doesn’t sound a lot, but that
medicine.
42_PATHWAY
http://pathway.rcpa.edu.au
a
riveting,
pathological
[P athWay]
read....
PathWay informs, entertains and celebrates the
vital contribution pathologists make to
sophisticated health care delivery. Each quarter,
PathWay is packed with stories about the
developments, issues and the people who make
pathology an exciting and rewarding profession.
Contents
T H E R O YA L C O L L E G E O F PAT H O L O G I S T S O F A U S T R A L A S I A
ADVISORY BOARD
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
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Autumn 2005
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Nuance Multimedia Australia
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S2i Communications
Annette Sharp
Representative, Pathology Section,
Commonwealth Department of Health and Ageing
PUBLISHER
Jim Clarke
EXECUTIVE EDITOR
Dr Debra Graves
ASSOCIATE PUBLISHER
Wayne Tregaskis
COVER STORY
EDITOR
Justine Costigan
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to share their vision for the future
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Jodi Webster
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Tsunami aftermath
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Virtual Microscope
How the merging of information technology and traditional
microscopy techniques is offering new opportunities for
quality assurance
14
Profile
Nadia Mikhael is a Canadian pathologist and
academic who is inspiring medical students
to join the profession
17
Interview with The Hon Tony Abbott MP,
Minister for Health and Ageing
The Royal College of Pathologists of Australasia
Tel: (02) 8356 5858
Email: rcpa@rcpa.edu.au
20
Pathology and the Law
Pathologists are often called upon to act as expert witnesses.
Dave Hoskin finds out what happens when science meets the law
24
Biopsies
The small samples that play a huge role
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PathWay
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FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF
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Conference Calendar
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Crossword
63
Backpage
68
Anita Punton takes a look at the history of
autopsies and finds some surprising stories
PATHWAY LIFESTYLE
WA Beachhouse
44
Haematologist Andrew Barr and his wife,
Kerry, found a hideaway in a rammed-earth
house among dunes near Margaret River
RESTAURANT REVIEWS
FOOD + WINE
Waterside dining
Restaurant reviews from around the country
Algate Ridge
48
A wine success story from the Adelaide Hills
Chemical Pathology
An in-depth look at one of pathology’s most fascinating disciplines
32
Farmhouse cheeses
The ancient art of cheese-making
is alive and well in Australia
Hepatitis
The Alphabet of hepatitis - is it A, B or C, etc?
36
TRAVEL
Travel Medicine
Being prepared is the best way to prevent travel related illness
40
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GIVING THE DEAD BACK
THEIR IDENTITY
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Communication strategies for explaining
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News and Letters
FEATURES
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MOTORING
Discovering Australia’s Top End
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Pathologist John Slavin and family
discover the delights of California
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Chris de Fraga looks at the latest options
in family vehicles
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FROM
ORANGE
THERE’S MORE TO WORKING AS A PATHOLOGIST IN REGIONAL AUSTRALIA THAN FRESH
AIR AND BEAUTIFUL VIEWS. AS JUSTINE COSTIGAN REPORTS, WORKING IN THE COUNTRY
OFFERS A WEALTH OF EXCITING CHALLENGES AND CAREER OPPORTUNITIES.
rofessor Sujatha Fernando may have
spent most of her career working in
major cities but now that she is based in
Orange, in New South Wales’ Central
West, she wouldn’t have it any other way.
P
“Orange is a very beautiful city,” she
insists, ‘and as the hub for medical
services for the whole of the Central West
there is always a lot to do.” In any given
week Prof Fernando may travel
throughout the region, giving educational
seminars to GPs, supervising students or
handling a case load that services a range
of hospitals throughout the Central West,
from Lithgow to Broken Hill and as far
South as Cooma and Bega. “It’s a
44_PATHWAY
wonderful place to work, and extremely
rewarding,’ she says.
Knowing there was a critical shortage
of pathologists in New South Wales’
Central West was a major reason
Professor Sujatha Fernando was attracted
to the idea of working in regional NSW.
Having always worked in teaching
hospitals in Sydney, the opportunity to
continue this work in a regional location
was too good to refuse and Orange, only
three hours drive from Sydney, seemed
the ideal base for a move to the country.
The University of Sydney’s rural
clinical school for graduate medical
students was definitely an added
attraction for Professor Fernando, whose
previous work at the University of New
South Wales, in addition to teaching of
medical students, included implementing
an advanced training programme for
Fellowship of the Royal College of
Pathologists Australasia as the Director of
Anatomical Pathology at South Western
Area Pathology in Liverpool.
“The pathology of the disease
processes in country New South Wales is
similar to what is encountered in Sydney,”
says Professor Fernando, “and it provides
excellent teaching material for medical
students and trainee registrars preparing
for the FRCPA examination.”
BACK: Dr Henry Lau, Dr Harry Lukse,
Margaret Barker (Business &
Operations Manger)
FRONT: Prof Sujatha Fernando
“Living in Orange has also been terrific, It is a
great town, with some fantastic restaurants and
wineries nearby plus I live a short stroll from work
so there’s no traffic jams!”
Stephanie Arnold
Dental Students 2006, School of Rural Health, University of Sydney – Orange Campus.
William Giblin, Dr Henry Lau, Dr Sabrina Manickam, Nirla Navsler, Prof Sujatha Fernando,
Ethel Lin, David Graham
PATHWAY_45
A large rural town
offering all the
amenities of a
metropolitan area,
Orange has a real
sense of community
and is only an
easy three hour drive
from Sydney or 35
minutes by air.
One of these aspiring trainees is
Stephanie Arnold, who made the decision
to do her medical internship in Orange
precisely because it is a regional town. “I
was interested in the challenges and
opportunities that come from being some
hours away from the major metropolitan
hospitals,” says Arnold. “Among the
benefits are the many new skills I have
learnt and of course the welcome and
46_PATHWAY
support of the staff, whether they be
medical, nursing or allied health.”
making a tissue diagnosis and I think the
“Living in Orange has also been
terrific,” adds Arnold. “It is a great town,
with some fantastic restaurants and
wineries nearby plus I live a short stroll
from work so there’s no traffic jams!”
disease processes will provides an
A large rural town offering all the
amenities of a metropolitan area, Orange
has a real sense of community and is only
an easy three hour drive from Sydney or
35 minutes by air. Orange experiences all
four seasons in the year, each one
spectacular in its own right and the
district supports varied industries that
include a fast growing wine industry. With
a teaching hospital in the city, Orange is
also the base for an extensive medical
fraternity.
three other pathologists, Henry Lau, Harry
While Arnold acknowledges the winter
chill requires some getting used to, on a
professional level her experience in
Orange has been excellent and she’s now
looking forward to starting pathology
training in Orange. “I have always been
interested in pursuing a career in
anatomical pathology. I like its problemsolving nature, and the satisfaction of
variety of working in a such a large
range of patients with a broad variety of
excellent basis for the study of
pathology.”
Based at Central West Pathology
Services, Professor Fernando, along with
Lukse and Amy Li, deliver diagnostic
services to the clinicians and participate in
educational programmes. Professor
Fernando has initiated and is also
managing various research projects, some
of which include skin cancer and
screening for oral cancer.
“A few people have attempted to lure
me back to Sydney,” says Professor
Fernando, “ but I enjoy my job and the
regional area too much to go back. The
intellectual and professional challenges
are the equal of any city practice, but here
I know I am really fulfilling a need.”
Currently two accredited positions are
available for pathology training, but both
are awaiting funding.
lP ia t hfWe
s
t
y
l
e
ay lifestyle
arts + culture
48
travel
56
food + wine
60
restaurant reviews
64
conference calendar 67
PATHWAY_47
ARTS + CULTURE
Black Angels
THERE IS NO DOUBT THAT THE DARK SHADOW OF ILLNESS HAS PLAYED A ROLE IN THE
PRODUCTION OF MANY GREAT WORKS OF ART. DAVE HOSKIN LOOKS AT THE LINK
BETWEEN DISEASE AND REMARKABLE ACHIEVEMENT.
t had been seven years since the death
of his sister Sophie, but the memory of
how she looked still haunted Edvard
Munch. For months he had been trying to
express the essence of her last moments,
sidestepping literal reality in his attempt to
capture what he called "soul art".
I
Sophie, like her mother, had died of
tuberculosis, the same disease that had
almost claimed Edvard too. Perhaps
inevitably, sickness became an obsession,
first coming to the fore in Munch's
seminal painting The Sick Child.
48_PATHWAY
It was the first real creative
breakthrough in the artist's life, and he
was sure that his later works owed their
existence to it. "Sickness, insanity and
death were the black angels that
surrounded my cradle," he would later
explain. "And they have followed me
throughout my life."
Certainly these black angels were
plentiful. Aside from the painful legacy of
tuberculosis, Munch's younger sister
Laura was diagnosed with schizophrenia,
and Munch himself grappled with mental
instability for much of his adult life.
The fruits of this sickness are
expressed in a remarkable body of work,
reaching its apotheosis in The Scream.
Only therapy finally changed Munch's art,
and even after his successful treatment he
fretted that he had sacrificed genius for
sanity.
Munch was not the first to ponder the
link between disease and extraordinary
behaviour, with mental illness in particular
having a long association with creativity.
Left: Starry Night, 1889 (oil on canvas) by Vincent van Gogh
Right: Self Portrait with Bandaged Ear and Pipe, 1889 (oil on canvas)
(Private Collection) Vincent van Gogh
As early as Socrates it was felt that poets
and priests communicated with the gods
through inspired “madness”, and Aristotle
later asked: "Why is it that all men who
were outstanding in philosophy, poetry or
the arts are melancholic?"
Similarly, John Milton seemed certain
that his blindness (probably caused by
glaucoma) had rendered him a better
poet, stating: "There is, as the apostle has
remarked, a way to strength through
weakness." Indeed, with its many
references to blindness and Milton's belief
that he could see "things invisible to
mortal sight", it is clear that Paradise Lost
would be a very different masterpiece if
not for its author's disability.
So why are we so interested in the
illnesses of the famous? One obvious
answer relates to basically the same
impulse that drives magazines such as
Who Weekly – we're interested simply
because they're famous. Another
explanation is that discovering that the
giants of our society are mortal can
appeal to our romantic ideal of the
suffering genius.
After all, who cannot be moved by
stories such as Stephen Hawking's –
deprived of movement and speech but
still battling to understand the birth of the
universe?
Perhaps the most intriguing thing
about investigating these illnesses is the
way they seem to explain the actions of
remarkable people. They can cast things
in a new light, or even make sense of
work that had previously appeared
inexplicable.
Certainly scientific study of the links
between mental illness and creativity has
already provided some fascinating
preliminary results.
For instance, the
research of Jordan
Peterson at the
University of
Toronto seems to
indicate that the brains of creative people
appear more receptive to incoming stimuli
than those of other people.
Most of us have to filter or block the
constant flow of information from our
brains in a process that Peterson terms
latent inhibition. People with less latent
inhibition may be able to handle more of
the data, and consequently be more open
to a greater number of possibilities and
concepts.
More specifically, Kay Redfield
Jamison of Johns Hopkins University has
found links between established artists
and mood disorders, and Gordon Claridge
at Oxford University has concluded that
creative types are more likely to have
certain kinds of schizophrenia.
Nobel Prize-winning mathematician
John Nash certainly feels that there was a
link between his incipient schizophrenia
and the innovative work he did before it
overwhelmed him.
"It's something of a mystery," he
explains. "It's a special area where smart
thinking and crazy thinking can be related.
If you're going to develop exceptional
ideas, it requires a type of thinking that is
not simply practical thinking… I can see
there's a connection between not
following normal thinking and doing
creative thinking. I wouldn't have had
good scientific ideas if I had thought more
normally."
Of course physical ailments can also
contribute to the way famous people see
the world. As with Edvard Munch, few
would argue that the art of Vincent Van
Gogh was not influenced by his various
ailments. He was also morose during his
childhood, and when he was eventually
admitted to an asylum, the diagnosis was
“a severe nervous attack accompanied by
hallucinations of the sight and hearing”.
Mood swings would plague him for
the rest of his life, and were reflected in
the dark themes that Van Gogh often
pursued (most startlingly in Self-Portrait
with Bandaged Ear).
But some have speculated that Van
Gogh's work was influenced by
something more particular. In the final
years of his life, his paintings show a
marked predilection for the colour yellow.
He lived in a yellow house, he wrote of
"beautiful yellow" and he mixed yellow
into the blue paint he used for skies.
More intriguingly, Van Gogh twice
painted portraits of the physician who
treated his mental illness, Dr Gachet. In
both paintings, Gachet is depicted holding
a sprig of purple foxglove. In the 19th
century, an extract from this foxglove
called digitalis was one of the main
treatments for mania and epilepsy, used
as a sedative, an anticonvulsive and an
anti-manic agent.
Thus, given Van Gogh's medical
history, it is tempting to speculate that
Gachet had prescribed digitalis. One of
the more idiosyncratic symptoms of
digitalis overdose is the appearance of a
yellow or greenish haze around objects.
PATHWAY_49
Below: Portrait of Dr. Gachet, 1890
(Private Collection) Vincent van Gogh
Supporters of this diagnosis point to
such paintings as Starry Night,
Enclosed Field with Reaper and
Sunflowers, all of which seem to
reflect the viewpoint of a person
suffering digitalis overdose.
to hide it from the American
public. Diagnosed as suffering
from poliomyelitis (although
some have recently asserted
that it was probably GuillainBarre syndrome), Roosevelt
became ill at the age of 39 and
was left with permanent
paralysis in his lower body.
Obviously such theories are
difficult to prove. Van Gogh's
predilection for yellow has been
argued about for years, and other
theories such as glaucoma or the
side effects of absinthe addiction
have their adherents.
Of course the simplest
explanation is that the paintings
reflect Van Gogh's artistic intention.
While it is tempting to try to solve the
“mystery” of why this specific creative
quirk came about, the reliability of such
diagnoses will always be controversial,
and at the very least they run the risk of
being needlessly reductionist.
That said, some retrospective
diagnoses are more credible. Ronald
Reagan was notorious for his erratic
behaviour during his presidency, and
many saw his diagnosis with Alzheimer's
disease in 1994 as an explanation.
In particular, many had noted
Reagan's vagueness in his second term
(he was most famously caught being
prompted sotto voce by his wife, Nancy,
after apparently zoning out at a news
conference), and some even muttered that
he should be removed. Moreover, given
that Reagan's standard defence when
queried about the Iran-Contra scandal
was that he couldn't remember the
details, there are grounds to suspect that
Alzheimer's was affecting his leadership.
To be fair, Alzheimer's is not the only
explanation for Reagan's behaviour. His
50_PATHWAY
doctors insisted that he was not
symptomatic before his official diagnosis
in 1994, and much of his behaviour can
be attributed to human fallibility. But
members of the investigation into IranContra tell a different story.
When chief prosecutor Lawrence
Walsh interrogated Reagan in 1992, it
quickly became apparent that the former
president was unwell. Despite a healthy
outward appearance, Reagan could not
remember, among many other things, the
name of his secretary of state, his
attorney-general, his chief of staff or even
giving trial testimony 18 months
beforehand.
With Reagan's memory so clearly in
tatters, Walsh shelved his investigation of
the former president, but his account
does call the later assertions of Reagan's
doctors into question.
Of course, even if the doctors were
lying for political reasons, they would
hardly be the first. There is little dispute
about the affliction of Franklin Delano
Roosevelt, and no question of his desire
It took seven years of
therapy for Roosevelt to accept
that his paralysis was
permanent, and he was certain
that it spelled the end of his
political career. It is ironic, then,
that many commentators feel it
was this experience that made him
presidential material.
Until that point in his life, Roosevelt
had been shielded from significant
hardship, a golden boy to whom
everything came easily. Polio taught him
humility, empathy and, as his wife,
Eleanor, put it, "an infinite patience and
never ending persistence".
Coming to power when his country
desperately needed hope, and later
leading it against an enemy that despised
the disabled, Roosevelt's inner strength
made him the perfect leader for his times.
While Roosevelt eventually realised
that his misfortune could be a political
asset (his battle with polio gave him a
heroic dimension in the mind of the
public), he also made sure to conceal his
true condition. He never walked again
unaided, but careful stage management of
his presidential appearances and a
remarkable compact with the media
played down his disability.
Given these measures, not to mention
the fact that the dominant media of the
Top: Governor Ronald Reagan
Giving a Speech
(Newsworld/NY Tribune)
Middle: Franklin D. Roosevelt
sitting behind desk (FPG)
Below: Franklin Delano
Roosevelt Memorial, with bronze
statue of the former President,
Washington, D.C., USA
(Altrendo Travel)
Above: Former U.S. President Ronald Reagan and First Lady Nancy
Reagan share a moment as Ronald Reagan turns 92 on February 6,
2003. (courtesy of the Ronald Reagan Presidental Library/Getty Images)
time was radio, millions of Americans
were amazed when they finally discovered
the truth of his paralysis.
be managed with a less hectic lifestyle,
and so he turned to television in order to
earn a living.
Considering stories such as
Roosevelt's, the impulse to search for
links between the behaviour of remarkable
people and disease is certainly
understandable. A celebrity willing to talk
about their illness can lessen its stigma,
increase public awareness and help raise
funds to find a cure.
The effect of his illness on Potter's
work is clearest in his masterwork The
Singing Detective, with anyone aware of
the author's life story being unable to
miss the similarities. The acerbic, psoriatic
writer who narrates Detective clearly has
much in common with his creator, and
even Potter admitted the story was close
to the bone.
However, in our fascination with the
illness, we run the risk of obscuring the
patient. Dennis Potter spent his life railing
against this tendency, although he
admitted that disease had heavily
influenced his career in writing for
television.
Despite dabbling in writing before the
onset of his illness, it initially appeared
that Potter's career would be in politics. It
quickly became apparent, however, that
the exhaustion and pain of psoriatic
arthropathy, in which the skin disease
psoriasis is linked to arthritis, could only
had really had that brought home to me
by a patient – it was an important stage in
my medical education."
If Potter's example tells us anything, it
is that illness has unquestionably changed
the lives of many remarkable people,
affecting the way they live, work, govern
and express themselves. However, just as
with The Sick Child or Paradise Lost, The
Singing Detective is a product of Dennis
Potter's illness, but it is imperative that we
But he was also keen to stress the
differences between himself and his
characters, and similarly, whenever he
found himself in hospital, he constantly
reminded the staff that he was more than
just an illness. "What I remember so well
is that he wanted to make me more
sensitive to him," said Patrick Rahilly, one
of the medical students with whom Potter
forged a bond.
remember that it is not a simple cipher for
"He said something to the effect of,
'I'm an individual, a person, as well as a
case,' and honestly, it was the first time I
often mysterious … and that some
decoding his life.
After all, it is a story all about the fact
that clues don't always mean what they
seem, and that what lies under the skin
can be just as revealing as what is on the
surface. But most importantly, it's a story
about a detective, a detective who
reminds us that what drives people is
mysteries can never be completely
solved.
PATHWAY_51
ARTS + CULTURE
Ancient voices
THE REMAINS OF OUR ANCESTORS CAN TELL US MUCH ABOUT
HOW THEY LIVED – AND DIED. PALEOPATHOLOGISTS ARE USING
MODERN TECHNOLOGY TO BETTER HEAR WHAT THOSE REMAINS
HAVE TO SAY. LISA MITCHELL REPORTS.
PHOTOGRAPHER: BRETT HARTWIG
52_PATHWAY
Paleopathology is the study of signs of disease in the remains of ancient
people. “Remains” might include anything from skeletons and
mummified tissue to the well-preserved faeces of American Indians
discovered in the dry caves of the Nevada desert.
alicious acts of poisoning or some
quirk of the environment? What
caused the wealthy folk of Pompeii to
succumb to lead poisoning? And why did
the hunter-gatherers of Greece and Turkey
shrink by as much as 12.7 centimetres
between the end of the Ice Age and
3000BC?
M
Around the world, a band of scientific
sleuths are busy putting their minds to
solving mysteries like these. They are
paleopathologists.
It was not the lead-pipe plumbing of
Pompeii that caused the numbing and
degenerative effects of lead poisoning;
lead does not leach into running water.
Rather it was the citizens’ penchant for
sweet, concentrated grape juice known as
sapa that harmed them. The juice was
acidic and boiling it in leaded kettles
added one gram of lead per litre to the
nectar.
As for those Mediterranean huntergatherers, adopting an agricultural way of
life had a significant, detrimental impact
on their health.
Paleopathology is the study of signs of
disease in the remains of ancient people.
“Remains” might include anything from
skeletons and mummified tissue to the
well-preserved faeces of American Indians
discovered in the dry caves of the Nevada
desert.
Methods of detection range from the
careful observation of bones with the
naked eye and the use of imaging
technologies to more invasive procedures,
such as taking tissue or bone samples for
DNA testing and laboratory examinations.
Paleopathologists bring an impressive
knowledge of diverse disciplines to bear
on their investigations and usually work
collaboratively. Most have backgrounds in
the medical sciences, such as anatomy,
physiology, microbiology, immunology and
epidemiology. There are even bioanthropologists. They also need to
incorporate whatever cultural knowledge
is available from archaeological studies.
Our ancient ancestors have plenty to
say via their skeletal remains despite their
limbs being scattered, sorted and stored
in all manner of disarray.
“To begin with, a skeleton reveals its
owner’s sex, stature and approximate age,
says Jared Diamond, professor of
geography at the David Geffen School of
Medicine at UCLA. “In the few cases
where there are many skeletons, one can
construct mortality tables like the ones life
insurance companies use to calculate
expected life span and risk of death at
any given age.
“Paleopathologists can also calculate
growth rates by measuring bones of
people of different ages... and recognise
scars left on bones by anaemia,
tuberculosis, leprosy and other diseases,”
Professor Diamond says.
Not all diseases leave traces on
bones, however. Only the chronic ones
have time to make such a deep and
lasting impact.
Abnormal changes in bone and dental
tissues may be the result of food
shortages, such as during a famine or due
to the impact of a disease when food is
not properly digested or metabolised.
Serious trauma to the bone, such as a
fracture, offers other clues to lifestyle or
culture.
In their paper Reconstructing Medical
Knowledge in Ancient Pompeii from the
Hard Evidence of Bones and Teeth,
Professor Maciej Henneberg, head of
anatomical sciences at the School of
Medical Sciences at the University of
Adelaide, and his wife, Dr Renata
Henneberg, explain how teeth reveal the
secrets of an era long after they have
stopped chattering:
“Once formed, crowns of the teeth are
not remodelled. Thus the structure of the
dental tissues retains information about
health conditions of individuals during
their childhood when teeth were formed in
the gums... An infection or other health
impediment that affected a developing
child may leave its mark on the enamel of
teeth that formed in the jaws of a sick
child. These enamel defects are called
hypoplasia and manifest on the tooth
crown as horizontal rings of thinned
enamel or as a series of pits.”
Bond University researchers Dr Steve
Webb, professor of Australian studies, and
Dr Walter Wood, associate professor of
anatomy, conducted fascinating,
pioneering studies of Aboriginal remains
before raised cultural awareness propelled
many subjects back to indigenous
communities.
Dr Webb studied the oldest human
remains discovered in Australia, 9000
post-cranial bones (those below the neck)
and 4500 skulls, being held in collections
around the world. It was the first time a
paleopathologist had endeavoured to
provide a snapshot of the health of an
entire continent.
To his surprise, Dr Webb found that
the Aboriginal people of the Central
Murray region suffered far worse health
than their desert cousins. Despite their
freshwater reserves and “open larder”, the
river people had high instances of
anaemia, for example. He could tell this
from small pits in the eye socket.
“As we’ve settled down as a human
race, we’ve experienced higher rates of
disease. You live in your litter, to put it
very politely, and until you know how to
get rid of it, you suffer from heavy
PATHWAY_53
“A common social habit among the Aborigines once they reached puberty
was to knock out an upper incisor tooth. We don’t know why, but I like to
think it was an example of ancient orthodontic treatment,” Dr Wood says.
parasitism, which causes anaemia. And
these people were living quite close
together (which invites the ‘crowd
diseases’ such as measles, smallpox,
chicken pox, herpes, influenza and
cholera).”
From the “scrape marks” around holes
in some skulls, he divined that they had
also performed brain surgery – “It’s been
done in the past to relieve headaches... or
spirits inside the head” – while another
group around Coobool Creek, near Swan
Hill, indulged in head binding, evidenced
by elongated craniums. The practice
came into fashion 14,000 years ago but
lost its chic 7000 years later. Amputations
were performed too, it seems, as
suggested by the characteristic
“pencilling” or thinning towards the end of
some bones.
“I did a lot of consultation with
orthopaedic surgeons... and I showed
them some fractures that they couldn’t
believe,” Dr Webb says. “One said: `You
can only get a triple fracture of the
thighbone if you’ve come off a motorbike
or in a car accident. I can’t see how a
hunter-gatherer would get this - it takes
one tonne of pressure to break it!’
“My first thought was that someone
had held this person down and smashed
his leg up deliberately... as ‘payback’,
which was (a form of justice) used in
traditional Aboriginal society, but that
would have (damaged soft tissue and)
introduced infection, it would have caused
osteitis, and there was none.”
There are several grades of infection
that show in the bone,” says Dr Webb.
“Osteitis the way we use it, is a
grade... Osteitis is a lesion that has gone
into hard material of the bone itself.
Periostitis is a mild disturbance of the
surface of the bone or there’s
osteomyelitis, which is an infection of the
internal part in the tube of the bone... One
we know today is golden staph... it stays
with you for life and eats away at the
bone,” he says.
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But there was no indication of
infection and the team was unable to
satisfy its curiosity for the causes of the
fractures in these cases of injury.
On the Gold Cost, Dr Wood found
many twisted, toothy smiles in a 1500year-old burial ground at Broadbeach that
he studied in the 1960s and early 1970s.
The indigenous people there had
exceptionally large teeth that crowded
their mouths.
The crowns of the teeth would
therefore wear down quickly, flattening the
biting surface, eventually exposing the
central nerve and leading to telltale
infections and abscesses in the jaw bone.
“A common social habit among the
Aborigines once they reached puberty
was to knock out an upper incisor tooth.
We don’t know why, but I like to think it
was an example of ancient orthodontic
treatment,” Dr Wood says.
Professor Henneberg says that
although burial grounds are an abundant
source for the study of ancient peoples,
they cannot offer a true snapshot of “the
living society” at the time. They don’t take
into account selective funeral practices or
a natural increase in population or the
demographic events that can influence
the numbers of people alive in various age
categories.
This is why Pompeii, where Mt Vesuvius
erupted in 79AD, leaves paleopathologists
weak at the knees; in just 16 hours, a living
population was preserved in volcanic ash
and lava. Professor Henneberg has
examined about 500 skeletons there.
Nearly one-third of all teeth observed
were affected by decay. Dr Henneberg also
found a high incidence of degenerative jaw
disorders, suggesting their diet included
hard or raw foods that required significant
chomping power. Nor were the good
people of Pompeii free from tumours.
Small, button-like, benign tumours were
found on skulls and long bones.
The statistical tools of paleodemography
allowed Professor Henneberg and his wife
to reconstruct mortality patterns, or “life
tables”, that showed newborns had a life
expectancy of a mere 25 years, while the
average age of death was 40. Only 14 per
cent of the population would have
reached old age.
Among Professor Henneberg’s most
significant findings as a paleopathologist
was the 1988 discovery of syphilis in the
ancient Greek colony of Metaponto in
southern Italy. This changed the established
view that syphilis originated in the New
World (the Americas) and was then spread
by Columbus’ crews after 1493.
Not everyone involved in the study of
the ancients is convinced that a bone is
worth a bone. Some archaeologists, says
Professor Henneberg, consider them a
time-consuming nuisance in the field and
an inferior source of information.
The mother of paleopathology finds is,
of course, the mummy. The ability to
examine a mummy’s well-preserved soft
tissue (which looks a bit like beef jerky,
depending how it is preserved) ranks high
on any scientist’s wish list.
Dr Frank Rühli, a senior lecturer and
head of the applied anatomy workgroup
at the University of Zurich’s Institute of
Anatomy, has spent many precious hours
on the Swiss Mummy Project. He was
also involved in uncovering the likely
causes of death of Otzi, the 3300BC
Iceman mummy found in Italy, as well as
Egypt’s King Tutankhamen, which
received worldwide media attention last
year.
“We basically suggested that a femur
fracture just above the knee may have
contributed to his (King Tut’s) death by
triggering a lethal cascade of things like
infection, and that he died probably from
the infection,” Dr Rühli says.
It was the first time a CT scan had
been done on the young Egyptian
pharaoh, given the logistical and funding
difficulties – the Valley of the Kings is
situated far from any hospital.
Professor Maciej Henneberg, head of anatomical sciences at the School of Medical
Sciences at the University of Adelaide, and his wife, Dr Renata Henneberg, explain how
teeth reveal the secrets of an era long after they have stopped chattering.
“Scanning is pretty new because up
Recently Dr Rühli conducted a CT-
until the 1970s, people did a lot of
guided biopsy on a mummy that was
autopsies, they just cut the whole body
diagnosed in the 1920s by conventional
up,” Dr Rühli says. Cutting the body up is
X-ray.
now frowned upon as paleopathologists
“People thought the mummy may
try to use the least invasive procedures
have suffered from spinal tuberculosis but
possible. New technologies are helping
we thought ‘Let’s get tissue to see if we
the effort considerably.
can find any indication for tuberculosis’,
The multi-slice CT scan, for example,
which wasn’t the case, we could find no
used for his examinations of Otzi and King
indication as having had spinal
Tut, creates a high resolution, cross-
tuberculosis. The new technology assisted
sectional image that allows better
in refuting the finding.
visualisation of the subject.
“With Otzi, we could interpret the
“With a needle we took some tissue
out of the mummy. If you do it under CT
whole story around the cause of his death
guidance, you know precisely where you
because we could see clearly where the
are.” He says using a CT scan is ethically
arrow was located and how it would have
better as well, “because you don’t want to
affected the surrounding blood vessels...
stick a needle in several times, it destroys
we can now be 95 per cent sure that the
the mummy. We have to treat them with
injury was lethal. It’s quite rare in
respect. We should keep the material as
paleopathology to have this level of
untouched as possible for future
certainty,” Dr Rühli says.
examinations.”
“By doing just an X-ray, you can’t
Many scientists herald DNA testing as
differentiate what type of soft tissue it is,
the answer for detecting so many modern
but in future you may be able to
ills, yet paleopathologists are less
distinguish between different soft tissue
convinced of its merits in terms of their
qualities, such as muscle from tendon or
own work. It may have enabled them to
collagen or whatever.”
determine germs and bacteria in ancient
bones, but there are still issues, Professor
Henneberg says.
“There are many problems with
degradation of DNA molecules and with
the contamination of specimens with
modern DNA from handlers”, he says.
“Great hope was expressed several years
ago in the use of DNA to identify ancient
pathogens, but it rarely works.”
He is pinning his hopes for the future
on non-invasive bone analysis techniques
such as Micro CT scans that use a minute
X-ray beam to study a bone tissue
sample.
“Instead of cutting bone samples and
putting them under the microscope, this
virtually pierces the small, tiny little specks
of bone with X-rays and reconstructs it
giving a 3D image of the microscopic
structure of the bone. Traditional histology
destroys the bone because you have to
cut and polish the sample to be able to
see anything under the microscope.”
PATHWAY_55
TRAVEL
Bali is back
– but if you read newspapers,
you’d be forgiven for not noticing.
THE ISLAND PARADISE BESET BY BOMBINGS AND HIGHLY PUBLICIZED DRUG ARRESTS IS ONLY
NOW STARTING TO EMERGE FROM ITS PROBLEMS, BUT IT SEEMS THAT SLIPPING ON A BANANA
SKIN – IF IT HAPPENS IN BALI – IS NEWSWORTHY.
B
ut this isn’t deterring a population –
2002, the island is working hard to
returned year after year. There is a
and tourism industry – determined to
reposition itself in the eyes of the world –
veritable army of Bali loyalists all around
reverse the unfair consequences of its
and in a manner that is credible and real.
the world – but most notably in Australia.
recent history.
And it has a not-so-secret weapon in
The head of the Bali Hotels’
its plan to return to ‘normality’ – the many
Association, Michael Burchett, says it is
therefore its people, has suffered severely
thousands of people holiday-makers who
time to put the past where it should be –
since the first terrorist attack in October
adore the place and, until recently, have
in the past.
While the economy of Bali, and
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Island
Paradise
PATHWAY_57
“In a world where the term ‘unique’ has become
anything but, Bali remains genuinely unique.”
“Have people stopped going to
London, Madrid or Cairo because they
were the targets of terrorist acts?” asks
Michael, knowing full well the answer.
“Unfortunately, they did with Bali and
hotel occupancies dropped for a while to
below 20% which translated into 100,000
Balinese losing their jobs.”
But the Balinese are nothing if not
resilient. They are a peace loving,
charming people whose easy-going
demeanour can belie their fierce
determination to restore Bali to its status
as ‘Island of the Gods’.
And for those who already know and
love Bali – and for millions of other
travelers who don’t – now is the time to
visit.
With the full support of the
Government and tourism industry,
including the airlines – and with a vast
improvement in security measures, visible
and invisible - Bali is clawing back its
reputation as one of the world’s most
beautiful holiday destinations.
Its new message to the world will
focus heavily on the people of Bali, their
friendliness, the gentleness of their Hindu
culture and their unique charm.
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“There is no place on earth like Bali,”
enthuses Michael.
“In a world where the term ‘unique’
has become anything but, Bali remains
genuinely unique.”
It’s probably fair to describe the
current holiday offers as “genuinely
unique” too.
“Everyone with an interest in the
recovery of Bali has come to the party to
ensure we offer the best value-for-money
holiday experience on earth,” says
Burchett.
“Who would have thought one could
enjoy a Balinese holiday for the cost of
parking a car in London overnight?”
The fact is, some the holiday
packages now on offer are even less than
that. For example, Jetstar has been
offering tickets for $169 one way
inclusive.
The Group General Manager for
Qantas Holidays, Jenny Lourey, says the
most poignant element of the terrorism
tragedies to hit Bali is the brutal fact that
such mindless acts of violence are just so
completely inconsistent in most peoples’
minds with the sheer cultural and physical
beauty of Bali.
“It is why Bali appeals, particularly to
the 50,000 Australians who have visited in
the past two years alone on Qantas
Holidays” says Ms Lourey.
But the final word on Bali and its
chances of recovery rest with Michael
Burchett; “Yes, the value-for-money offers
currently available for holidaymakers to
Bali are unprecedented, but what will
really attract people back here are the
memories of the place, the images of its
unique beauty and the unchanging charm
of its people – these are the assets that
make Bali what it is, and what it always
will be.”
PATHWAY_59
FOOD + WINE
Thoroughly fortified
BEN CANAIDER CAMPAIGNS
FOR SOME ENDANGERED
TIPPLES.
ort is dead, brandy is no longer the
drink for heroes (that’s Sustagen), and
no one drinks dessert wine any more. We
are all of us concerned about our
waistlines and alcohol intake.
P
And no doubt that’s a good thing. But
there are negative outcomes. A handful of
the world’s most interesting and long-lived
drinks are slowly disappearing. Fortifieds,
brandy, dessert wine … they are the drinks
of dinosaurs.
Or cutting-edge retro-lifestylers. Some
of us will not give in. We will keep fighting
the good fight. Let’s consider the potted
biographies of each of these drinks. They
make for interesting reading, and
contemplation.
Fortified wine is the product of a
worthwhile and happy tradition. When the
Spaniards and the Portuguese supplied
England with rough red wine in the 17th
century, they fortified it with Iberian brandy
so that the wine might make the journey
more successfully than not. The result was
the quick evolution of a remarkable spiritstrengthened red wine – port.
Brandy, in its truest guise, was nothing
more than the reduced and distilled
essence of rather thin and acidic wines
from around Charente in western France.
Brandy’s traditions are more Arabian than
European, however. Arab chemistry and
distillation practices employed to produce
medicines and perfumes didn’t really get
to Europe until the 6th century AD. With
some barrel-age, brandy became a minor
drinks miracle.
Dessert wines are more a piece of
happenstance than anything else. Grapes
left out on the vine contracted a fungus,
botrytis cinerea, and this fungus attacked
the grape, expelling the water and thus
concentrating the juice inside. The
resultant wine had lush richness and an
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underlying marmalade-like sweetness, but
was long and balanced with enough
acidity to make it suitable for a second, or
third, or 54th glass.
To not show an interest in these drinks
is morally equivalent to standing by whilst
some lunatic lets an endangered animal
become extinct. To save these beverages
you need to buy and drink them. Here are
a few patriotic suggestions.
Fortified
Stanton and Killeen in north-eastern
Victoria make the best vintage port in the
country. They offer full, 750ml bottles but
also half bottles so that you can take a
sneak preview of the wine when it is
merely 10 years old.
The key to Stanton and Killeen’s
success has been their devotion to proper
port grape varieties. Shiraz and cabernet
do not make long-living ports. But such
things as touriga nacional do. S&K have
planted these and the proof of the
pudding is in the port. Buy their VP and
buy it by the box. The 2000 VP is currently
doing the rounds; it’s another example of a
wine that will take a decade and a half of
careful cellaring before it ‘‘cracks’’ – that
is, it drops its hard and angular nature and
becomes an elixir of life. Of elderly life …
Brandy
Brandy can be a ruinous drink,
particularly if you go long on it with soda
and ice. I know … Nowadays, I drink it
neat in a tiny snifter and treasure the
moment. Which is why I don’t mind
spending the money on something such
as Hardy’s XO Brandy ($110).
Australian brandy used to be a big
thing, but changes in government excise
in the 1970s wrecked it all. This drink is a
kind of dinosaur, which is another reason I
love it. It is deep, rich, round and very
long. Heady stuff, but in the right way.
Dessert Wine
What a disastrous time dessert white
wine has had of it recently. Everyone
drinks red and no one bothers with the
sweet course any more. What a pity.
There’s a lot of good dessert white going
unnoticed.
With your best apple or lemon tart try
some Bimbadgen Estate Myall Rd Botrytis
Semillon 2005 (375ml, $19). This half
bottle of intense, sweet dessert beverage
has all the lushness and raciness you
could want (or handle) in such a style of
wine, with plenty of clean grapefruit,
quince and marmalade flavours.
It finishes with leaner lemon zest
notes. Serve it well chilled and let the wine
slowly warm up in the glass to get more of
the lusciousness. Chill it more heavily if
you prefer the opposite effect.
Keep a bottle of each of these drinks
in the house at all times and use with
scant regard for convention, trendy rules
of the day, or the sideways glances of
your loved ones. You’re being a true
conservationist.
FOOD + WINE
Visionary Vue
JUSTINE COSTIGAN MEETS THE MAN BEHIND VUE DU MONDE,
A CONTENDER FOR THE TITLE OF AUSTRALIA’S BEST
RESTAURANT.
PHOTOGRAPHER: EARL CARTER
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OEUF DE CANARD AU LARD
Egg and bacon duck egg
Photographer: Tim James
SHANNON BENNETT IS REPORTED TO
HAVE ONCE SAID THAT HE WANTED TO
HAVE THE BEST RESTAURANT IN
AUSTRALIA. WELL, WITH STUNNINGLY
SOPHISTICATED NEW CITY PREMISES,
UNIVERSAL ACCLAIM FOR HIS COOKING
AND A SWAG OF AWARDS UNDER HIS
BELT, HE MAY WELL HAVE ALREADY
ACHIEVED HIS GOAL.
n a close and sticky February night in 2004, one of an
endless stream of hot nights following even hotter days (the
kind of weather people who don’t live in Melbourne refuse to
believe ever happens here) my partner and I walked through
Carlton’s back streets to Vue du Monde, an intimate French
restaurant located in one of the suburb’s small but elegant
Victorian terraces.
O
Despite the heat we were looking forward to trying this
restaurant we had heard so much about - apparently the chef
was only few years past 20, a boy wonder who knew how to do
amazing things with French food and had all the reviewers
gushing. We settled into our seats, let the waiters fuss over us
and relaxed into the pleasure of fine food and wine. Or so we
thought.
One bite into our first course and suddenly the room
descended into darkness. The faint whir of the air conditioning
stopped, music jerked to a sudden halt and the only available
light was the blue-red glow from the gas flames at the stoves,
visible through the open kitchen. The customers gasped and the
staff froze. Then, all was immediate action. What was previously
subdued lighting became the romantic glow of candles.
Windows and doors were opened to let in air and the staff
reassured us that all was business as usual. All the while the chef
didn’t miss a beat and the food didn’t strike a wrong note. Did
the staff apologise or try and over-compensate? No, there was
no need. This team knew how to make a restaurant work and
despite completing our evening in a humid gloom, we knew we’d
had one of the most enjoyable nights in a restaurant we’d ever
had, electricity or no electricity.
When I tell this story to Shannon Bennett, owner and chef at
Vue du Monde, he laughs. It’s clearly not the worst thing that has
ever happened during service but he seems genuinely pleased at
how the story turned out for us, nonetheless. This is a chef who
knows that looking after customers is the other half of the
successful restaurant equation. Great food is only half the story.
And the food at Vue du Monde is wonderful. A new take on
French food, Bennett focuses on the exquisite preparation and
attention to detail of fine French cuisine and adds his own touch
– re-interpreting classics and reducing their richness and
predictability, exploring local ingredients, taking advantage of
other cultures and influences to produce superb creations.
Precisely the sort of food you would not want to cook at home
even if you could. Bennett is the expert and when you dine at
Vue du Monde you put yourself in his hands. In the evenings, he
offers the gourmand menu, a specially devised menu of a set
number of courses that reflects your table’s wishes and the best
produce of the day. After a brief discussion with the waiter you
simply wait to receive course after course of Bennett creations.
And the chef always knows best.
Not quite 30, Bennett is at the top of his game. After an
Australian apprenticeship followed by stints with London’s
infamous Marco Pierre White and Alain Ducasse among others,
Bennett returned to Australia to open his own restaurant in 2000.
He was 22.
“No one would give me an opportunity”, says Bennett of his
return to Melbourne. So with savings from his time in Europe and
a $70,000 loan from a family friend, Bennett decided to create
one of his own and opened Vue du Monde in Carlton. It took him
three and half years to pay back his friend, an effort that he
claims is “one of my greatest achievements.”
Bennett grew up in West Meadows, a pretty rough part of
Melbourne, although apparently it has improved a lot since he
lived there. “Living there taught me how to be tough,” says
Bennett, “and in the food business you’ve got to be tough and
never take no for an answer.”
You’ve also got to be strong and preferably young. Bennett
works very long hours but regards them as normal. He starts
mid-morning and doesn’t finish til late, leaving little time for his
partner, actress Madeleine West and new baby daughter
Phoenix. Time off is devoted to them both.
“It’s a young person’s business,” says Bennett, “and I can’t
do what I’m doing now until I’m 50.” He still sees himself at Vue
du Monde for the next 10 years or so though. There’s still plenty
to do and big ambitions to be realised. And one day, there’s the
ultimate goal – to open a restaurant in Paris. You’ve been warned
– make sure you visit Vue du Monde before he goes.
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RESTAURANT REVIEWS
Top finds
PathWay makes the rounds at some of Australia's most interesting and well-loved restaurants from 5-star food at
Melbourne's Vue du Monde to waterside dining in Perth, casual food in Sydney and Brisbane and a formal Italian
dining experience in Adelaide.
Vue du Monde
Vue du Monde has a reputation as one of, if not the finest
restaurant in Melbourne. With exquisite ingredients, superb wines
and Chef Shannon Bennett’s magic touch, Vue du Monde has
become a special occasion restaurant that requires a big budget
and a reason to celebrate. But not at lunchtime. Vue du Monde’s
fixed price lunchtime set menu brings a meal at Vue du Monde
within almost everyone’s reach. At $38 for two courses and a
glass of wine or $45 for three courses and a glass of wine, this is
a meal that can only be described as a bargain. For at this price
you get 5 star food and service at only a little more than you
would pay at one of the city’s far inferior cafes and restaurants.
The French influenced menu changes regularly but at this
reviewer’s visit we chose from a choice of entrée of sardines and
polenta and a delicate duck terrine. Pausing for a complimentary
palate cleanser, we moved on to a main course of grilled tuna on
pommes boulangere with black olive tapenade and verjuice and
Augé
the hare gallette with pea puree and red wine jus. All
accompanied by a glass of 2005 T’Gallant Juliet Pinot Grigio or
The beautifully restored cream 1953 Vespa in the entrance says it
all about this restaurant – Italian, attention to detail, interesting
Pinot Noir. Superb.
and good looking. Not as racy as a Vespa could be, but still a
Don’t bother telling yourself you won’t have a dessert, the truth is
very modern take on Italian cooking with a firm eye on tradition.
you won’t be able to resist after your first two sublime courses.
Today it’s a choice between the pannacotta of stilton with port
syrup or the cherry and almond sponge. Of course you can order
from the a la carte menu if you wish, but why would you?
The fixed price menu is now a fixture at most of Melbourne’s
great restaurants and its easy to see why. The best possible way
to market itself to customers, it’s an easy way to convince them
to return for an a la carte meal. At Vue du Monde, there’s no
question they succeed at this goal every time.
- Justine Costigan
Vue du Monde
Normanby Chambers
430 Little Collins Street, Melbourne
Tel: (03) 9691 3888
Hours: Lunch Tue-Fri bookings 12noon- 2pm, dinner Tue-Sat bookings
from 6.30pm-9.30pm. Reservations essential.
Fixed price lunch per person 2 courses and a glass of wine $38, 3 courses
and a glass of wine $45. A la carte between $40-$80 per person.
Dinner from $100 -$250 per person without wine.
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Centrally located across the road from the Adelaide Hilton and,
more importantly, facing the Adelaide Central Market, Augé has
at its doorstep the best and freshest seasonal produce available.
Adelaide has few formal Italian restaurants, and Augé provides a
welcome change to the staple fare provided by endless Italian
cafes. The restaurant’s long bar, with a lounge area, is well
separated from the dining room by a thick glass wall and makes
an ideal spot for pre or post-dinner drinks. The dining room itself
sets the tone with a flurry of white linen, discreet lighting and a
long banquette that is sumptuously comfortable – just like the
food.
This is one place where you can be sure the risotto of the day,
perhaps with poached lobster, saffron and chives, is always
exemplary, just like the house-made pasta – such as agnolotti
filled with braised beef and goat’s cheese.
Right: View from the Matilda Bay
Left: Vue du Monde
CEVICHE SAINT-JACQUES
Marinated scallops draped over a
pumpkin and apple remoulade,
bound in truffle mayonnaise,
completed with passionfruit
Photographer: Tim James
In winter there are hearty soups such as lentil and white bean,
flavoursome, if needing perhaps a little more balsamic dressing.
with feather-soft bread dumplings. Main courses might include
My partner’s mussels with chorizo sausage, roasted capsicums
crisp-skinned braised pork belly, its succulent meat teamed
and garlic cloves had a rich heartiness well suited to the
with baby spinach gnocchi and roast shallots, or venison loin
season.
with a parsnip and rosemary pie and an assortment of beetroot.
For mains I bypassed the Amelia Park lamb and Geraldton
There’s a small but excellent cheese menu that’s very good
snapper for western rock lobster, fresh from the tank, grilled
value, while the desserts here come highly recommended – look
and topped with lemon herb butter on a bed of potatoes
for treats such as a tasting plate of rhubarb and quince
dauphinoise. Though meaty enough, I feel the crustacean is an
crumble, quince panna cotta and rhubarb and lemon crostata.
offering better suited to a summer menu.
Service is fastidious, while the wine list, though not huge,
The other main, however, was a revelation – Margaret River
provides interesting choices.
venison done in three styles – slices of rare roasted venison with
– Nigel Hopkins
Augé
22 Grote Street, Adelaide
Tel: (08) 8410 9332
Hours: Lunch Tue-Fri 12noon -3pm, dinner Tue-Sat from 6pm
Bookings recommended
About $130 for two plus drinks
a salad of grapefruit and pickled vegetables, a hefty chunk of
osso bucco and a serve of roast. All were succulent, tender and
tasty, with the salad style a clear winner. We shared a side dish
of smoked roasted pumpkin, green beans and pumpkin seed.
To complement the West Australian produce, about two-thirds
of the Matilda Bay's wine list is regionally sourced, with a
Matilda Bay
strong selection from the Ferguson Valley, Great Southern and
Perth’s Matilda Bay Restaurant and Function Centre is so close
We barely managed dessert but couldn’t resist a dainty glass of
to the water’s edge its dining area was built around the stately
crème brulee atop of a dollop of rhubarb and cardamom
river gums flanking one of the Swan River’s prettiest vistas.
compote, dressed with a lid of toffee swirls. My vanilla bean
The setting is a perennial drawcard for Perth families, coach
panna cotta was beautifully balanced by warm poached pear
loads of tourists and bridal parties. On a chill winter’s night, city
segments in heady nutmeg syrup.
lights dancing on the water, yachts at anchor and the
We finished with excellent coffee and tiny shortbreads. When
occasional pelican skimming the water in search of a feed are
we left, the adjacent function room crowd looked to be as
enticing.
Margaret River.
satisfied as we were. The poor old pelican, however, was still
The restaurant’s staff, cheerfully attentive without being
trawling the riverfront in search of quarry.
obsequious, plied us with bread rolls freshly baked on the
- Alison Goodwin
Matilda Bay Restaurant
3 Hackett Drive, Crawley, Perth
Tel (08) 9423 5000
Hours: 7 days, lunch and dinner from 11am, Sunday buffet breakfast
from 8am
About $200 for two plus drinks
premises as we settled in to sample their presentation of West
Australian produce.
My entree of field mushroom frittata on wild rocket with airdried tomatoes and cabernet dressing was delicate yet
PATHWAY_65
At Credo we combine freshness, style, colour and simplicity in order to deliver some of Sydney's best
modern food. Winter ingredients bring robust flavours and textures to our menu, giving a somewhat
warmer palate with more comforting visual form on the plate. This season’s produce includes: root
vegetables, beans, pulses, fennel, chestnuts, cabbage, rhubarb and pears, just to name a few. Enjoy!
William Smirnios
Head Chef
Credo
Noi Bar
Credo Restaurant and Lounge is located in the Sydney suburb of
Cammeray, only 10 minutes from the CBD.
Noi Bar is part of the hardcore gentrification of Brisbane’s
Fortitude Valley. Situated in a long, narrow shop, it is part of the
new breed, blending a bar scene with the potential for fine allhours dining.
Nestled in amongst a bustling ‘village’ of shops, Credo quickly
found its niche since opening several years ago, with open air
seating in the front to watch the world go by, through to a more
intimate, contemporary interior with seating for approximately 80.
Lunch started in style, with impressively tall bloody marys that
had a refreshingly tangy edge, before starting on Chef William
Smirnios’ tantalizing menu. Smirnios works on the credo of using
only ‘in-season’ produce. The simplicity of the menu belies the
fact it actually features plenty of choice.
We started off with a shared platter of delectable red wine
oysters ($15 for half dozen).
The pear & walnut salad, with baby spinach, fetta, roasted
pumpkin, raspberry vinaigrette ($19) was light and crispy, but
surprisingly filling as a meal.
The roast pumpkin baklava, with pine nuts and fetta salad ($17)
was beautifully presented. The subtle flavour was perfectly
accompanied by our choice of wine from the extensive and
impressive wine list, a 2005 tamar ridge pinot gris ($40).
We were not able to resist temptation – the dessert menu was
divine – and thus ordered virtually one of everything to try,
including the white chocolate mousse, with honeycomb, nuts,
and passionfruit anglaise ($14), an incredibly smooth pudding of
chocolate and rhubarb confit ($14), a wintery poached pear with
chestnuts, filo crisps and caramel sauce ($15) and the most
unusual affogato, which comprised butterscotch schnapps,
espresso, ice-cream, and biscuit ($12).
There was no way to pick a favourite from amongst the
contenders – they were all particularly good.
- Andrea Plawutsky
Credo Restaurant And Lounge
504 Miller Street, Cammeray
Open 8 am till late, six days ( closed Mondays )
Entrees: from $14
Mains: from $17
Desserts: from $12
Ph: 9922 6662
66_PATHWAY
Apart from the extensive wine list, there are pages of cocktails for
those in the mood. On the menu, tapas, mids and mains provide
for any time of the day or night out.
The tapas is a selection of small but rich titbits – white bait
frittata, aioli and rocket salad ($9.50), crusted lamb cutlets
($15.50), squid stuffed with pancetta and rosemary, lemon and
olive oil ($10.50). The cutlets were superb, but I found the
contents of the squid a bit overwhelming for their casing.
The Angus beef sirloin, paired with mushroom risotto ($28.00)
was the stand-out choice from the mains. The ricotta ravioli
($18.50) was light and vibrant, and the buttered greens ($6.50)
perfectly crisp. Chef Trent Robson is showcasing the freshest
produce in his pithy selection of meals.
The dessert menu is limited to two dishes: a brulee ($10.50) and
a magnificent assiette of chocolate ($13.50). Zia Mick’s struffoli
($3.50), honey-glazed, oven-baked gnocchi, is an unusual dish,
yet my partner manfully gnawed his way through an entire cupful.
Noi is a stylish addition to the burgeoning scene around the
Valley’s popular clubs. With its slick stainless steel and dark
brown leather fit-out and muted chandelier-style lighting, it is a
cosy perch from which to observe the noise, traffic and crowds
of this central city hub
– Louise Martin-Chew
Noi Bar-Dining
350 Brunswick Street
Fortitude Valley, Brisbane
Open 7 days for breakfast and lunch and dinner Wed-Sat until 2am.
Tel: 07 3252 4349
2006
Conference Calendar
AUGUST 2006
21
2006 Harvard Medical International
Professional Development Program for
Medical and Healthcare Educators
21-25 August 2006
Brisbane, Australia
registration@som.uq.edu.au
22
Regional Conference on
Professionalism in Medicine 2006
22-25 August 2006
Singapore
www.pgmi.com.sg
SEPTEMBER 2006
12
The International Skeletal Society
12-15 September 2006
Vancouver, Canada
info@ryalsmeet.com
www.ryalsmeet.com
13
4th Annual Pathology Refresher
Course
Non-Neoplastic and Neoplastic
Conditions of the Skeletal Tissues
13-15 September 2006
Vancouver, Canada
info@ryalsmeet.com
16
The United States and Canadian
Division of the International Academy
of Pathology Centennial Congress
16-21 September 2006
Montréal, Canada
IAP - International Academy of Pathology
OCTOBER 2006
6
RCPA NZ Committee/NZSP
– Annual Scientific Meeting
6-8 October 2006
Taupo, New Zealand
anne.mackle@ccdhb.org.nz
19
NICS Using Evidence: Using
Guidelines Symposium
19-20 October 2006
Melbourne, Australia
www.usingevidence.com.au
19
The 2006 Defence Health and AMMA
Conference
19-22 October 2006
Brisbane, Australia
www.amma.asn.au
26
Gynaecological Symposium Pathological & Clinical Aspects
26-28 October 2006
Melbourne, Australia
nicholas.mulvany@austin.org.au
29
2007
Looking Ahead......
January
Annual Postgraduate Neuropathology
Course
18-20 January 2007
Sydney, Australia
www.pathology.usyd.edu.au/Neuropathology_
Courses/Neuropath_Index.html
March
Pathology Update 2007
2-4 March 2007
Sydney, Australia
evep@rcpa.edu.au
May
5th Asia Pacific International Academy
of Pathology Congress and Chapter
of Pathologists Annual Scientific
Meeting
27-31 May 2007
Singapore
iap2007@ams.edu.sg
www.ams.edu.sg/iap2007
August
VTEC 2006 – 6th International
Symposium on Shiga Toxin
(Verocytotoxin) Producing E. Coli
Infections
First World Congress on Pathology
Informatics (WCPI)
16-17 August 2007
Brisbane, Australia
29 October – 1 November 2006
Melbourne, Australia
www.pathologyinformatics.org/
www.vtec2006.org
24th World Congress of Pathology and
Laboratory Medicine
20-24 August 2007
Kuala Lumpur, Malaysia
NOVEMBER 2006
3
acadmed@po.jaring.my
Short Course in Forensic Pathology
3-5 November 2006
Hobart, Australia
chris.lawrence@dhhs.tas.gov.au
PATHWAY_67
BACK PAGE
Don’t try this at home
IF THE IDEA OF RIPPING OFF A BAND-AID OR DIGGING A SPLINTER OUT OF YOUR
FINGER MAKES YOU WINCE, LOOK AWAY NOW, WRITES ANITA PUNTON .
f your life hung in the balance, what
would you be capable of? Would you, for
instance, be able to cut off your own arm?
Hiker Aron Ralston did. Pinned under a
boulder after a hiking accident, alone and
miles from anywhere, he used a multi-tool
(a kind of Swiss Army Knife) to snap
bones and cut through skin and tendons,
amputating his arm in order to extricate
himself.
I
In extreme situations, when medical
help is not available, human beings can
be capable of the unthinkable. While
geographical isolation might prove the
most likely scenario in which self-surgery
is considered, it’s not the only reason.
Lack of money, fear or sheer bloody
mindedness can drive people to play
doctor – with themselves as the patient.
SOLITARY SURGERY
In 1996, during a round-the-world
race, solo yachtsman Pete Goss was
forced to operate on himself to repair
ruptured muscles around his elbow. Using
a head torch and a mirror strapped to his
knee, Goss froze his arm with a local
anaesthetic then cut out the hernias with
a scalpel.
The South Pole has seen a number of
incredible emergency procedures,
including a Soviet doctor removing his
own appendix and a doctor conducting
her own biopsies and administering her
own chemotherapy for breast cancer.
Trepanning has been practised by
man since prehistoric times. The
procedure – basically putting a hole in the
cranium - was believed by primitive man
to allow disease or evil spirits to escape
the body.
However, it was mental freedom that
was on the mind of Dutchman Peter
Halvorson in 1972 when he drilled a hole
into his skull. Just missing the main artery
that supplies blood to the brain,
Halvorson claims that his little excursion
into his own head cured his depression
and gave him greater mental capacity.
DIY DELIVERY
Obstetrics is a specialised branch of
medicine that requires years of dedicated
study. Or you could simply skip all that
and try DIY, as one Mexican woman did in
2004. Living in an isolated mountain
region with no phone, no husband (he
was drinking at a cantina) and the nearest
doctor 80 kilometres away, the woman
endured 12 hours of labour before
deciding to deliver her baby herself.
Swigging from a bottle of rubbing
alcohol, she took a knife she usually used
for butchering chickens and spent an hour
cutting through fat and muscle into her
uterus. She removed a healthy baby boy
and just before losing consciousness
managed to remember to cut the
umbilical cord with a pair of scissors.
Mother and baby survived.
COST CUTTING - LITERALLY
LIKE A HOLE IN THE HEAD?
For some, the promise of a higher
degree of consciousness is enough to
warrant getting out the toolbox and
attempting a spot of brain surgery.
68_PATHWAY
In 2004, an unemployed Bosnian man
gave self-surgery a whirl because he had
no money to pay a doctor. Waking in the
middle of the night in extreme pain, the
man noticed that his genitals had swollen.
He took a wild guess that a kidney stone
was stuck in his urinary tract. Using a
razor blade and a sterilised needle, he cut
the skin under his testicles and dug out
three stones. Doctors in a nearby town
were so impressed that they cleaned and
restitched his wound for free.
SAY ‘AAAAGGGHHHH!!’
No homemade set of surgical
instruments would be complete without a
trusty pair of pliers. Earlier this year, a
great grandmother from North Yorkshire in
the UK extracted seven of her own teeth
with her husband’s pliers after repeatedly
failing to get an appointment with a
National Health Service dentist.
AGONISING PROBLEMS,
CREATIVE SOLUTIONS
Then there was the Mexican man who
performed a successful haemorrhoid
operation on himself because he was too
proud to see a doctor. And his compatriot
who, after experiencing breathing
difficulties, inserted a needle through his
navel and successfully drained three litres
of fluid from his lungs.
Or one final, shocking story, involving
a US marine bitten by his pet rattlesnake.
The soldier decided to cure himself by
giving himself a jump start, connecting
sparkplug wires between his car and his
lip, then revving the car’s engine for five
minutes.
Incredibly, he survived, and at least
one person took his self-help technique
seriously. The incident was the subject of
a medical report entitled Failure of Electric
Shock Treatment for Rattlesnake
Envenomation.