Pathway Winter 2007 - Blood Feuds

Winter 2007 | Issue #12
Blood Feuds:
MASSIVE CHANGES TO NZ PATHOLOGY SERVICESTEACHING STANDARDS: UP TO THE MARK? SPOTLIGHT ON NEW ZEALAND
Blood Feuds
MASSIVE CHANGES CREATE WAVES IN NZ
NEVER HEARD OF ORAL PATHOLOGY? YOU'RE NOT ALONE
MOUNTAIN HIGH: THE BEST OF NZ SKIING
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ADVISORY BOARD
Contents
Dr Debra Graves (Chairman)
Chief Executive, RCPA
Dr Bev Rowbotham
Vice President, RCPA
Professor Jane Dahlstrom
Representative, Committee of Deans of
Australian Medical Schools
Dr Tamsin Waterhouse
Deputy CEO, RCPA
PATHWAY
Winter 2007
Issue #12
Wayne Tregaskis
S2i Communications
PUBLISHER
Wayne Tregaskis
EXECUTIVE EDITOR
Dr Debra Graves
EDITOR
Kellie Bisset
COVER STORY
ART DIRECTOR
Jodi Webster
Blood feuds:
ADVERTISING SALES DIRECTOR
Bronwyn Sartori
PUBLISHING CO-ORDINATOR
Andrea Plawutsky
Massive changes to New Zealand pathology services have
unsettled the profession
8
FEATURES
Movers and shakers
Scalpel please: keeping forensic pathologists in regional Australia
is tough, but entirely possible
14
In profile
A floating asset: Dr Tony Barker’s nautical skills have helped him
navigate a rewarding career
17
Disciplines in depth
Teething troubles: never heard of oral pathology? You’re not alone
21
Spotlight on disease
Silent assassin: spotting patients at risk of kidney disease is a
medical challenge
26
Foreign correspondence
People power: Dr Richard Williams has developed some
rewarding links with China
30
Practice portrait
Seeds of Change: Symbion Laverty is about to celebrate 25 years
in specialist gynaecological pathology
32
Teaching Notes
Pathology Training: PathWay special report
34
FOR FURTHER INFORMATION ON THE ROYAL COLLEGE OF
Pathology Update 2007
40
IN THIS ISSUE OF PATHWAY CHECK OUT THE WEBSITE
A round up of research presented at the RCPA annual conference
Testing, testing
46
PathWay is published quarterly for the Royal College
of Pathologists of Australasia (ABN 52 000 173 231)
by S2i Communications, Suite 1201, Level 12,
4 O’Connell St Sydney 2000
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PathWay
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PATHOLOGISTS OF AUSTRALASIA OR ANY OF THE FEATURES
www.rcpa.edu.au
New horizons: thyroid testing is almost too good
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PATHOLOGY
UPDATE 2007
PAGE 40
REGULARS
From the CEO
Welcome from RCPA CEO Dr Debra
Graves
4
Under the microscope
6
News + views
Conference calendar
65
Postscript
68
Nutmeg liver and sago spleen:
pathology serves up abundant
culinary adjectives
SNOW BUSINESS
PAGE 50
LIFESTYLE
Travel
Snow business: Choice is not lacking on the NZ ski fields
50
Private passions
Keeping the faith: Dr John Bothman gives his beloved racehorses a run
for their money
54
Travel doc
Southern exposure: Julia Potter and Peter Hickman are seduced by
Antarctica
56
Recipe for success
Make it a double: the Doyle brothers share a love of food and good
waves
58
Dining out
A yen for Japanese: PathWay’s search for sushi uncovers so much
more
61
The good grape
Hello mellow yellow: Ben Canaider welcomes the arrival of a more
demure Aussie chardonnay
64
Rearview
66
Dark side of Venus: who’s to blame for foisting syphilis onto the
modern world?
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from the CEO
Welcome
to the 12th Edition of PathWay
n this edition our cover story explores
I
the major and controversial changes to
New Zealand pathology. There has been
much activity across the country with the
21 district health boards tendering out
community pathology services for periods
ranging from 18 months to 10 years.
We explore the implications of all this
for pathologists and pathology, particularly
the lack of a national overarching
framework to address workforce and
training needs.
L-R: Visiting speaker Lord Carter of Coles; Debra Graves; chair of Update's overseeing committee
Jeanne Tomlinson; RCPA president Dr Stewart Bryant
We also profile Dr Tony Barker, Clinical
Director of Auckland’s LabPLUS. Tony has
had an interesting career, including a
board role at IANZ, the New Zealand
Laboratory Accreditation organisation.
But he also has a passion for sailing.
What better place to indulge this
pastime than Auckland, with its beautiful
harbour? Well I do live in Sydney, so
maybe I can think of just one…
Continuing our New Zealand theme,
we check out what’s hot on the ski slopes
in both the North and South Islands. If
We now have a total of 63 new funded
positions, so we’re getting there slowly
Nicolaides laboratories in Brisbane, is
but are still far short of the 400 we need
employing part-time medical students in
to address our workforce shortage.
pathology as a career.
College to attain her Fellowship via the
Private Practice Training Scheme is
featured in this issue. Dr Alash is an Iraqitrained pathologist who only required
several years top-up training while
There are many other interesting stories
in this edition, including an update from the
RCPA annual conference, an in-depth look
at the little-known discipline of oral
pathology and a review of kidney disease.
I hope you enjoy this edition of PathWay.
preparing for the RCPA exams. She did
this at Symbion Health in Melbourne and
and getting into the ski spirit this winter,
attained her Fellowship earlier this year.
Workforce issues remain vital in
the laboratory so they can learn about
Dr Aman Alash, the first Fellow of the
you’re planning on building up those quads
New Zealand is a great travel option.
Another initiative, from Sullivan
We also look at a number of initiatives
the College and laboratories are
pathology. We look at the federal
undertaking to attract medical students
Dr Debra Graves
government’s support for private-sector
into pathology. While we currently have
CEO, RCPA
training, including the good news that
more medical students wanting to do
10 extra places have just been funded
pathology than we have training places, it
via the Expanded Settings for Specialist
is important we maintain this interest.
Training Scheme. This now brings the
number of Commonwealth-funded
Initiatives such as the RCPA and ACT
positions to 20 – the highest number of
Pathology medical school scholarships
any government, closely followed by
are designed to provide financial support
Queensland with 18 positions, and
for medical students to do an elective in a
Western Australia with 11.
pathology laboratory.
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At Symbion Pathology we recognise
that our primary responsibility is to
the patients, medical practitioners and
communities we serve. Remaining
at the forefront of laboratory testing,
Symbion Pathology constantly strives
to innovate and improve accuracy and
efficiency within pathology practice.
With a national network of
distinguished pathology providers,
we remain committed to delivering a
service based on superior quality and
customer satisfaction.
A National Network of
Pathology Providers
03 9244 0444
03 5174 0800
02 9005 7000
08 9317 0999
07 3121 4444
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under the microscope: news + views
Government funds
10 new private pathology
training spots
he federal government has announced
T
funding for another 10 pathology
training positions in the private sector.
The RCPA has welcomed the move,
with CEO Debra Graves describing it as
“further evidence that the Commonwealth,
in contrast to many state governments,
has recognised the seriousness of the
workforce crisis in pathology”.
The positions will be offered under the
Expanded Settings for Specialist Training
program, and are based largely on the
existing Private Practice Training Scheme
(PPTS), which is currently training 10 new
pathologists.
The RCPA has called for applications
for funding under the program, which
offers $75,000 per position per year.
It says at least two years of the
training must be provided within the
public sector and that there should be an
appropriate mix of pathology trainees at
different stages of training at any one
time.
It’s envisaged that an appropriate
balance of trainees will also be allocated
across the states and territories, with
respect to the priority disciplines, location
of providers and satisfactory applications
received.
For more on pathology training, see our special
report, page 34
Melbourne researchers
developing Parkinson’s
blood test
new screening test being developed
for Parkinson’s disease (PD) may also
be able to monitor treatment and measure
the effectiveness of drug therapy,
researchers say.
A
The diagnostic blood test, which
measures the levels of the brain-secreted
protein alpha-synuclein, was developed
by researchers from the Howard Florey
Institute, The University of Melbourne and
the Mental Health Research Institute of
Victoria.
They found Parkinson’s patients had
low blood levels of the protein while those
without the disease had high blood levels.
“Currently there is no specific PD
diagnostic test, so doctors rely on their
observations to make a diagnosis – which
means some patients may not be
prescribed the most suitable medication,
and around 15% of those diagnosed may
actually be suffering from something
else,” said Professor Malcolm Horne,
from the Howard Florey Insititute.
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“Further studies are required to
Dr Peter
Garcia-Webb
awarded AMA
fellowship
ong-time RCPA fellow Dr Peter
L
Garcia-Webb has been inducted as
an AMA fellow for his outstanding
service to the association.
Dr Garcia-Webb, the chief
pathologist and general manager of
establish whether this test can distinguish
Symbion Pathology, was one of a
between people who are responsive to
handful of AMA members awarded
treatment and those who are not.”
fellowships at the association’s national
The research team is now conducting
conference in late May. The list of his
a large-scale study to determine the test’s
contributions is long, but includes his
effectiveness and is seeking funding for
role in helping position the AMA as a
further development.
leader in e-health and his skills in
“If the results of our large-scale study
financial management – he is currently
are encouraging, this test could be
director of AMA Commercial and has
available for clinical use within two years,”
served as a member of the association’s
Professor Horne said.
finance committee and as a director of
The team still needs to establish
whether the test is applicable to all types
of PD and whether it can measure
disease severity and rate of progression.
But the test’s availability will ensure
AMPCo, the Australasian Medical
Publishing Company, which publishes
The Medical Journal of Australia.
An RCPA fellow since 1971, Dr
Garcia-Webb has previously been
drug trial participants actually have the
awarded the AMA President’s Award for
disease so research outcomes will be
his ongoing commitment to addressing
more statistically valid.
the medical indemnity crisis.
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he Australian and New Zealand
And in Australia, a lack of clarity
T
over whether Rh(D) antibodies were
just released revised guidelines for red
due to prophylaxis or active
blood cell antibody testing in pregnant
alloimmunisation has caused problems
Society of Blood Transfusion has
women following recent cases of
adverse foetal outcomes after routine
anti-D prophylaxis.
Rh(D) immunoglobulin (anti-D) is
currently used to prevent the effects of
Rh blood group incompatibility
in another two cases. In both cases
Rh(D) was given before the blood
samples were collected and
complicated the laboratory results.
The guidelines were reviewed in
between a woman and her baby.
conjunction with the Joint Rh(D)
Existing guidelines recommend all
Consultative Committee, made up of
Rh(D)-negative women should be
professional representatives including
screened for red cell antibodies at the
the RCPA.
initial antenatal visit and at least once
between 28 and 36 weeks’ gestation.
However, adverse events reported
in Australia and the UK have
The new guidelines recommend
that when antenatal red cell antibody
testing is indicated, blood samples
highlighted the need for the correct
be taken before administering Rh(D)
timing and interpretation of screening.
immunoglobulin. However, if
In the UK, misinterpretation of
PHOTO CREDIT: EAMON GALLAGHER
Revised guidelines
for antenatal red cell
antibody testing
administration has already occurred,
antenatal antibody investigations in
the test should still be performed
two cases resulted in severe
and the situation noted on the lab
haemolytic disease of the foetus.
request form.
Correction
story published in our Summer
2006 edition (‘STDs on the rise’)
suggested there could be an
additional role for pathologists in
screening women who were sexually
active and not found to be exposed to
HPV types 16, 18, 6 and 11, who
might still be suitable for vaccination.
A
However, at present the National
Centre for Immunisation Research and
Surveillance says pre-vaccination
testing is not warranted. Serological
testing is too poorly sensitive to be
clinically useful and is only used in
epidemiological studies. Testing for
the detection of HPV DNA identifies
only current, not past, infections.
PathWay apologises for any
confusion caused.
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cover story
Blood feuds
NEW ZEALAND PATHOLOGY SERVICES HAVE BEEN GIVEN A MASSIVE OVERHAUL,
BUT NOT EVERYONE IS HAPPY WITH THE RESULT, AS MARILYN HEAD REPORTS.
n Aotearoa, the Land of the Long White
Cloud, things are looking particularly
cloudy when it comes to the delivery of
pathology services.
I
Over the past three years, the
pathology scene in New Zealand has seen
massive change as services have moved
away from central government control.
Pathology will now be provided by
regional contractors, who will tender for
the work from each of the country’s 21
autonomous district health boards (DHBs)
and be paid on a bulk-funding basis.
This is a move predicted to save
millions – but at what cost?
There are fears the change might see
a drop in service quality – and that
patients will lose out.
Some regions have opened their
services for tender, and others have
retained the status quo, but the regime
change has been far from seamless.
The transition has been overcast with
vociferous criticism from unions and
professional associations, intervention by
business watchdog the Commerce
Commission and a high-profile court case.
Added to the melee is the Ministry of
Health’s steady refusal to intercede, and
an information void from the health
boards’ representative body, the DHBNZ –
all of which has enshrouded the process
in unwarranted mystery.
It seems the bunfight has resulted in
diverting public attention from a crucial
question: can restructuring the funding
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and delivery of New Zealand’s pathology
services result in better healthcare
delivery?
New Zealand’s population of 4.25
million is getting older, more urban and
Auckland-centred.
These major demographic changes,
combined with new technologies that
could deliver superior diagnostic testing,
are behind the moves to look at pathology
resources differently.
Automation has reduced costs (and
increased volumes) for specific schedule
tests, but an ever-expanding list of new
ones – including genetic and ‘wellness’
testing – has sent costs spiralling.
diabetes and other recognised risk factors
– which should be funded.”
Despite this view Dr Beer can see the
flip side of change.
“The tendering process is fairly
brutal,” he says.
“It’s a bit disasterous for the industry
in that somebody has to lose and some
lab has to go under, fold up, or go away.”
Another problem with the old system
however, was the ad hoc distribution of
pathology services. In Auckland, for
example, there are not enough services –
and they’re often not situated where the
population is.
And despite all the news-column
centimetres devoted to the changes, the
debate about how far the public purse
should be stretched has never emerged.
Now it’s estimated there will be a 50%
reduction in the number of laboratory
collection centres, where testing is free, in
favour of GP collection, which is usually
not.
Necessity for change
But those collection centres that do
remain will be located more appropriately.
As pathologist Dr Ian Beer points out,
preserving free testing for ill patients in
the face of uncapped costs was a major
motivation for reform.
“The risk was really that if testing kept
growing at the same rate, the system
might have fallen over,” says the director
of Pathology Associates Ltd, a private lab
that has won extra contracts under the
new system.
“There’s a whole range of testing for
symptom-free patients like ferritin tests for
athletes, which could be paid for by
patients, and others – such as monitoring
And then there’s the issue of over- and
under-testing. Under the centralised
regime, pathology providers were paid on
a fee-for-service basis, so there was no
incentive to monitor what level of
schedule tests were necessary.
While there have been some concerns
about over-testing, Canterbury DHB in
fact felt pathology services were being
under-utilised, with people ending up in
hospital as acute cases when they should
have been treated earlier.
Providers will now be paid on a bulkfunding basis, putting the onus on labs to
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Providers will now be paid on a bulk-funding basis,
putting the onus on labs to manage their volumes
adequately, analyse ordering patterns, and
rationalise equipment and personnel
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“The risk was really that if
testing kept growing at the
same rate, the system might
have fallen over.” – Dr Ian Beer
manage their volumes adequately,
analyse ordering patterns, and rationalise
equipment and personnel.
“[Bulk funding] means the lab is going
to become responsible for managing the
volumes because the bureaucrats believe
that the pathologists should be sorting
out what is more appropriate testing,” Dr
Beer says.
“That’s probably a fair call. The
gatekeeper responsibility has changed
from GPs to pathologists. There’s a real
incentive to discuss things with doctors.
We haven’t got the time to review every
doctor’s decision, but we can review
ordering patterns using ICT, and look for
people who are being over-tested.”
It’s also envisaged DHBs will be able
to better control costs. They’ll know upfront what their costs will be, as providers
will sign contracts on the basis of an
agreed price.
Models galore
Some believe that in the variety of
cooperative and competitive tendering
models that have emerged, there is a
wonderful opportunity to assess what
works and why.
But this variety of models has also
caused a few raised eyebrows – and
each DHB has approached the new
system in its own way (see page 12).
And while this might be a way of
tailoring local services to the local
community, there is no central control
authority for pathology services to deal
PHOTO CREDIT: NICOLA TOPPING
with national areas of concern such as
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training and workforce retention.
RCPA chief executive Dr Debra
Graves says this is a major concern. The
college wants a national framework
developed for laboratory services but is
getting nowhere fast.
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“Our fundamental concern is about
having a national framework of quality,
especially around issues such as training,”
she says.
“We would have liked the Minister to
set the ground rules of a national policy
within which the DHBs had to operate.
The workforce is already so thinly
stretched that if the numbers fall, they will
not have the capacity to train new
pathologists under the accepted
apprenticeship model or to develop new
tests, so the quality goes into a ‘death
spiral’.”
The other concern is the
destabilisation that has occurred in some
DHBs as a result of the changes.
“I have never seen pathologists so
distressed,” Dr Graves says.
“New Zealand is an integral part of the
Australasian region, so it affects everyone
if the quality of their service falls behind –
and we are concerned that within their
policy framework they’re losing the ability
to monitor how pathology is being
delivered in the community.”
As for the government’s view, while
the DHBs are autonomous, they must still
work within “Operational Policy and
National Service Frameworks”, according
to Ministry of Health spokesperson Julie
Rodgers.
people who use it and maintaining as ‘flat’
a bureaucratic structure as possible,
others say it has led to inconsistency and
unnecessary duplication.
“Twenty-one DHBs equals 21
bureaucracies” is a frequent observation,
though Otago DHB’s Brian Rousseau
argues “we’re not advocates for a single
model, because each region is quite
different”.
Concerns over fragmentation have
been exacerbated by the somewhat
invidious position of DHBNZ, the
incorporated society formed by the DHBs
in 2000 to support and coordinate
This structure was first introduced in
2001, when the Ministry contracted the 21
DHBs to deliver all health services to their
respective regions.
activities. While it does operate nationally
Planning and funding are carried out
under the auspices of the Deputy
Director-General, DHB Funding and
Performance, which also monitors the
boards’ performance against agreed
indicators.
DHB, nor is it accountable in the same
But while the government sees selfdetermination as critical to keeping
healthcare in the hands of the local
being restructured nationwide, there were
on selected issues where there is
agreement among all the DHBs to do so,
DHBNZ has no mandate to direct any
way as a government body, since it can,
and does, operate behind closed doors.
So the peculiar and frustrating
situation arose that, while the provision
and funding of pathology services was
no national guidelines: the government
had devolved responsibility and DHBNZ
couldn’t speak on behalf of individual
DHBs.
This left representative bodies such as
the RCPA, the New Zealand Medical
Association and health workers’ unions
out in the cold. For those concerned
about the long-term implications, the only
mechanisms available for challenge or
discussion were the law and the lengthy
process of policy change.
The fallout
So what has been the result of all this in
terms of service provision? As you’d
expect, a mixed bag. While West Coast
DHB opted to maintain the status quo,
Southland and Otago sought economies
of scale, firstly by linking together, and
secondly by selecting a single provider to
cover both hospital and community
services.
Some private companies merged;
others were forbidden to do so by the
Commerce Commission. Several boards
opted to keep hospital and community
services separate, while others negotiated
cooperative contracts between the two.
The duration of contracts, which
strongly impacts on the level of
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THE CHANGES:
region by region
NORTHLAND: separate providers for hospital and community services, the latter provided
by Northland Pathology Laboratory (18-month contract). Review of services currently underway.
AUCKLAND, COUNTIES-MANUKAU AND WAITEMATA: have negotiated an
18-month contract for transitional services with Diagnostic Medlab following a High Court
decision to overturn the contract to newcomer Labtests as sole provider for the greater
Auckland Region. Contract exclusive for first 12 months only. Both companies intend retendering for sole provision of services.
WAIKATO: selected Pathology Associates over the incumbent Medlab Hamilton for
community services. Hospital laboratories remain with the DHB.
BAY OF PLENTY: opted for a sole provider, NZ-owned Pathology Associates trading as
Medlab Bay of Plenty.
LAKES (ROTORUA): a proposal for a joint venture between a private provider and the
hospital laboratory likely to be signed off later this year.
HAWKES BAY: has a single provider – a partnership between the hospital laboratory and
Southern Community Laboratories (SCL). Hospital lab covers hospital services, all histology and
non-gynaecytology and certain automated biochemical and haematology tests. SCL responsible
for all sample collections, microbiology and the remainder of tests.
TAIRAWHITI (GISBORNE): will have a sole provider (joint venture between hospital
laboratories and Medlab Central) for hospital and community services, to start in September.
TARANAKI: has retained its hospital services and contracted Taranaki Medlab for community
work (three-year+ contract).
WHANGANUI: announced the first preferred tender for all services to Medlab Central last
October. Contract is yet to be signed.
WAIRARAPA: selected Medlab Central as the sole provider from 1 March.
MIDCENTRAL DHB (PALMERSTON NORTH): tender evaluation process complete
and preferred single supplier selected, but contract not yet signed off.
CAPITAL AND COAST (WELLINGTON) AND HUTT VALLEY: will maintain their
respective hospital laboratories and jointly tender out community work. Contract awarded to
Aotea Laboratories Limited, a merger between private providers Hutt Valley Diagnostics and
Medlab Wellington.
NELSON MARLBOROUGH: five-year contract to single provider, Medlab South.
CANTERBURY: has kept hospital laboratory, and opted to keep both private providers
Medlab South and Southern Community Labs for community schedule work with capped
agreements.
SOUTH CANTERBURY: the first DHB to tender services three years ago, it selected the
incumbent Medlab South. It says it has made significant savings without compromising service.
WEST COAST: smallest DHB has opted to maintain the status quo – hospital services
provided by the hospital lab, and community services from Medlab South and the hospital lab.
OTAGO AND SOUTHLAND: joint call for a sole provider of hospital and community
services was won by Southern Community Laboratories, after the Commerce Commission
forbade the merger of the private providers.
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“New Zealand is an integral part
of the Australasian region, so it
affects everyone if the quality of
their service falls behind.”
SOURCE: NZ MINISTRY OF HEALTH
– Dr Debra Graves
District Health Boards
Since the legal wrangle, the company
investment, ranges from short 18-month
‘rollovers’ to up to 10 years.
fact that Labtests had no existing
laboratories raised alarm bells with many
has been forced to make the 180 staff
With thousands of jobs, millions of
dollars, and a critical component of the
health system at stake, change was never
going to be easy.
in the profession.
members it recruited redundant, though
But when NZ Medical Association
president Dr Ross Boswell notes that
“we’re so far steeped in the river of blood
it’s too late to turn back”, one contract
dispute has made it all the way to the
High Court, and strong dissatisfaction has
been expressed by a workforce that has
lived with job insecurity for years, it’s clear
the process has been massively
disruptive.
Nowhere is that more obvious than in
the Auckland region. Last year, the
Auckland, Waitemata and CountiesManukau DHBs jointly awarded their $560
million contract to newcomer Labtests
Limited – a company part-owned by
Auckland DHB member Dr Tony Bierre
and Australian company Healthscope.
While it promised to deliver an annual
$15 million saving to the community, the
This, and the ousting of the incumbent
many of them have taken up the
provider Diagnostic Medlab, sparked a
company’s offer to relocate to Australia
highly public and vituperative debate,
and other parts of New Zealand. Labtests
which ended in a $2 million High Court
is currently working on placing the
case where the contract was invalidated.
remaining 18 staff in other jobs, though
Justice Asher noted the DHBs had
failed to properly consult GPs and the
community as required, said Dr Bierre’s
conflict of interest “amounted to an
Ms Moss says it would want to re-instate
all former staff if it won the contract
further down the track.
“We’re committed to re-tendering
attempt to further his own interests”, and
because we have some very innovative
also criticised DHB chairman Wayne
ideas about improving the delivery of
Brown for allowing Dr Bierre’s
pathology services, especially to low
“impermissible” involvement. Since then,
socio-economic groups who are not
an interim 18-month agreement has been
getting the testing they need,” Ms Moss
negotiated with Diagnostic Medlab to
says.
ensure continuity of services beyond 1
July, when the contract was due to begin.
Meanwhile, Healthscope has since
There is still a long way to go to see
whether the grass on the other side of the
“river of blood” will be greener, but it’s
bought out Dr Bierre’s share in the
worth remembering that New Zealand
company, and Labtests’ Chief Operating
derives from Zeeland, whose coat of arms
Officer Grainne Moss says the company
bears the text luctor et emergo – “I
will retender.
struggle and I emerge”.
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movers and shakers
Scalpel, please…
KEEPING FORENSIC PATHOLOGISTS IN REGIONAL AUSTRALIA IS A TOUGH ASK, BUT SOME
STATES ARE MAKING HEADWAY. KATE WOODS REPORTS.
he deceased man was Mr Maxwell
T
Marshall, found dead at his home in
December 2003.
The autopsy was performed by Dr
John Scott, an experienced GP who had
been working as a government medical
officer (GMO) in Queensland for nearly
three decades.
Dr Scott concluded the cause of death
was drug toxicity due to oxycodone.
But the Queensland Coroner decided it
was impossible to determine the cause of
death, labelling the autopsy “inadequate”.
Dr Scott’s report was too brief, the
Coroner said. It omitted too many basic
details; the GP was misled by inaccurate
information in the police report; and he
had decided on cause of death before
seeing the toxicology analysis and before
making “adequate” inquiries about the
deceased’s medical history.
But the coroner also concluded that
these problems were due to Dr Scott’s
lack of training, not a lack of professional
application or commitment.
This case was followed by media
reports in NSW about the shortage of GPs
prepared to conduct autopsies. Both the
AMA and the Rural Doctors Association
called for ongoing training to be offered to
GPs doing this work.
14_PATHWAY
But the media debate seemed to
overlook an obvious question: what about
the forensic pathologists?
The GMO’s role in autopsies has long
been a source of debate and discussion in
Queensland and NSW.
Both states – due to their size and the
fact their populations are spread over large
areas – need more pathologists in regional
areas than other jurisdictions.
But with the workforce shortage, they
have been forced to rely on GMOs.
This coroner’s case – among other
things – has spurred Queensland into
finding a way to increase the profile of
forensic pathology in regional areas,
although little progress has been made
in NSW.
And while the issue is not currently an
urgent one in other states, the pathology
workforce shortage could change that. The
threat that coronial autopsies carried out in
regional areas could be significantly
reduced in future looms large.
Sunny side up
Queensland, in a bid to boost forensic
pathology in the state, is now leading the
way in establishing and filling trainee posts
for young doctors.
“In my view, this is absolutely the
fundamental issue,” says Associate
Professor Charles Naylor, chief forensic
pathologist with the Queensland Health
Scientific Services (QHSS).
“You can speculate about putting
forensic pathologists in regional centres
all you like, but it is never going to
happen unless you have the doctors to
put in there.”
He says Queensland has three trainee
posts: two permanent, and one that may
soon become permanent. Two of the
trainees filling these positions are due to
complete their final exams in forensic
pathology this year.
The hope is that if their roots are
planted in Queensland, they will stay on
after completing their specialist training.
Professor Naylor says one of the
reasons Queensland has been able to
attract young doctors is its facilities. As
well as pathology, the QHSS contains
biology (including DNA PCR), chemistry
and toxicology facilities, allowing young
doctors to be exposed to a full range of
cases at the one centre.
The QHSS is also linked to a network
of major pathology labs at hospitals
around the state.
“This means that during their
training, registrars can, for example,
rotate to the anatomical pathology labs
at some of the big teaching hospitals
like the Royal Brisbane and the Princess
Alexandra Hospitals,” he says.
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“You can speculate about putting
forensic pathologists in regional
centres all you like, but it is never
going to happen unless you have the
doctors to put in there.”
PHOTO CREDIT: ROBERT SHAKESPEARE
– Associate Professor Charles Naylor
“And while we might not be unique in
this, we are probably better placed than
most to offer this kind of well-rounded
training to young doctors, and that is
probably why we have had success in
attracting and recruiting trainee forensic
pathologists in Brisbane.”
In Queensland, forensic trainees are
attached to forensic laboratories from their
first year of training and any time spent on
rotation to other laboratories is paid for by
the forensic lab.
Keeping connected
In other states, trainees are attached to an
anatomical pathology laboratory for the
first three years of training to obtain the
basic surgical pathology they requre to be
a forensic pathologist. As a result, they
often get disconnected from forensics and
lose interest.
The Queensland model overcomes
this problem and the RCPA is trying
to encourage other states to adopt a
similar model.
With the ability to train and maintain
forensic pathologists, the state is now
working on an innovative way to promote
the service in regional and remote areas.
The initiative came about after a
ministerial taskforce was established in
2005 to look at forensic services and the
challenges it was facing, Professor
Naylor explains.
Of the 70 recommendations made by
the taskforce, more than 90% were
endorsed by Cabinet, including one that
outlined the need to develop standard
procedures for autopsies and running
mortuaries across the state.
As part of this drive, Queensland
Health decided to establish facilities at
seven regional centres, with enough
trained mortuary staff and pathologists to
service the local area.
Dr Peter Ellis is the first forensic
pathologist to be placed in a regional area
under this scheme. Although he has only
been in the job for four months or so, he
says he is “delighted” with the situation.
He says there are many benefits to
working in a regional area over a big
capital city like Sydney, where he worked
for 19 years before taking up this post.
“I have a reasonable workload,
interesting case material and have been
able to develop good, close relationships
with the police, Coroner and other
professional colleagues, which makes for
better and more efficient working
conditions.”
Dr Ellis says while the downside to
working in a regional area can be
professional isolation, countering this was
at the “top of the list” when he and
Queensland Health were designing his post.
The solution? He travels back to the
QHSS one day a fortnight.
“Maintaining professional contact
with your peers is important in
maintaining your standards. You need to
be able to exchange ideas, bounce ideas
off them, and if you are 500 km away
from the nearest significant centre this
becomes difficult.
“If you can counter that or make
provisions, then you are more likely to
attract people to rural areas, including
places as distant as Cairns or
Rockhampton.”
Dr Ellis adds there are also limitations
with the type of cases that can be
performed at his mortuary, because the
facilities are not as large or as well
equipped as they are at the larger centres.
“It’s a bit of an experiment, but very
exciting to be part of,” he says.
“There are also a number of specialist
trainees in the pipeline, which bodes quite
well for the future. The hope is we will be
able to spread this kind of regional service
elsewhere in the state very soon.”
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In the shadows
In NSW however, things aren’t looking up,
though it’s not for want of trying on the
part of forensic pathologists.
Associate Professor Johan Duflou says
there are a number of reasons for the
shortage, including the low profile
pathology has in the medical curriculum,
and the low profile forensic pathology has
among other medical practitioners –
despite the popularity of crime television
programs such as CSI.
Very few medical schools have a
formal series of lectures in forensic
pathology, so students are not exposed to
the topic and therefore don’t consider it
when deciding their future, explains the
chief forensic pathologist at the
Department of Forensic Medicine, Glebe.
And then there is the job itself. The
work is “smelly”, night call-outs are not
uncommon, and court appearances
frequent.
“On top of that, there is an income
differential between forensic and
anatomical pathology in NSW which is not
insignificant; about $1000 a week,”
Professor Duflou says.
“Frankly, if you are starting out and get
offered two jobs, one gets paid 50 grand
more than the other, what would you do?”
of Forensic Medicine, this system actually
The institute – responsible for forensic
pathology and clinical forensic medicine
services throughout the state – has five or
have been able to develop
good, close relationships with
undertake coronial autopsies on its behalf.
the police, Coroner and other
There are no GMOs because under
Victorian law, autopsies must be carried
professional colleagues”
out by a pathologist or a medical
– Dr Peter Ellis
practitioner under the direct supervision of
a pathologist.
“Certain cases do automatically come
to Melbourne – for example sudden infant
death syndrome cases, all homicides,
multiple fatalities and any other deaths the
pathologists in regional areas are not
happy to do,” Professor Cordner says.
Shrinking numbers
But he predicts this may not last long, with
the continuous decline in pathologists
expected to make it increasingly difficult to
maintain the service in the future.
“In the middle 1990s, about 800 or
900 deaths were autopsied in country
Victoria every year; now the number is
more like 400.”
Professor Cordner says the main
reason for this decrease is because some
country centres now have their pathology
“Over the decades, there have been
multiple working parties and committees
looking at the structure of forensic
pathology services in NSW, and not
surprisingly, they consistently come up
with the same ideas – it’s just that these
ideas keep being rejected.”
inclination to engage with this work, and
services provided remotely, and therefore
autopsies have had to be transferred to
Melbourne.
It is also because some pathologists,
for a range of reasons, don’t have a strong
historically the pay has not been
commensurate with the responsibility.
While this second issue is being
addressed with assistance from the state
government, Professor Cordner says
Victoria may have to consider other
options, such as the feasibility of having
forensic pathologists travel from the city to
regional centres for certain cases.
“The numbers do show an absolutely
continuous downward trend in autopsies
carried out in country areas due to the
“It was a government policy decision, I
suspect because they didn’t see the value
in committing extra resources and funding
in it.”
unavailability of pathologists.
But according to Professor Stephen
Cordner, director of the Victorian Institute
ones whisked hundreds of miles away to
16_PATHWAY
interesting case material and
six regional centres with pathologists who
Professor Duflou is a member of the
NSW Department of Health’s Forensic
Pathology Services Committee, which is
looking at service delivery throughout the
state, but he says the solutions they are
coming up with aren’t new.
He says there was a plan to develop a
NSW Forensic Medicine and Pathology
Authority, which would operate in a similar
way to the Victorian Institute of Forensic
Medicine – “a statutory body with an
independent board” – but this too was
scrapped.
“I have a reasonable workload,
works “very well” in his state.
“We are trying to maintain country
services for as long as possible because
we know families don’t want their loved
the capital cities.”
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PHOTO CREDIT: BRENDON O’HAGAN
in profile
Floating asset
DR TONY BARKER HAS FOUND THE PERFECT BALANCE BETWEEN HIS PASSION FOR QUALITY
PATHOLOGY AND LIFE OUTSIDE MEDICINE, WRITES REBECCA GREATREX .
uality assurance in medical testing
has come a long way since Dr
Antony Barker first began work as a
chemical pathologist in the late 1970s.
Q
“It was very crude in the early days,”
he recalls.
“We made up our own control material
from cow’s blood. The freezing workers
would fill several buckets in exchange for
a dozen bottles of beer, then we’d put this
through a cream separator to produce a
bright-pink serum control for use with the
Technicon AutoAnalyzer. It was a huge
breakthrough when uncontaminated
commercial material became available in
New Zealand.”
Today, Dr Barker is Clinical Director
of LabPLUS, the pathology service for
Auckland City Hospital and the wider
Auckland region that employs about 380
staff and has an annual budget of
NZ$47 million.
He sees his role as “being there to help
other people achieve their aims. If you do
that, and encourage people, it becomes a
good place to work. People enjoy working
where they feel their ideas are being
valued. I try and be fair to people and I
think people appreciate that.”
Long-term colleague and fellow
pathologist Kitty Croxson certainly does.
“It’s very nice to work with someone
so calm that you can rely on, and who
always gives you a fair deal,” she says.
And Don Mikkelsen, National Manager
(Operations) of the NZ Blood Service,
who has known Dr Barker for many years,
describes him thus: “meticulous, honest,
very considerate – and always thinks
things through”.
Dr Barker’s office overlooks the
emergency helicopter landing pad on top
of the Starship Children’s Hospital.
On the wall is a photograph of his
boat and an attractive print showing a
view across the Hauraki Gulf – an area
that he sailed frequently as a child.
The work space encapsulates the
balance between his professional and
personal life. And this balance is a
philosophy that he strongly believes in.
“It’s the contrast between the
challenges of a professional life and the
pleasures of family life that make you
appreciate both more fully,” he says.
>
PATHWAY_17
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“I do think there’s a balance
between work and the things
you do outside of work that
adds to both and makes them
both more enjoyable.”
Spirit of adventure
Born in England in 1944, Dr Barker
emigrated to New Zealand at the age of six.
His architect father was an attractive
proposition to the New Zealand
government back then: it paid for the
family’s passage on the Ruahine to
alleviate the country’s architect shortage.
The boat trip demonstrated that the
young Tony’s sense of adventure was
already well developed, though it included
a heart-stopping incident for his parents.
“There was a fancy-dress ball one
night for all the children – and then I went
missing.
“They searched the ship for me, but
there was no point in turning the ship
round in the middle of the night. I was
discovered the next day asleep in one of
the life boats – so all was well.”
The Barker family encountered
another stroke of luck on that trip. They
met a New Zealand judge by the name of
Stanton who owned a house at Torbay.
He invited his new acquaintances to live
in the house, and they readily agreed.
“You can imagine the contrast of
going from the industrial north of England
to staying in a beach house right on the
sand, surrounded by paddocks,” Dr
Barker says.
The two families became firm friends
and one of Judge Stanton’s daughters,
Aileen O’Dell, had a major influence on Dr
Barker’s life. Not only did he meet his
future wife, Chree, during a sailing trip on
Aileen’s boat during one university
vacation, but Aileen was also his chemistry
teacher at Takapuna Grammar School.
“I was one of the lab boys, setting up
the experiments for the next class, so we
used to get into all sorts of mischief, as
you can imagine, with a storeroom of
chemicals to experiment with. We learnt a
lot of chemistry, most of it outside the
normal curriculum,” he laughs.
CV in brief
DR ANTONY (TONY) BARKER
1966
BSc
1974
MSc (Pathology)
1970
1977
1982–
MB ChB
MAACB, FRCPA
Medical Testing Professional Advisory Committee,
International Accreditation New Zealand
1983–89 Board of Education, Royal College of Pathologists of
Australasia
Education Committee member, Australasian Association of
Clinical Biochemists
1990–96 NZ Councillor, Royal College of Pathologists of Australasia
Member, Council of Medical Colleges in New Zealand
1989–96 Director of Laboratory Services, Auckland Hospital
2002–
2005–
18_PATHWAY
Clinical Director, LabPLUS, Auckland District Health Board
Council Member, International Accreditation New Zealand
It was that interest in chemistry, though,
that led him to consider a career on plant
disease research, until he was advised that
medical research had better funding.
He studied organic chemistry and
biochemistry at the University of Otago –
despite being told by one of his
teachers that he was “not suitable
material” for university.
He attributes this unlikely comment to
the fact that so much of his time was
devoted to sailing and athletics throughout
his school years. Although the athletics
has now morphed into strolls around the
islands of the Hauraki Gulf, he and his wife
still enjoy sailing and try to spend every
other weekend on their (third) boat.
“I’ve always been interested in
boating,” he says, estimating that the
family sails over 1000 miles each year.
“It bought us close together,
especially when conditions were bad.”
After graduation, a short interval in the
(then) very small medical laboratory at
Auckland Hospital convinced him that he
needed a medical degree to get an
appointment as a medical researcher with
a secure salary.
So back he went to Otago.
“As I went through
medical school, I had
chemical pathology in mind
as my main interest. A lot of
my fellow students used to
tease me and say I was only
choosing pathology so that I
could have the weekends off
to go sailing, and of course I
would irritate them by
agreeing with them because
there was some truth in that!
“I do think there’s a balance between
work and the things you do outside of
work that adds to both and makes them
both more enjoyable.”
He worked as a house surgeon in
Auckland before starting an MSc in
pathology in parallel with his pathology
registrar training, but his thesis work
convinced him that pure medical research
was not for him.
“I like a problem that can be solved
practically within a fairly short period of
time. I had to recognise that that was my
personality and there was no point in
pretending otherwise. My present job
involves a lot of troubleshooting and
sorting out issues on a day-to-day basis –
I really enjoy that.”
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“I like a problem that can be
solved practically within a fairly
short period of time. I had to
recognise that that was my
personality and there was no
point in pretending otherwise.”
Enjoying family life; Right: Dr Barker and wife Chree on their first date;
Opposite page: Boating trip 1984
Dr Barker is often invited to speak
publicly and toured Australia last year as
one of the Australasian Association of
Clinical Biochemists (AACB) Current
Concept Lecturers, promoting the need
for reference interval standardisation,
which enables laboratory results to be
accurately compared.
Dr Barker joined the Medical
Testing Professional Advisory
Committee of International
Accreditation New Zealand
(IANZ) soon after it was
established, helping to write the
laboratory accreditation-specific
criteria.
It was a subject that he had first
presented at the AACB Conference in
1978, but back then his lecture had no
impact whatsoever.
Program Manager of Medical Testing
at IANZ Graham Walker describes him as
“highly skilled and highly capable”, and
pays tribute to him as “one of the few
pathologists that has dedicated his career
to the less lucrative public health sector”.
“People couldn’t understand how a
group of competing laboratories could
cooperate so closely, sharing problems
and helping each other out,” he explains.
But since then there has been a
complete change of attitude in the
profession, so it was “a pleasurable
experience” to receive a very different,
enthusiastic response from the audience
last year.
Another marked change that has
occurred since the 1970s is the
development of the RCPA/AACB Quality
Assurance program, which Dr Barker
describes as “amongst the best in the
world today”. The Auckland Regional
Quality Assurance Group that Dr Barker
and like-minded colleagues were
instrumental in setting up in 1977 to
standardise reference intervals is still
going strong. It now includes most
laboratories in the upper North Island.
“We’ve been meeting once a month
for over 30 years. There has to be
something of value for everybody there to
keep it going, especially when people
travel from as far away as New Plymouth,
Whangarei and Tauranga.”
Major contribution
Dr Barker’s involvement with the RCPA
began around the same time, when he
became the chemical pathology
representative on the college’s Board of
Education
And as if this wasn’t enough work, he
was also appointed to the AACB
Education Committee and helped organise
and contributed to the annual RCPA/AACB
chemical pathology course for six years.
(His contribution to the college also
includes a six-year stint as New Zealand
councillor – from 1990 to 1996).
By the early eighties, he and his wife
had three young children, and he
describes a “slightly mad” idea that saw
them purchase 40 acres of land to
develop into a forestry plantation.
It was covered by gorse, however, and
Dr Barker admits that “the family spent
more time clearing this gorse – by hand –
over the next 10 years than anything else
put together”.
It doesn’t sound relaxing, but he
explains the attraction.
“When you’re working in the health
system there are lots of things that you
cannot change so it can be very
frustrating.
“Some years, you feel you haven’t
made a lot of advances, but the forestry
block is something where you can literally
see the difference that you’re creating. In
retrospect though, it was a mind-boggling
undertaking.”
Today, the 18,000 trees that the family
painstakingly planted are maturing and it’s
“a lovely spot to be in”.
There is still a way to go with quality
assurance, though, so it’s fortunate he is
not thinking of retirement just yet.
One future goal is to “work with my
colleagues to standardise the reference
intervals used by laboratories across the
whole of Australasia”, he says.
“A network of regional qualityassurance groups needs to be developed
to work together and share ideas and
proposals for standardisation.”
Given the huge amount Dr Barker has
managed to achieve so far, it seems likely
this is another of his goals that will
become reality.
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PathWay #12 - Text
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PathWay #12 - Text
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This radiolucency around the
crown of an unerupted
wisdom tooth was diagnosed
radiographically as a
dentigerous cyst
Teething troubles
PHOTO CREDIT: SUPPLIED BY DR MICHAEL ALDRED
disciplines in depth
ORAL PATHOLOGY IS BOTH A MEDICAL AND DENTAL SPECIALTY, BUT FEW PEOPLE ARE AWARE IT
EVEN EXISTS. CATHY SAUNDERS REPORTS ON THIS UNHERALDED DISCIPLINE.
ral pathologists carry out sleuthing
work every day for doctors, dentists
and patients – and their work can be lifesaving.
O
But they do all this in relative
obscurity: some have even dubbed their
under-recognised and under-funded role
‘the Cinderella discipline’.
As a result of this, oral pathologists
are becoming an endangered species –
there are only about 10 of them in
Australia and New Zealand.
These low numbers are partly
explained by low remuneration compared
with other dental specialties. And job
opportunities are scarce.
So while dentists are queuing to
become orthodontists because ‘everyone
wants their teeth straightened’, oral
pathologists are struggling for survival.
While patients certainly don’t register
the term ‘oral pathology’, many doctors
and dentists aren’t aware of its role either,
despite the fact it is a discipline of both
medicine and dentistry.
Its practitioners deal with pathology of
the soft and hard tissues of the mouth,
jaws and salivary glands. Diagnoses
include consideration of the clinical
picture and radiographs as well as
biopsies.
“But no-one really knows what an oral
pathologist is,” says Dr Anna Talacko,
chair of the RCPA Faculty of Oral
Pathology.
And according to Dr Michael Aldred,
secretary of the college’s oral pathology
faculty committee, oral pathologists
diagnose “lumps and bumps” in the
mouth, which can range from benign
conditions to serious malignancies.
“As one example, a lot of tissue we
deal with is from changes in the jaw
associated with teeth or with cysts,” says
“Many clinicians removing tissue from
the head and neck do not even realise
that oral pathologists, who are people
with expertise in this area, exist.
Dr Aldred, who shares the diagnostic oral
“In addition, some anatomical
pathologists are not familiar with the role
of oral pathologists.”
some of which are caused by a dead
And yet their work is indispensable.
Training in oral pathology has
traditionally been combined with training
in oral medicine – a discipline of dentistry
– in Australia. Some work exclusively as
oral pathologists, dealing with the
microscopic diagnosis of oral and
maxillofacial conditions, and some
combine this with oral medicine.
pathology reporting with Dr Talacko at
Dorevitch Pathology in Melbourne.
There is a bewildering variety of cysts,
tooth that can be removed but some of
which are likely to recur, and “that will be
important for the long-term management
of the patient, to intervene if there is going
to be a recurrence to catch it early rather
than late”.
It’s also important to get a correct
initial diagnosis: some samples diagnosed
by the clinician as cysts can prove on
examination to be tumours.
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Oral pathologists diagnose “lumps and bumps” in the mouth,
which can range from benign conditions to serious malignancies.
If teeth could talk
While oral pathologists might often be
asked by medically qualified pathologists
to give their opinion on specimens from
the oral cavity, they also deal with
extracted teeth.
Dr Aldred, who has a special interest
in inherited diseases of the teeth, helps
clinicians distinguish between
amelogenesis imperfecta and
dentinogenesis imperfecta in which the
enamel or the dentine, respectively, is
imperfectly formed.
“Clinically, these can sometimes be
confusing,” he says. “A correct diagnosis
is important for patient management
because if the dentine is affected, it can
be associated with the medical problem
Oral pathology
– how to get there
o become an oral pathologist, it
is possible to qualify as a dentist
and then complete a higher degree in
oral pathology or a combined degree
in oral medicine and oral pathology,
depending on the university.
T
Alternatively, dental or medical
graduates can train for the
Fellowship of the Faculty of Oral
Pathology (FFOP) through the RCPA,
which sought to set standards of
training and assessment in oral
pathology with the establishment of
the Faculty of Oral Pathology in
1996. Dental and medical graduates
can enrol in accredited laboratories
(two in Australia and one in New
Zealand) to train for the FFOP, which
requires five years of training with
specific requirements for the number
of cases reported, similar to the
requirements in anatomical
pathology.
Oral pathologists who have done
a Masters can apply for exemption
from part of the FFOP training. The
degree of exemption depends on the
training undertaken, particularly with
regard to diagnostic work.
22_PATHWAY
osteogenesis imperfecta or ‘brittle bone
disease’.”
Dr David Booth, a retired WA oral and
maxillofacial surgeon who works part-time
as an oral pathologist, agrees that because
the mouth is such a good litmus test for
overall health, oral pathologists often
diagnose serious diseases long before they
manifest in other parts of the body.
Some gastrointestinal disorders for
example – such as Crohn’s disease and
ulcerative colitis – can present with oral
manifestations.
Persistent ulcer of the lip
Dr Nick Boyd, an oral pathologist who
works for the WA pathology company
PathWest and at the University of Western
Australia’s Oral Health Centre of WA, has
other pertinent examples.
to do with the oral cavity and jaws – they
have a gap in their education, which
starts at the lips and ends at the tonsils.”
When a woman with a history of
cancer had a wobbly molar for no
apparent dental reason, he examined the
extracted tooth and found islands of
carcinoma on the root. When he reported
he did not think it was from an oral
location, a CT scan was performed and
her sinus was found to be cancer-ridden.
Because the role of oral pathologists has
largely been under-recognised, the work
generated from pathology laboratories
does not fill a week.
A tight squeeze
So most also teach, conduct research
in universities, or work as oral medicine
specialists, combining oral medicine with
oral pathology.
Another recent diagnosis of metastatic
prostate cancer followed the biopsy of a
patient who presented with a numb lower
lip, and was found on x-ray to have a
suspicious area of bone in his jaw.
Dr Aldred says only about five oral
pathologists report in commercial
laboratories, and full-time posts in oral
pathology do not exist.
Despite valuable diagnoses such as
these, Dr Boyd says patients with oral
pathology are often referred inappropriately
by their GPs to ear–nose–throat surgeons.
Worse still, there are only two registrars
in training, one unfunded in Victoria and
one in a half-time funded training post at
Westmead Hospital in NSW.
“I often say I wonder which part of
ENT stands for mouth,” he says.
The Australian Medical Workforce
Advisory committee recommended 400
extra pathology training posts over the past
four years and only 53 (soon to be 63) have
been funded.
Similarly, GPs may see problems with
the oral mucosa, think it is a skin problem
and refer the patient inappropriately to a
dermatologist.
Dr Booth says the lack of
understanding by GPs about oral
pathology is due to little exposure during
training. Medical students have no, or at
most two, lectures on it in six years of
training compared with a full year of
training for dental students.
None of these are for for oral
pathology, Dr Aldred says.
“A number of years ago we put our
bid in for two oral pathology posts but
have never had any success.”
But there may yet be some hope.
And he believes this “downgrades oral
pathology in the eyes of the medical
profession”.
A federal health department
spokesperson says the department is
currently in discussions with the RCPA
about pathology specialties in particular
shortage.
Dr Aldred agrees. “Most medical
students have limited teaching of anything
“Funding will take into consideration
specialities and sub-specialities that are
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PHOTO CREDIT: EAMON GALLAGHER
PathWay #12 - Text
Drs Michael Aldred and Anna Talacko: indispensable but unheralded work
experiencing severe shortfalls,” the
spokesperson says.
able to become an approved pathology
practitioner, the spokesperson says.
But training posts and recognition are
not the only hurdles for oral pathology.
The lack of patient rebates presents
another difficulty.
Despite this impasse, the college’s
Faculty of Oral Pathology is hopeful of
success soon in a different field: receiving
accreditation from the Australian Dental
Council (ADC).
Because they traditionally have dental,
not medical, training, oral pathologists are
not eligible for a Medicare provider
number and cannot access Medicare item
numbers for pathology reports on
microscope slides.
Medicare claims for their work are
therefore made by anatomical
pathologists in the pathology companies
they report for.
The RCPA has been lobbying the federal
government to have Medicare provider
numbers instated for oral pathologists and
discussions are still underway.
But the federal health department
spokesperson says that in general,
Medicare benefits are available only for
professional services provided by, or on
behalf of, a medical practitioner.
An oral pathologist with only dental
and no medical qualifications would not be
This is on the basis that the Australian
Medical Council has recently carried out
its accreditation review of the RCPA and is
likely to have implications for registration
of oral pathologists as specialists.
To date, state dental boards have
accepted that the three-year combined
masters degree course (or equivalent) in
oral medicine and oral pathology is
sufficient for a specialisation in both
disciplines. All state dental boards, except
Victoria, have allowed oral pathologists
with a Masters degree to register with
them as specialists. (The WA Dental
Board does not have a category for
specialist registration in oral pathology.)
In Victoria, the Dental Practice Board
requires the Fellowship of the Faculty of
Oral Pathology (FFOP), and so agrees
with the RCPA that the five-year
fellowship should be the basis of an oral
“Most medical students...
have a gap in their education
which starts at the lips and
ends at the tonsils.”
– Dr Michael Aldred
pathology specialisation before dentists
can register.
“Traditionally, the Masters degree has
been the registrable specialist
qualification, but we believe the College
really has the benchmark standards… and
there should be one exit – the College
Fellowship,” Dr Talacko says.
The Faculty is hopeful that once it has
gained formal recognition by receiving
accreditation from the ADC, the FFOP will
be the only pathway to specialisation.
While there is still some way to go in
gaining better recognition for oral
pathology, formal accreditation may well
be a promising step towards a brighter
future for this unsung speciality.
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close up
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Coloured scanning electron micrograph
(SEM) of the mass of capillaries (red),
known as glomeruli, which carry blood
to be filtered in the kidney.
PHOTO CREDIT: SUSUMU NISHINAGA / SCIENCE PHOTO LIBRARY
PathWay #12 - Text
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spotlight on disease
Silent assassin
HUGE GAINS ARE BEING MADE IN OUR ABILITY TO DETECT EARLY SIGNS OF CHRONIC KIDNEY DISEASE
– BUT AS MATT JOHNSON REPORTS, SPOTTING THOSE AT RISK REMAINS HALF THE BATTLE.
ou would certainly notice if half your
heart had become so diseased it
couldn’t function. And you wouldn’t feel
well with just one lung, or one side of your
brain. But lose up to 50% of your kidney
function and you won’t notice much.
Y
Such is their efficiency that your
kidneys can actually cope with losing
nearly half the nephrons they use to filter
your blood.
By that stage though, the disease
process could be so well entrenched that
reversing it is next to impossible. Then, all
that lies between you and catastrophic
physiological collapse are two organs,
each the size of your fist and weighing
less than 2% of your body weight.
For decades, the appearance of
symptoms marked almost the end for
patients with chronic kidney disease
(CKD), which can be caused by diabetes,
obesity, hypertension or smoking.
But advances in pathology have
shown that early detection is possible. We
know that treatment can slow the disease
– but ultimately, we may be able to
prevent it developing at all.
Every day, fleets of mini-buses collect
patients with CKD for their dialysis
treatment. The bus trip precedes four or
five hours of sitting tethered to a machine
as it filters and cleans their blood. By the
time they arrive home these patients have
lost another day to simply surviving. Most
of them have to repeat this process every
second day. Forever.
But what is most disturbing is that
until 90 days before they required dialysis,
26_PATHWAY
more than a quarter of these patients had
never seen a kidney specialist. For years
they had unknowingly been developing a
condition that would not clinically declare
itself until it was too late.
Appalling costs
The economic costs of CKD are, quite
simply, appalling. This year it will directly
cost $700 million. That will rise by $1
million per week next year and continue to
do so until 2010, when conservative
estimates of the total health sector cost lie
between $4.26 and $4.52 billion annually.
nearly all solutes out through the capillary
wall and into a series of tubules that run
parallel to the capillaries.
In an energy-sapping process, the
kidneys then pump 99% of the filtrate and
its dissolved components back into the
bloodstream, leaving wastes, drugs and a
small amount of water in the tubules to be
excreted as urine.
The glomerular filtration rate (GFR) for
a healthy kidney is about 100 mL/minute,
which means nearly 200 litres of filtrate is
collected every day in the tubules: all from
a blood volume of just six litres.
Every day during that time will have
seen five more Australians added to the
list of patients requiring dialysis or a
transplant.
The effort of returning nearly all this
filtrate requires almost as much energy as
the heart, and about twice as much as
the brain.
But these figures pale against the
human cost. The burden of regular
dialysis and the general disability
associated with CKD are so severe and
interminable that many – such as
Australia’s then richest man, Kerry Packer
– chose to decline the treatment and
succumb to the disease.
But the process of filtration and
reabsorption allows the kidney tubules to
delicately control blood volume and
pressure, nitrogenous wastes, pH
(acidity/alkalinity), haematocrit
(percentage of red blood cells) and even
bone density.
The million or so nephrons that lie
near the outer edge of your kidneys
receive 25% of the blood pumped by your
heart every minute. It’s a totally
disproportionate amount for organs their
size, but as the blood flows through the
capillary beds, it’s not just supplying the
kidney with oxygen and nutrients.
Those delicate glomerular capillary
beds are much more porous than normal
capillaries and they act like sieves,
allowing the passage of plasma and
Nephrons severely damaged by
disease or trauma cannot be replaced –
but the surviving nephrons can, to a point,
take on an increased workload. Patients
who have a kidney removed effectively
lose half their nephrons, resulting in a
50% reduction in GFR at the time of
surgery, but within several months their
total GFR will have risen to 80% of the
pre-operative value.
But beyond a 50% nephron loss, the
remaining nephrons are forced past their
capacity, become irreversibly damaged,
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PHOTO CREDIT: CNRI / SCIENCE PHOTO LIBRARY
PathWay #12 - Text
Light micrograph of a section through kidney tissue in a case of diabetes.
and the symptoms of uraemia (literally,
urea in the blood) begin to emerge. The
increased workload itself causes the
relentless destruction of the remaining
nephron pool – and at this point, even if
the original disease process is halted, the
degeneration can continue.
Raising awareness
Alerting GPs and the public to this long
asymptomatic development period of
CKD has become the focus for groups
such as Kidney Health Australia.
“The emphasis in the past five years in
CKD has swung to early detection of
damage and impaired function rather than
on diagnosis of explicit disease that is
causing the damage,” explains Kidney
Health Australia Medical Director Dr Tim
Mathew.
“A number of large studies across the
world have led to the realisation the
kidney function is significantly reduced in
greater numbers in the community than
we have previously realised.
“Surveys of otherwise healthy people
show up to 8% have reduced function –
and there’s another 6.5% on top of that
figure who show some signs of significant
damage. That’s one in seven.”
Standard tests
There are several tests commonly used to
assess kidney disease. A urine sample
can be analysed for red and white blood
cells or proteins that get into the urine
through damaged nephrons. Or a blood
sample can be analysed for waste
products such as urea and electrolytes
that start to accumulate in the blood as
kidney function fails.
An ESR (erythrocyte sedimentation
rate) test used to measure inflammation
can also be indicative of kidney disease,
but most of these tests are non-specific,
and it’s the presence of creatinine in the
blood and its relationship to GFR that is
considered the most reliable test.
Pathologists and clinicians have
known for decades that the onset of CKD
symptoms would be preceded by a long
period of steadily falling GFR, but the lack
of an accurate test made it difficult to
predict if a person was indeed on the path
to CKD, or how far they had to go before
the point of no return and becoming
permanently dependent upon dialysis or
transplantation. Under these conditions it
was difficult to determine treatments and
how aggressively they should be
administered.
The standard test was to use the link
between GFR and creatinine – a product
of muscle metabolism that is freely filtered
at the nephrons but never reabsorbed in
the tubules, so high creatinine levels in
the blood reflect low GFR. However, the
creatinine figure gained in testing could be
affected by diet, weight loss, ethnicity, sex
or age, making its clinical significance
difficult to interpret.
“There’s been more than 50 equations
over the past 30 years that have tried to
estimate GFR from a creatinine result,”
explains Dr Graham Jones, SydPath’s
staff specialist in chemical pathology at St
Vincent’s Hospital in Sydney.
“But for previous equations to be
accurate they need detailed information
about the patient, such as weight and
body composition.”
>
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A new formula – the MDRD equation –
has changed that and given pathologists
the ability to accurately quantify renal
function on lab tests alone.
“There were a number of companies
supplying assays for creatinine, but they
were all slightly different,” Dr Jones
explains.
“The MDRD equation is robust and at
least as accurate as any alternative. It’s
been widely validated and doesn’t need
any measurement of the patient – just age
and sex,” Dr Jones says.
“We weren’t able to compare the
results gained with one assay with the
same person tested by another assay. Lab
to lab there would be differences.”
The new formula has also been easy
to integrate into the existing testing
process.
“It’s much easier to add a calculation
to existing samples than if you were to
bring [in] a new test, where there’s not
only the cost of the test, but also the cost
of educating GPs and pathologists about
the test and what the results mean.
“The cost of the new formula to
Medicare has been zero.”
Significantly, Kidney Health Australia
has persuaded every lab to report the new
eGFR value created by the MDRD
equation with every creatinine test.
Technically the eGFR test is quite
simple: a chemical reaction changes light
absorbency, depending on the volume of
creatinine in the sample, but even with the
new MDRD equation, problems remained
with standardisation between laboratories
and the testing products they used.
Synergy and standardisation
But unprecedented cooperation between
clinicians, pathologists and the companies
that develop the assays led to a
breakthrough.
“Most diagnostic companies have a
very high level of expertise, but their
ability to cooperate has not been great,”
Dr Jones says.
“In this case the doctors and
scientists provided the diagnostic
companies with what they needed to align
their assays, and the companies agreed. It
has been expensive for companies in the
short term, but doctors and patients have
benefited enormously.”
The significance of uniform lab
reporting cannot be overstated as it now
allows expert groups to review the
evidence and know if a treatment is
effective, regardless of which lab the
patient has attended. From there clinical
TREATMENT APPROACHES
reating CKD involves firstly treating the underlying causes, and secondly,
slowing the progression.
T
The optimal time for treating the underlying cause is usually well before
CKD is established, and effective control of blood pressure and blood glucose
levels is often enough to stop the progression of the disease. Once the
disease is established these remain just as important, but additional
treatments such as restricting protein intake can help slow progression.
Ultimately, most patients will require renal replacement therapy: either
peritoneal or haemodialysis. Unfortunately, even optimal dialysis therapy is not
a panacea, with some of the symptoms unlikely to respond fully, while others
will continue to progress and some new problems may even arise.
Haemodialysis currently costs the community $72,000 per person per
annum, and has a significant impact on the lifestyle of those restricted to
attending a dialysis centre every second day. Technological advances are
allowing more patients to dialyse at home – and if taken to the optimum level
this would, according to Kidney Health Australia, produce an annual saving of
$88.2 million, as well as improving the freedom and lifestyle of these patients.
Simply increasing the rate of peritoneal dialysis to an optimal level would
produce a saving of $135.4 million.
Virtually all abnormalities associated with CKD are completely reversed by
successful renal transplantation, and increasing the number of kidney
transplants by 10% to 50% would save $5.8 million to $25.9 million a year.
28_PATHWAY
guidelines and policies can be
implemented.
This standardisation has ultimately
extended beyond the researchers,
clinicians, laboratories and diagnostic
companies, to include a standardisation
between countries.
“The work on serum creatinine is
hopefully the forerunner of many other
tests that could become aligned.
“It’s one of the most dramatic
examples of cooperation between
pathologists and clinicians – and it’s a
paradigm for future collaboration, and the
way healthcare should be coordinated
and then delivered,” says Dr Jones, who
sees this degree of accuracy as integral to
pathology.
“We should aim to deliver a message
to the doctor with every result. We should
be able to provide every doctor, every
time, with information to assist with the
diagnosis or management of the patient.
This way pathology can essentially be an
‘effector organ’ for the guidelines.”
The eGFR test has proved successful
not only for its accuracy, but because it
has made the test easy to understand.
Normal GFR is 100, so any eGFR result is
effectively a percentage which doctors
say is simple for patients to understand.
And long-term studies have accurately
established the values at which
treatments need to be implemented.
As advantageous as the new eGFR
test has proven, it remains only a
screening test – and once it identifies
kidney damage, doctors and pathologists
must then try to identify what disease is
causing the damage by a range of other
blood and urine tests and interpretation of
biopsy samples.
But with the emphasis on early
detection, are there other ways of
identifying these patients?
The presence of protein or albumin in
urine may actually be an earlier marker
than creatinine, but before it can be used
as a screening test it too needs to be
standardised.
Reaching those at risk
There also needs, according to Dr Tim
Mathew, to be a shift towards conducting
more urine tests on high-risk individuals.
“We’ve already identified the high-risk
groups for CKD: it’s those over the age of
50 years, with diabetes, hypertension,
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“It’s one of the most dramatic
examples of cooperation
between pathologists and
PHOTO CREDIT: ELIZABETH ADAMS
clinicians.” – Dr Graham Jones
obesity, malnutrition, family history and
those who smoke, and Aboriginal and
Torres St Islander people,” he says.
“And we know that early detection
reduces the impact of the disease, but we
have to take the message out to both
doctors and patients that this is a silent
condition, and unless you get a regular
CHRONIC KIDNEY DISEASE:
risk factors, stages and complications
Risk factors are hypertension, obesity, diabetes, family history, smoking, and
Aboriginal or Torres Strait Islander descent.
CKD has been divided into five stages based on GFR.
kidney check – that’s blood pressure,
eGFR, and urine protein and blood sugar –
you won’t know until it’s probably too late.”
Dr Mathew has been encouraged by
Stages 1–2
Patients usually remain symptom free, other than those symptoms associated with
the original disease causing the damage.
large cost-effectiveness studies that
applied best care to high-risk groups and
Stage 3
found the process more cost effective
Anaemia; loss of energy and appetite.
than the current screening processes for
breast, cervical or bowel cancer.
Abnormalities in sodium and water balance can lead to generalised oedema,
congestive cardiac failure and shortness of breath.
But he is dismayed by other studies
that found of 1600 diabetics, 30% had not
Stage 4
had a proteinuria test in the preceding
Cardiovascular and gastrointestinal disturbances continue.
year, despite their cycle of care requiring it
Possibility of uriniferous odour to the breath (associated with metallic taste).
annually.
Gastritis, peptic disease and mucosal ulcerations can lead to abdominal pain,
nausea, vomiting, blood loss.
“Chronic kidney disease is simply not
being thought about enough at a GP level
– and if it’s not considered it can’t be
diagnosed,” he says.
“Once diagnosed, treatment is
Skin affected with anaemia, bruising and yellow discolouration from the deposition
of pigmented metabolites, or even urea itself forming in a ‘frost’ on the skin.
Stage 5
remarkably effective.”
Severe disturbance in activities of daily living, sense of well-being, nutritional
status and electrolyte balance.
GPs NOTE: This article is available for
Survival without renal replacement therapy impossible.
patients at http://pathway.rcpa.edu.au
PATHWAY_29
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foreign correspondence
People power
WHAT BEGAN AS A ONE-OFF TRIP TO SHANGHAI HAS TURNED INTO AN ONGOING CROSSCULTURAL PARTNERSHIP FOR PROFESSOR RICHARD WILLIAMS. KIM COTTON REPORTS.
hen Professor Richard Williams first
visited Shanghai, it wasn’t the
cultural polarities between East and West
that surprised him.
W
Instead, what intrigued him was the
gleaming new medical equipment and the
forward thinking of his Chinese peers’
approaches to pathology.
“Their knowledge is just racing.
They’re just really bowling into the 21st
century – we’ll be playing catch-up within
a few years time,” says Professor Williams,
the director of anatomical pathology at
Melbourne’s St Vincent’s Hospital.
He first arrived in Shanghai two years
ago on the back of a one-week
symposium held at Peking University in
China’s capital, Beijing.
While there, he was invited to
Shanghai’s Changhai Hospital Second
Military Medical University – which boasts
30_PATHWAY
more than 1500 beds and 3000 staff – by
the hospital’s director of pathology,
Professor Minghua Zhu.
The intermediary was Chinese
pathologist Dr WeiQiang Zheng, who had
spent six months in Professor Williams’
department to investigate breast
pathology research.
“When Dr Zheng heard I was going to
Beijing he contacted me and asked if I
would accept an invitation from Professor
Zhu to visit his department and talk about
what we did in Australia,” Professor
Williams says.
“I think the [presentation to] medical
students might have been so they got
used to listening to lectures in English,”
he laughs.
“And I could do it on one of my
interests – pathology of the appendix.”
Quiet revolution
Formerly known as the Paris of Asia,
Shanghai is fast becoming the citadel of
China’s modern economy.
And like the racing pace of its fiscal
expansion, Professor Williams believes
the medical system is enjoying a similar
transcendence.
“I was shown the pathology
department in the cancer hospital…
they’ve got molecular pathology going on
not only as diagnostic adjuncts but as
research work, and they’ve got all this
equipment spread round in what looks like
very old buildings but with very up-to-date
facilities,” he says.
“I don’t know what I really expected…
but every door they opened up [at
Changhai Hospital] was full of the latest
equipment you could buy internationally in
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“Every door they opened up
was full of the latest equipment
you could buy internationally in
every part of the anatomical
pathology department.”
Above: Professor Williams with wife Julie and daughter Siobhan
Left: Old Shanghai Town preserved in the middle of modern Shanghai
every part of the anatomical pathology
department.”
Professor Williams says pathology
appears to be enjoying a high profile in
China as it keeps pace with modern
Western science.
“What they’re trying to do is make
sure their people are keeping abreast of
everything that’s going on everywhere,”
he says.
“They will put the resources into it
[pathology], whereas the problem with
Australia is there are too few of us
around.”
Professor Williams was invited to
return to Shanghai in 2005 to discuss the
e-learning tool InView. Developed by an
associate, Professor Peter Hamilton at
Queens University in Belfast and i-Path
Diagnostics Ltd, the tool helps young
pathologists make more reliable
detections in cancer pathology based on
analytical rather than intuitive diagnostic
practices using virtual microscopy. The
RCPA is closely involved in the
development of the educational content
and responsible for Australasian
distribution.
During the visit, Professor Williams
was also asked to the annual symposium
held between the professional pathology
bodies in Shanghai and Osaka, Japan.
And last year, he and three colleagues
were asked to present keynote lectures at
the symposium. The collaboration has
since led to the formation of the
Shanghai–Osaka–Melbourne meeting.
Four things
you didn’t know
about China
Professor Williams says the tri-city
partnership will prove valuable for
•
China’s projected population
for the year 2050 is 1.5
billion
•
During the 2008 Olympic
Games, about 1890
professional medical staff will
provide voluntary healthcare
services to athletes and
spectators
•
The leading cause of death in
2000 was cerebrovascular
disease (17.7%), followed by
chronic obstructive pulmonary
disease (13.8%) and ischaemic
heart disease (7.5%)
•
China accounts for almost
one-third of all cigarettes
smoked annually around the
world – about 350 million
smokers puffed on 1722
billion cigarettes in 2003
Australian pathologists because of the
exposure it will give them to different
groups of pathologies, such as China’s
broad variations of liver disease and
Japan’s string of gastric cancers.
There is also the potential for
professional training exchanges based on
interest from China in developing a
national assessment system for
pathologists, with inquiries having been
made about the RCPA’s assessment
system.
Contrary to the global trend, China’s
pathology workforce is buoyant and
competitive. However, the notion of China
supplying Australia with much-needed
consultant pathologists is unlikely in the
foreseeable future, Professor Williams
says.
And even if it were, perhaps they
wouldn’t want to come:
“Some of the Chinese and Japanese
pathologists thought the team in my
Sources:
department were actually doing a bit too
China Population Information and Research Center
– http://www.cpirc.org.cn/en/eindex.htm
much service work and not enough
World Bank
research and development.
World Health Organization
“They thought our workload was
pretty high – and ours isn’t as high as
some of the private laboratories.”
To purchase InView please log onto
www.rcpa.edu.au
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practice portrait
Celebrating 25 years
FROM LITTLE THINGS, BIG THINGS GROW. KATE WOODS
PROFILES THE 25-YEAR RISE OF A SPECIALIST
GYNAECOLOGY PATHOLOGY PRACTICE WITHIN SYMBION
LAVERTY.
TIMELINE: 25 years of change
Late 1980s New sampling implements introduced to replace the spatula.
Laverty Pathology trials and promotes the now widely used Cervex
brush.
1991
The National Cervical Screening Program is introduced after a
decades-old ad hoc approach. Dr Colin Laverty is a member of the
steering group.
1992–6
The first automated equipment designed to prepare and/or read
slides is introduced into Australia.
Mid 1990s
He watched it grow exponentially over 16
years, and by the time he sold the business in
1998, it was firmly placed at the cutting edge.
The NSW Pap Test Register is launched. Laverty Pathology is a pilot
lab.
Commercial HPV testing becomes available in Australia.
Laverty becomes one of the first labs to offer it as a regular service.
ThinPrep Imaging system becomes available in Australia.
Symbion Laverty conducts first Australian study looking at its
efficacy.
2006
Revised NHMRC ‘Guidelines for the Management of Women with
Screen-Detected Abnormalities’ introduced.
Symbion Laverty Pathology a pilot lab for the required changes in
NSW Pap Test Register.
32_PATHWAY
As the practice, now known as Symbion
Laverty Pathology, celebrates its 25th
anniversary, it has much to be proud of. It’s
now at the forefront of its field in Australia as a
specialised gynaecological cytology service. It
employs more than 60 people, processing
more than 200,000 Pap smears each year. And
while it doesn’t eschew its humble beginnings,
life is now a little more comfortable – with
facilities and staff housed in a spacious
laboratory in North Ryde.
Rapid re-screening is discussed as a quality assurance technique.
Colin Laverty involved in development.
2005
The premise was sound: cervical cytology
and histology results would be correlated, and
pathologists would have the opportunity to
develop a high degree of knowledge and skill
in the area.
Dr Colin Laverty and his wife began the lab
as a private practice in 1982, a bold move
considering he was the only one in private
practice to become specialised in this area.
National Pathology Accreditation Advisory Council (NPAAC)
Performance Measures developed.
1998
The first of its kind in NSW, Dr Colin
Laverty and Associates was a lab designed
specifically for quality gynaecological
pathology.
Laverty Pathology performs and publishes trials of these new
technologies, becoming the first lab to introduce ThinPrep into
Australia.
Laverty Pathology introduces rapid re-screening as a regular part of
its quality assurance program.
1996
t started with a handful of staff in a small
house in the western suburbs of Sydney.
I
“We were really lucky, although they say
you make your own luck; all we ever tried to
do is achieve the highest standards and
success followed.”
He says since this time, there have been
numerous changes and achievements; "We
were the first people in the world to prove and
publish evidence that many more women than
previously recognised contracted wart virus
infection but that the great majority didn't ever
get clinical recognisably warts; rather they got
a sub-clinical infection which it was postulated
might be pre-malignant. This was later
confirmed and preventive vaccination is now
being introduced worldwide”.
But he believes the most interesting
changes have been in improvements in the
standards of Pap smear screening and
detecting and managing cervical
abnormalities.
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“We anticipate the landscape will
evolve to include a predominance of
liquid-based cytology, imagerassisted screening, HPV testing and
use of molecular techniques.”
– Dr Clare Biro
PHOTO CREDIT: ELIZABETH ADAMS
"In the 1960's when Pap smear
screening was introduced into Australia
standards really were pretty low. But
subsequently, with increasing awareness
among doctors about how to take a truly
representative smear; awareness in
laboratories of the quality controls needed
to ensure the highest standard of
reporting; new advances in automatic
slide preparation and screening; and the
advent of papillomavirus DNA testing, we
now have enormously improved standards
and have achieved a substantial reduction
in cervical cancer”.
Ron Bowditch has worked with Laverty,
as it’s known, for most of its 25 years.
The senior scientist and full-time
training officer has had a number of roles,
including monitoring cytologists’
performance and ensuring quality
assurance measures are up to scratch.
“While a number of laboratories carry
out rapid re-screening as a quality
assurance procedure, we actually insert
disguised abnormal cases into the rapid
re-screening so we can assess the quality
of the quality assurance,” he says.
“I believe this is unique to our
laboratory.”
The lab also provides Pap smear,
ThinPrep, cervical biopsy and HPV testing
services, and employs a statistician to
collect data about the laboratory’s overall
performance, and also to profile each
cytologist – how many smears they are
screening a month, how many are called
high grade, negative and so forth.
While this overall performance
information is now required as part of
National Pathology Accreditation Advisory
Council performance measures, Laverty
has been collating these statistics for
most of its 25 years.
Specialisation has led to several
advantages.
Dr Jennifer Roberts, one of the lab’s
senior gynaecological pathologists, says
L-R: Drs Suzanne Hyne, Clare Biro and Jennifer Roberts
at the lab’s multi header microscope
one advantage is that doctors can ring
with questions, knowing they are
“speaking to someone who is up-to-date
and has a special interest in the subject”.
“Because of our volume and because
we monitor outcomes of our Pap reports,
including rarer conditions, we are well
placed to provide clinicians with statistical
data to aid them in management of their
patients. And this can be very useful when
doctors have a worried patient sitting in
front of them.”
Specialisation and volume also mean
the lab is able to easily trial new
technologies.
Its most recent trial looked at the
effectiveness of the ThinPrep Imaging
System – technology designed to
enhance the ability of cytologists to
assess abnormal slides.
It was the first Australian study to be
published on the topic (Diagn Cytopathol
2007;35:96–102).
The laboratory is now concentrating
on assessing the efficacy of the ThinPrep
Imaging System in detecting rarer
glandular lesions – “an area of
controversy which will be important to
elucidate if liquid-based cytology is ever
to replace conventional cytology in
Australia”, says chief gynaecological
pathologist Dr Clare Biro.
Looking ahead, Dr Biro predicts a
bright future. While the HPV vaccine
marks an exciting new development, she
says cervical screening will remain an
integral part of the health system for years
to come.
“We anticipate the landscape will
evolve to include a predominance of
liquid-based cytology, imager-assisted
screening, HPV testing and use of
molecular techniques,” she says.
And while Dr Roberts says there’s no
doubt technology has made great leaps in
25 years, rather than remove the need for
human expertise, she says it has actually
produced a need for enhanced human
input.
“Screening and interpreting Pap tests
remains as challenging as it ever was.”
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PathWay special feature
Widening pupils
GETTING MEDICAL STUDENTS AND YOUNG DOCTORS INTERESTED IN PATHOLOGY IS CRITICAL
TO ADDRESSING THE WORKFORCE SHORTAGE. KIM COTTON UNCOVERS A RANGE OF
STRATEGIES THAT ARE ENJOYING SUCCESS.
“I began considering anatomical
f you ask medical students what goes on
inside a pathology lab, you might get a
few blank stares.
science students part-time is paying
“The approach has got great benefits
year of medical training. My time at SNP
For many, pathology remains in the
laboratory – out of sight, out of mind – as
young students are lured to medical
specialties that dominate the hospital
wards.
because for most people what goes on in
gave me the necessary insight to make a
labs is unknown to them – they are the
well-informed choice,” Dr Khamu says.
Downsizing of pathology subjects at
medical schools over the past decade
and the elevation of problem-based
learning are deemed by some to be
largely to blame.
had five of our young scientists
I
And fewer qualified pathology
lecturers at some universities has meant
there are limited opportunities for student
exposure to mentors who are passionate
about the discipline.
It’s feared that this, combined with a
growing pathology workforce crisis, is
becoming a toxic cocktail.
So what’s the antidote?
dividends.
original black box,” says SNP chief
executive officer Dr Michael Harrison.
“This last year here in the main lab we
successfully join the graduate medical
pathology as a career path during my third
“The knowledge and skills I gained
made the transition to my registrar
position smoother, while being integral
now to my day-to-day work.”
Dr Harrison says working in a lab
course. Because of their experience in a
gives all medical students valuable
laboratory there is a good chance they will
experience because they learn the rigours
come back as pathologists.”
of quality control and quality assurance,
how to build systems and processes that
Opening doors
are safe and accurate, and how to
Dr Tim Khamu is one of SNP’s success
scientifically evaluate and assess the
stories.
value of what they’re doing.
A science graduate, Dr Khamu began
“Even if they don’t come back to
working as an SNP laboratory assistant
pathology as a career I think they will
during his first year of medicine at the
have achieved a basic understanding of
University of Queensland in 2002. As a
those principles, which will stand them in
matter of course, he went on to do his
a really good stead.”
Like most complex problems, there’s
no single answer, but the pathology
profession has begun the process of
changing mindsets by starting at the
grassroots – with the students
themselves.
fourth-year MBBS elective at SNP’s
Opening budding doctors’ eyes to the
possibilities of pathology is taking several
forms.
year. And this has led to a place in the
know of anybody who has worked here as
Queensland Health pathology training
a medical student who has not said
program – he is now placed for his first
they’ve gotten great benefit from it
At Sullivan Nicolaides Pathology (SNP)
in Queensland, employing medical and
year as an anatomical pathology registrar
personally – and of course the money
at SNP’s main Taringa laboratory.
doesn’t hurt either!”
34_PATHWAY
The caveat to employing medical and
histopathology department, where he
other university students as lab assistants
gained a deeper understanding of
without formal qualifications is the need
histology, histopathology and cut-up skills.
for them to commit to the job for several
He was subsequently offered a regular
cut-up position at SNP during his intern
years, Dr Harrison adds.
“Once people commit to it I don’t
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“My time at SNP
gave me the
necessary insight to
make a wellinformed choice.”
PHOTO CREDIT: ROBERT SHAKESPEARE
– Dr Tim Khamu
RCPA scholarships popular
Another approach to stimulating student
interest in pathology is the scholarship
route.
The RCPA has offered its Scholarships
in Pathology for Medical Schools for 10
years and by all accounts, inroads are
being made.
“The idea is to give $2000 to allow
students to either go into a lab in their
own city or travel to a lab somewhere else
to work with a pathologist to see what’s
actually involved,” says RCPA CEO
Dr Debra Graves.
used the funds to complete her elective in
anatomical pathology at The Canberra
Hospital under Professor Jane Dahlstrom,
a pathologist and Professor at the ANU
Medical School.
part of her time in the lab and was required
to produce a lecture on gastrointestinal
pathology as well as a practical, which is
now being used by second-year students
at the ANU Medical School.
“An elective allows you to appreciate
the lifestyle and training area of medicine
and whether that’s going to suit you. It was
really valuable from that point of view,”
says Ms Hunt, who now has a better
feeling for the nuts and bolts of pathology.
“[I got a] much better idea of what my
job would be as a pathology registrar so I
was able to come into it knowing what my
day-to-day duties would be and [also
gained] an interest in medical education –
I didn’t expect that,” she says.
Vacation scholarships
“It’s fairly flexible in how they can use
it. It’s an incentive to think about doing
pathology.”
Another avenue for medical students to
road-test pathology is via hospital salaried
specialists’ private practice funds, which
make money available for various causes
including pathology scholarships.
The program of up to eight
scholarships is made available annually to
Australian and New Zealand universities
that have a medical school or medical
faculty. Two of these scholarships are
offered to the Faculty of Medicine at the
University of Papua New Guinea.
The $2000 Private Practice Fund
vacation scholarship offered at The
Canberra Hospital is similar in structure to
the RCPA scholarship, allowing six
medical students each year to take on a
supervised project during their elective
across any department.
Dr Graves says the funds support
medical students’ participation in a
pathology-related project under the
supervision of an RCPA fellow during an
elective term or for the duration of their
medical degree.
For Dr Andrea Rapmund, the
opportunity to complete her elective in
anatomical pathology under Professor
Dahlstrom with the support of a vacation
scholarship was the cornerstone in her
decision to pursue pathology.
Rosalyn Hunt, a fourth-year medical
student at the Australian National
University (ANU), became an RCPA
scholarship recipient last summer. She
Now an anatomical pathology registrar,
Dr Rapmund was able to immerse herself
in the program without having to worry
about juggling part-time work. She spent
The anatomical pathology elective
program developed by Professor
Dahlstrom has in itself become a
promotional device for the profession.
“The program is unique because it
involves all aspects of pathology and it
offers a medical education component,”
she says.
“Some of it is about the consolidation
of knowledge, the other is to try and help
a student understand that as a pathologist
my job is so varied and interesting.”
Despite the competition for vacation
scholarships across The Canberra
Hospital, Professor Dahlstrom says her
students have always received hospital
funding to participate in the program
since its development in 2003.
“I think the reason the program is
successful and that students receive
funding is that the scholarship committee
knows from the student report how much
they enjoy the program and what they
have achieved,” she says.
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>
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PathWay special feature
Private schooling
THE PRIVATE SECTOR HAS AN IMPORTANT ROLE TO PLAY IN TRAINING AUSTRALIA’S
FUTURE PATHOLOGISTS.
hree years ago, a commitment was
made that would leave a significant
imprint on pathology training in Australia.
T
The federal government’s $3.75 million
in funding for the Private Practice Training
Scheme (PPTS) saw the introduction of a
unique training model that it is hoped will
make a dent in the pathology workforce
shortage.
Under the scheme, the private sector
is responsible for training 10 doctors to
become pathologists. Each position is
funded for $75,000 per year for five years
(until 2009) with the provision that
registrars spend two years training in
public hospitals.
RCPA CEO Dr Debra Graves says
while the scheme has placed pathology
further ahead of other medical specialties
on private training, moving away from the
traditional public hospital training model
has been a matter of necessity. While the
public sector has the capacity to take on
registrars, there are not enough
pathologists available in the labourintensive specialty to train all the new
pathologists that are needed.
“Opening up the private sector… has
increased the pool of pathologists who
can actually train the doctors to become
pathologists,” she says.
“It’s a good partnership between the
public and private sector – it’s a model
that gives the labs a lot of flexibility so it is
not prescriptive to the [last] degree.”
The government’s agreement to fund
the program was part of the Pathology
Quality and Outlays Memorandum of
36_PATHWAY
“There used to be quite a significant difference between public
pathology and private pathology and slowly as time goes by those
differences are disappearing.” – Dr Michael Guerin
Understanding 2004/05–2008/09,
developed in consultation with the RCPA,
Australian Association of Pathology
Practices and National Coalition of Public
Pathology.
It came in response to the 2003
Australian Medical Workforce Advisory
Committee report recommending an extra
100 pathology training positions annually
for at least five years to sustain the
profession.
“There used to be quite a significant
difference between public pathology and
private pathology and slowly as time
goes by those differences are
disappearing,” he says.
“It won’t be all that long before it will
be difficult to pick if you’re with a private
or a public organisation.”
The scheme is also expanding the
scope of opportunities for private sector
Dr Graves says there should have
been 400 new places established since
the report’s release, and instead there
have been just 53 (soon to be 63).
pathologists.
But she says the 10 positions
generated by the PPTS have been a “big
contributing factor” to the overall numbers
of new training positions.
Guerin says.
“It’s very helpful and we’re very
appreciative. It certainly recognised there
was a need for this well before the state
governments did anything about it.”
$60 million plan to expand training in
Meshing together
further 10 positions created by the
“Almost in every pathologist there is a
latent teacher. What it does is bring
satisfaction to those individuals,” Dr
A spokeswoman for federal health
minister Tony Abbott says the government
is in consultation with the RCPA over a
private settings across many different
specialty areas.
A very recent development has seen a
Commonwealth, which will be managed
Dr Michael Guerin, president of the
Australian Association of Pathology
Practices and chief medical officer at
Symbion Health, says the new training
model is strengthening and broadening
the profession by merging the individual
skill bases practised within each sector.
by the PPTS.
Dr Graves says any other additional
funding that becomes available will be
used to create up to another 30 positions
in private laboratories based on their
training capacity.
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First new RCPA Fellow:
Dr Aman Alash
“Opening up the private
sector… has increased the
pool of pathologists who
can actually train the
doctors to become
pathologists.”
– Dr Debra Graves
While most of the registrars who joined the Private Pathology Training Scheme will
complete their training in 2009, it has already been a long journey for Dr Aman Alash
(above), an Iraqi-born pathologist who is the first federally funded trainee to
successfully complete the RCPA fellowship.
Previously a senior lecturer at Al-Mustansiriya University’s College of Medicine in
Baghdad and in charge of the attached hospital’s histopathology and cytology
departments, Dr Alash fled the war-torn country with her husband and children in
2001.
She travelled with her family to Yemen and was employed as a consultant
pathologist in one of the private hospitals before leaving for the United Arab Emirates,
where she continued working.
Dr Alash arrived in Australia in 2003 to establish a new life with her family
She applied to the RCPA for assessment as an overseas-trained doctor when the
PPTS was being rolled out and was offered a registrar position in anatomical
pathology at the Victorian-based laboratory Symbion Health.
Dr Alash passed her exams on the first sitting and in January this year attained her
college fellowship. She says the support and encouragement she received from
colleagues and family helped her complete the fellowship in such a short period of
time.
“It’s a big relief,” she says.
“It’s a stepping stone to achieving a bigger dream of specialising in cytology or
breast pathology.”
PATHWAY_37
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PathWay special feature
Thinking globally, acting locally
INTERNATIONAL DIAGNOSTICS MANUFACTURER DADE BEHRING IS DOING ITS OWN BIT TO
ADDRESS PATHOLOGY WORKFORCE ISSUES.
PaLMS, he will rotate between the public
year ago Dr Chris Farrell was
contemplating his future career as an
anaesthetist. The notion of landing a
training position in his dream job as a
chemical pathologist was just too remote.
A
and private laboratories – and the shared
structure will give him enormous
opportunities.
“Chemical pathologists in the private
“I didn’t think I had much of an
opportunity to pursue chemical pathology
because I knew there weren’t many
training positions. I only had it in the back
of my mind as a future career,” Dr Farrell
says.
labs have a much bigger exposure to the
general practitioner market. That’s
experience he wouldn’t have otherwise
gotten without this opportunity,” Dr
Chesher says.
As part of the scholarship, Dr Farrell
In a sweet twist of fate, he joined the
ranks of chemical pathology registrars in
January when he became the first
Australian recipient of the Emil von
Behring Scholarship, a US$1.25 million
global initiative developed by diagnostic
company Dade Behring to help address
the worldwide pathology workforce
shortage.
Dr Farrell will complete his training via
a unique collaboration between Dade
Behring, Pacific Laboratory Medicine
Services (PaLMS) and Symbion Health.
Dade Behring Australia’s managing
director Erica Flynn says the company will
fund one-third of Dr Farrell’s position,
which is worth nearly $500,000 over five
years, with PaLMS and Symbion Health
contributing equally to the remaining
costs.
“It’s a really innovative and exciting
way to fund a pathology position,” she
says.
“This is the first time we’ve actually
had a pathology trainee position that
involves the interaction between a
diagnostic supplier, a public teaching
hospital and a private lab providing
teaching support.”
will also visit Dade Behring’s headquarters
in the United States.
Dr Michael Guerin, chemical
pathologist and chief medical officer at
Symbion Health, says learning how
diagnostic companies operate is an
advantage to all young pathologists.
Dr Chris Farrell: realising his dream
of chemical pathology
One-off position – for now
Internationally, the scholarship has been
awarded to clinical laboratory science
students, but the decision to support a
pathology position in Australia was based
on Ms Flynn’s observations of the industry
workforce crisis and subsequent
discussions with the RCPA.
At this stage, the scholarship is a oneoff proposition in Australia, but based on
the collaboration’s success, Ms Flynn
says Dade Behring may award it again in
future.
Dr Douglas Chesher, PaLMS
department head of clinical biochemistry,
who is overseeing Dr Farrell’s training,
says while Dr Farrell is employed by
“They will one of these days become
directors of departments and therefore
have multimillion-dollar budgets. It would
be handy for them to have to learn this
stuff upfront rather than the way I did it,
which was to learn it on the floor.”
Dr Guerin says the scholarship’s
structure is an example of the ingenuity
needed to support the industry moving
forward, particularly when private
laboratories have relied so heavily on
pathologists trained in the public system.
“Neither of them currently has the
capability on their own to be able to
provide the numbers of positions we
need,” he says.
“The private sector therefore has got
to understand that it can’t just keep
feeding off the public sector trainees as
has been the process in the past – it’s got
to do its part in the future.”
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update 2007
Pathology Update 2007
ANOTHER YEAR, ANOTHER SUCCESSFUL PATHOLOGY UPDATE. BIANCA NOGRADY REPORTS ON
THE WIDE RANGE OF RESEARCH PRESENTED AT THE RCPA’S ANNUAL CONFERENCE.
O
n one side of Sydney, lycra and
sequins were in, but at Darling
Harbour, lab coats were definitely the
order of the day. As Sydney’s gay and
lesbian community celebrated Mardi
Gras, the Royal College of Pathologists of
Australasia held their annual Pathology
Update conference on March 2–4,
hosting nearly 1000 delegates from as far
afield as Malaysia and London.
The conference was a great success,
according to RCPA Chief Executive
Officer Dr Debra Graves, thanks to a
combination of great venue, weekend
Genes predict child leukaemia
prognosis
The future for children with acute
lymphoblastic leukaemia is looking a little
brighter now that Australian and
The result is a group of genes that,
group of genes that could help target
form the basis of a diagnostic tool to
more aggressive treatment to those who
need it most.
Using high through-put microarray
technology (where the whole human
genome can be monitored on a single
DNA chip), researchers also identified two
conference’s event manager.
disease.
The head of the Tumour Bank at The
way to keep pathologists up to date with
Children’s Hospital at Westmead, Dr
the latest advances in pathology. It’s also
Daniel Catchpoole, said the use of
a chance to bring together pathologists
microarrays provided a wealth of genetic
from all disciplines to meet, network and
information, but distilling useful
‘cross-fertilise’.
knowledge from the mass of data was
from within Australia and New Zealand,
are likely to relapse.
international researchers have identified a
previously unknown genes linked to the
While most of the delegates came
that might distinguish those patients who
once validated by further research, could
timing and the tireless efforts of the
Pathology Update is exactly that – a
The challenge for researchers was to
sift through microarray data for genes
daunting.
“Microarray is a way of looking at the
single out patients who would benefit
from more aggressive therapy.
In the course of this research, Dr
Catchpoole and colleagues also came
across two genes that appeared to play a
significant role in acute lymphoblastic
leukaemia, but which had not previously
been associated with the disease.
“It’s highlighted new and interesting
genes that we can follow through, and
that can highlight new and interesting
mechanisms of leukaemia,” he said.
Assay points to subarachnoid
haemorrhage
A new approach to diagnosing
subarachnoid haemorrhage offers a
there were significant numbers of
activity level of thousands of these genes
robust screening alternative to the more
attendees from Hong Kong, Singapore
in one go,” Dr Catchpoole said.
costly and difficult spectrophotometric
and Malaysia, Dr Graves said.
The conference’s social events were
popular and gave delegates the chance
to mingle over cocktails and dinner, with
“In the past, we were looking for a
needle in a haystack – whereas now we
look at the whole haystack.”
New patients with acute
scanning, say New Zealand researchers.
Using an assay to measure very low
concentrations of bilirubin – a by-product
of the haemoglobin released by a
Sydney’s spectacular harbour scenery
lymphoblastic leukaemia are classified as
subarachnoid haemorrhage (SAH) – in the
providing a wonderful backdrop.
being either at standard or high risk of
cerebrospinal fluid, researchers have
disease relapse according to various
correctly identified 100% of confirmed
next year’s conference, and for the
clinical characteristics. However, about
cases of haemorrhage.
combined Pathology Update and World
10–25% of standard-risk patients still fail
Association of Societies of Pathology and
to respond to therapy and therefore
chosen cut-off point were accurately
Laboratory Medicine conference in 2009.
experience a relapse.
ruled out for SAH, thus avoiding the need
Preparations are now underway for
40_PATHWAY
Patients with bilirubin levels below a
>
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PHOTO CREDIT: FIREFLY PHOTGRAPHY
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“If we’ve got 24,000 genes, it could be that there’s somewhere between 100 to 1000 mutations
in each of those which cause disease.” – Professor Richard Cotton
for samples to undergo further testing
said in contrast to the Human Genome
using spectrophotometric scanning.
Project, which focuses on a single
Associate Professor Christopher
genome, the Human Variome Project will
Florkowski, Consultant in Chemical
be collecting genetic information from
Pathology at Canterbury Health
across the community.
Laboratories in Christchurch, said in
“If we’ve got 24,000 genes, it could
Sweat-testing standards
on notice
Early detection and improved treatment
have significantly increased life expectancy
for children with cystic fibrosis, but an
Australian expert has stressed the need for
future, outlying hospitals and laboratories
be that there’s somewhere between 100
increased vigilance and standardisation in
may be able to use this approach to
to 1000 mutations in each of those which
testing for the disease.
screen samples from suspected SAH
cause disease,” Professor Cotton said.
Dr John Coakley, a specialist in
For example, cystic fibrosis can be
paediatric chemical pathology, said
cases and then send those that are
above the cut-off point for scanning.
“We’re confident that we’ve got a
system that doesn’t replace scanning but
is a robust initial screen, which means we
the result of more than 1000 mutations in
sweat testing for cystic fibrosis was an
a single gene.
involved test, and a false positive or false
“That is a vast quantity of variation
don’t have to scan about 90% of
that’s going to come in that causes
samples,” Professor Florkowski said.
disease, and we better get ourselves
In the past, many labs would simply
organised,” he said.
eyeball a sample to see if it looked yellow
The Human Variome Project is a
– an indicator of bilirubin – but Professor
global initiative conceived in 1994, when
Florkowski said this technique was
a meeting of some of the world’s leading
extremely crude and inadequate.
geneticists decided experts in genes
Spectrophotometric analysis has
been advocated as the most reliable way
to test for bilirubin in the cerebrospinal
negative result could have extremely
detrimental effects.
“It’s not a simple test like putting a
blood sample on a machine and getting a
result,” said Dr Coakley, head of
biochemistry at The Children’s Hospital
at Westmead.
“Sweat testing requires some
expertise in doing it, so it’s important
were the best curators of information
people are well trained and that they are
about those genes.
doing the test regularly so they maintain
Several mutation databases already
their expertise.”
fluid, but spectrophotometers are
exist around the world, but the
expensive and the results can be unclear.
fragmented nature of work in the area
working in the area do at least 10 sweat
has meant these collections are
tests a year to keep their skills up to date.
“There is still some subjectivity and if
you get blood in the cerebrospinal fluid
incomplete and in some cases the
from the lumbar puncture itself, you can
information is incorrect.
get peaks that can make it difficult to
interpret,” he said.
The assay could detect the low
concentrations of bilirubin in the
cerebrospinal fluid and was easier to
perform.
However Professor Florkowski said
the results of the study needed to be
carefully validated in other centres before
the assay could be introduced into wider
“One of the unique parts about this
project is we want to have variations in
each gene curated accurately by an expert
then measuring chloride and sodium
concentrations in the sweat.
A chloride concentration above 60
mmol/L is a strong indication of cystic
The mutation information will
fibrosis, while a result of 30–60 mmol/L
therefore be collected via a federation of
‘locus-specific database curators’ around
the world, then fed into a central location
requires follow-up and potentially further
testing.
Dr Coakley said the challenges of
with mirror sites in other countries to
sweat testing for cystic fibrosis included
enable global access.
getting a proper volume of sweat from a
Professor Cotton said this information
could be used by patients, clinicians,
An Australian researcher is heading the
diagnostic laboratories, genetic
mammoth task of building a database of
counsellors, researchers and diagnostic
human genetic variation, which could
companies.
revolutionise genetic medicine.
Sweat testing involves stimulating
sweat production for up to 30 minutes,
in that gene,” Professor Cotton said.
practice.
What mutation is that?
He recommended pathologists
“They are knocking on doors already,
very young patient, handling children and
babies for the test, and carefully
explaining the test and its consequences
to parents.
“In terms of reporting sweat-test
results, there’s not uniform reporting
across Australia, so we’re working
but it’s just that they don’t have a one-
towards having uniform results, so when
Cotton, also the director of Melbourne’s
stop shop and they can’t be confident that
GPs get the result they know what is
Genomic Disorders Research Centre,
it’s all there and it’s accurate,” he said.
abnormal or borderline,” he said.
Project convenor Professor Richard
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PHOTO CREDIT: FIREFLY PHOTGRAPHY
PathWay #12 - Text
South East Queensland Allied Practitioner Opportunity
Located within the Caboolture Shire, The Village at Burpengary presents opportunity for members of the allied
health and wellness fraternity to establish a complementary business alongside several general practitioners
and a brand name pharmacy. The development is due for completion late-2007 and includes a supermarket,
childcare centre, food outlets, retail and office accommodation.
To register your interest for lease contact Ken Kramme | 0418 144 855 or addedval@bigpond.net.au
PATHWAY_43
PathWay #12 - Text 23/5/07 2:07 PM Page 44
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PathWay #12 - Text
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Page 45
“Efficiency alone will not make professionals reconfigure a service if they are not
confident quality will be safeguarded.” – Lord Carter of Coles
Dr Coakley and colleagues have
However, this procedure was not
“For instance, would we create free-
recently initiated a survey of laboratories
without its own risks and could have long-
standing pathology organisations into
around Australia that perform sweat
term consequences for quality of life.
which employees who currently provide
testing to identify any problem areas and
Another option was regular
ensure a high standard across all
endoscopy or chromoendoscopy, where
laboratories.
stains or pigments are applied during the
Genetic link discovered
for gastric cancer
A new group of genetic mutations has
been identified that places carriers at a
70% lifetime risk of gastric cancer, and
also significantly increases the risk of
lobular breast cancer in female carriers.
The hereditary mutations affect the Ecadherin gene, which is expressed in
epithelial tissues.
This gene is known to be involved
pathology services in existing hospitals
would be transferred?” Lord Carter said.
“Would that organisation be
endoscopy to aid diagnosis. However,
responsible for providing and staffing
researchers were uncertain if this process
both hot and cold laboratories? Which
would be able to detect gastric cancers
labs would be shut? Where would new
before they metastasised.
ones be built?”
Discovery of the mutations also raised
The pilot projects were launched in
the question of a possible screening
January this year and are expected to be
process for the mutation which may
completed by September, with
identify at-risk individuals and families
implementation of the new system
early.
proposed for April 2008.
Professor Huntsman proposed criteria
One of the main aims of the pilot
for mutation testing which included young
projects is to gain a deeper
age of onset (under 35 years) in a low-
with tumour invasion and cancer
understanding of the whole system of
incidence population, and family history of
progression, according to genetic
costs of pathology, “to avoid privatising
two or more cases of gastric cancer, with
pathologist Associate Professor David
at least one diffuse gastric cancer
Huntsman from the BC Cancer Agency at
diagnosed before age 50.
the University of British Columbia,
Canada.
Research has shown these mutations
underlie nearly one-third of families with
hereditary diffuse gastric cancer, but have
also been identified in patients without a
family history of gastric cancer.
First-degree relatives of patients with
gastric cancer linked to E-cadherin
mutations are themselves at more than
double the relative risk of the cancer. The
first E-cadherin mutations were detected
in Maori families by two New Zealand
researchers.
Because patients with the mutations
were at such increased risk of gastric
cancer, a number of more aggressive
management options could be considered
to reduce their risk of the disease.
Professor Huntsman said unaffected
mutation-positive individuals could
consider undergoing a prophylactic total
gastrectomy.
An earlier study had found 29 of 32
UK Pathology heads for a
shake-up
the obvious and putting up costs in the
remainder, resulting in a total increase
rather than decrease in expenditure”.
“At its simplest level, we are trying to
get our service to understand its costs
Pathology services in the United Kingdom
and make decisions based upon these,”
are set to undergo a radical overhaul after
Lord Carter said.
an inquiry chaired by Lord Carter of Coles
However, he highlighted the
found fragmentation of service and a lack
importance of maintaining quality in
of centralised, standardised information
pathology services.
on pathology services.
“What was clear was that there were
“Efficiency alone will not make
professionals reconfigure a service if they
significant discrepancies in performance
are not confident quality will be
and standards throughout the country,
safeguarded.”
and many leading members of the
profession believed it was time for
reform,” Lord Carter told the conference.
His report, released in August last
year, highlighted issues such as wide
variations in standards of equipment,
processes and results, significant
duplication between primary and
secondary care, and a desire within
pathology departments for independence.
Lord Carter identified six main
priorities for change and proposed a
series of pilot projects in metropolitan,
prophylactic gastrectomies in patients
urban and rural areas to determine the
with the E-cadherin mutation already bore
best configuration for the new-look
signs of early diffuse gastric cancer.
pathology system.
The Pathology Update 2007 Overseeing
Committee thanks all the exhibitors and
partners for their ongoing support of Pathology
Update.
Exhibitors: Olympus, Informa Health Care. QLab, Helena Laboratories, QAP, Department of
Health and Ageing, Dictaphone, Vision Bio
Systems, Tourism Tasmania, Ventana, Novartis,
Bio- Rad, Millipore Aust Pty Ltd, Howden
Medical Books Pty Lts, Abbott Diagnostics,
Diagnostic Technology, Dako and Inview.
Partners: Department of Health and Ageing,
AACB, NATA, RCPA QAP Pty Ltd, Dade
Behring, Roche Diagnostics, Symbion Health,
Bayer Health Care Diagnostic Division, UBS,
Deacons, PKF, Abbott Diagnostics, Lenton Brae
Wines, What’s new in Lab Technology and
Sonic Health Care
PATHWAY_45
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testing testing
New horizons:
thyroid dysfunction
THE ACUTE SENSITIVITY OF PATHOLOGY TESTS FOR DIAGNOSING THYROID DYSFUNCTION IS
RAISING INTERESTING QUESTIONS FOR CLINICIANS. MATT JOHNSON REPORTS.
he principle is simple. Identify the
symptoms that define the disease.
Use the symptoms to determine the
cause. Develop a test that identifies the
causative factor or, at least, the
physiological clues it leaves behind.
Refine the test so it becomes increasingly
accurate and treatments can be better
targeted and managed.
T
It’s this principle that so effectively
guides the interaction of scientists,
pathologists and other doctors.
But what happens when the tests
become so accurate that the patient,
despite a positive test, shows no
symptoms?
Do you change the ‘positive’ value
and risk normalising the disease?
Or do you commence treatment for
something that may never cause a
problem?
Over the past decade the sensitivity of
some of the tests for thyroid dysfunction
have increased their accuracy by 100fold, and with rapid growth in the number
of tests being conducted, an increasingly
large number of patients are being
captured in the ‘abnormal’ range.
46_PATHWAY
Some have raised concerns that this
has led to confusion – not clarity – for
patients.
But others argue that identifying subclinical thyroid dysfunction could prove
highly beneficial in the long term.
The thyroid and its hormones
Weighing about 30 grams, the two
connected lobes of the thyroid gland wrap
around the sides of the larynx in the
throat.
The gland secretes two hormones
directly into the bloodstream:
tri-iodothyronine (T3) and thyroxine (T4),
both of which regulate an enormous range
of metabolic and growth functions. The
two most common dysfunctions of the
thyroid gland are hypothyroidism
(decreased hormone output) and
hyperthyroidism (increased hormone
production), with one in 20 people
estimated to experience some form of
thyroid dysfunction in their lifetime.
T3 and T4 are the active hormones
released by the thyroid gland, but their
production is controlled by the pituitary
gland located in the base of the skull. The
pituitary gland secretes thyroidstimulating hormone (TSH).
Too little T3 or T4 in the blood
prompts the pituitary to release more
TSH, causing thyroid activity to increase.
Too much T3 or T4 decreases the amount
of TSH released by the pituitary.
Because it controls the release of T3
and T4, measuring TSH is usually the first
step in investigating thyroid function. In
fact, the logarithmic relationship between
T4 and TSH means small changes in T4
levels normally result in very large
changes in TSH levels, making TSH a very
sensitive indicator of thyroid gland
dysfunction.
Too good to be true?
The TSH test currently used in Australia is
a chemiluminescence immunoassay that
is highly automated, extremely accurate
and takes less than 20 minutes to
complete. Blood in the collection tube is
centrifuged to separate the plasma and
the tube goes directly into a machine for
analysis.
Perry Giannopoulos, senior hospital
scientist at SydPath, says the accuracy of
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Page 47
“It may be that identifying
these sub-clinical patients
allows them to be treated
and never develop more
serious symptoms, but the
outcome studies will take
time to do.”
PHOTO CREDIT: DR. E. WALKER / SCIENCE PHOTO LIBRARY
– Dr Graham Jones
Light micrograph of a section through a thyroid gland
with the autoimmune disorder Hashimoto's disease
the chemiluminescence method is now
almost too good.
“Over the past 30 years we’ve moved
through different assays. The original
radio-immunoassays measured down to a
lower limit of about one. When we moved
to enzyme-immunoassays, that limit
improved to 0.1 – and now, these thirdgeneration chemiluminescence assays are
10 times better again,” she says.
The improvements in accuracy with
each generation of assays has been the
key factor in allowing doctors to make the
distinction between true hyperthyroidism
and the non-specific changes in thyroid
results in people with other illness.
But the increased accuracy has raised
concerns that the clinical aspects – the
signs and symptoms – of hypo- and
hyperthyroidism have been downgraded,
with many patients now returning
abnormal results but showing no
symptoms.
One article published in the BMJ
(2000;320:1332–4) described this as
having led to “chaos” in the diagnosis of
hypothyroidism.
And some have noted that the
concept of “sub-clinical hypothyroidism”
and using TSH concentrations above 2
mIU/L to suggest an increased risk of
hypothyroidism mean half the population
fall into this category.
SYMPTOMS OF
HYPOTHYROIDISM
Too little T4 and T3 causes the
But to Dr Graham Jones, SydPath’s
staff specialist in chemical pathology at St
Vincents Hospital in Sydney, the increased
testing accuracy is a positive virtue.
metabolism to slow down too much.
•
lethargy and fatigue
He contends the significance of
borderline values will only be borne out in
longer-term studies that now, at least, can
be based on very precise data.
•
sensitivity to cold
•
unusual weight gain
•
depression
•
confusion
•
hair loss
•
dry skin
•
constipation
•
goitre.
“It may be that identifying these subclinical patients allows them to be treated
and never develop more serious
symptoms, but the outcome studies will
take time to do,” he says.
In the short term Dr Jones sees the
accuracy as providing better answers for
doctors and their patients.
“The symptoms of hypothyroidism
such as lethargy and weight gain are so
common that TSH testing is often
required to exclude thyroid disease, and
with the current tests, you’ll arrive at the
right answer nearly all the time.”
Chemical pathologist and
endocrinologist Professor Creswell
The symptoms include:
Eastman agrees it will take years to
determine how many of these sub-clinical
patients will develop clinical signs, but
says the increased accuracy of the test is
already allowing doctors to identify and
treat high-risk patients.
“Before we had a highly sensitive TSH
test, there were a group of people who
had normal T4 and T3 levels and were not
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Page 48
“Over the past 30 years we’ve moved through different
assays… now, these third-generation chemiluminescence
assays are 10 times better again.”
– Perry Giannopoulos
evidence of subclinical hyperthroidism
than wait for clinical signs. It’s a judgment
at this stage, but you have to make a lot
of judgments in clinical practice.”
The increased accuracy has also seen
a trend towards treating some patients
identified with sub-clinical hypothyroidism.
“There is certainly some conflicting data
whether treating sub-clinical patients
delays the development of clinical signs,”
Professor Eastman says, “but it certainly
shows improvements in cardiac function
and lipid levels, and it means patients with
elevated cholesterol are much more likely
to be treated earlier rather than later.”
“TMA and TGA tests are ‘old
fashioned’; they’re manual, time
consuming and only semi-quantitative,”
says Ms McGill, comparing the tests to
the more expensive TPO test. “Although it
may be difficult to justify TPO on cost
grounds, in every other way, TPO is the
method of choice for thyroid antibody
testing as part of a strategy for thyroid
disease investigation.”
In most circumstances, TSH is the
only thyroid function test ordered for
patients, but if the result is outside the
normal range, a T4 level can also be
requested.
The thyroid gland requires iodine to
produce T3 and T4, and how much of the
substance the thyroid absorbs from the
blood is an accurate measure of thyroid
activity.
Much of the T3 and T4 produced by
the thyroid is bound to other molecules
and is not available to act on its target
cells, so Australian laboratories measure
‘free’ T3 and T4. That is, the active
amount of the hormones.
Injecting a small amount of radioactive
iodine allows pathologists to scan the
thyroid and measure the uptake to
determine the cause and help plan
treatment.
Other thyroid tests
identified as being at risk of developing
hyperthyroidism because we were unable
to measure subnormal TSH levels,” he
says.
“But if you become more selective
and look at the high-risk patients in this
group – those older patients with longstanding goitre and with cardiovascular
disease – you are now much more likely
to treat these people on their biochemical
SYMPTOMS OF
HYPERTHYROIDISM
Too much T4 and T3 causes the
metabolism to speed up too much,
and ultimately damages the heart and
liver and leads to death.
Symptoms of an overactive thyroid
include:
•
rapid pulse
•
tremor (shaking) of the hands
•
sweating
•
sensitivity to heat
•
weight loss (despite a high
appetite)
•
agitation and anxiety
•
fatigue
•
diarrhoea
•
bulging eyes
•
goitre.
48_PATHWAY
may easily be linked to other thyroid
testing strategies; hence there is a
worldwide trend towards TPO analysis, a
trend which Kate McGill, senior operations
manager of immunochemistry at St
Vincent’s Hospital in Sydney, would also
like to see adopted.
Free T4 (FT4) is also commonly used
to monitor the effectiveness of treatment
and is typically measured every few
weeks in the early stages.
Thyroid antibody tests can be used to
support the diagnosis for patients who
have returned abnormal TSH or FT4
results, or who are displaying clinical
signs of thyroid disease but have returned
normal tests.
Only 10% of healthy individuals will
have positive thyroid antibodies, with a
higher prevalence among the elderly.
Thyroid peroxidase antibodies (TPOs)
– the predominant thyroid microsomal
antibody (TMA) component – and
thyroglobulin antibodies (TGAs) are
regularly produced in thyroid disease.
The specific test for TPOs is
quantitative, can be fully automated and
The diagnosis of thyroid nodules,
autoimmune hyperthyroidism and thyroid
cancer can all be assisted by the scan,
which uses a specialised nuclear imaging
camera to take pictures of the thyroid
gland from three different angles over 20
minutes.
Associate Professor Judith Freund,
director of nuclear medicine and bone
densitometry at the St Vincent’s Clinic in
Sydney, says the accuracy of other
thyroid tests has improved so much that
the thyroid uptake test is only really used
now in Australia for diagnosing sub-acute
thyroiditis and in therapy for
thyrotoxicosis.
“The test also helps us decide how
much iodine therapy a patient requires,
and if certain treatment will not be
effective because their iodine uptake is
too low,” she says.
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lP ia t hfWe
s
t
y
l
e
ay lifestyle
travel
50
private passions
54
travel doc
56
recipe for success
58
dining out
61
the good grape
64
conference calendar 65
rearview
66
postscript
68
PATHWAY_49
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Page 50
travel
Snow business
VISITORS TO NEW ZEALAND’S
SKI FIELDS HAVE A PROBLEM:
WHICH ONE TO CHOOSE?
DEANA HENN GIVES A
SNAPSHOT.
ith preparations for the southern
hemisphere’s winter snow season
underway, skiers and snowboarders are
gearing up for another season of powder
thrills. But figuring out where the heavens
will open for the 2007 season will be
anyone’s guess.
W
The numbers bear this out – almost
50,000 Australians skied or snowboarded
in New Zealand last year.
For many, the question isn’t whether to
take advantage of the many snow packages
that make skiing in New Zealand great value.
It’s which of the country’s 11 commercial
resorts (or increasingly popular club fields)
will offer the experience you’re after.
Kiwis looking to frolic in the white stuff
this winter will face the same quandary.
Many Aussie snow-goers will be
tossing up whether to venture across the
Tasman to play in the snow this winter.
Fortunately, in this corner of the world,
where winter is truly wonderland, everyone
is catered for – adrenaline junkies wanting
to carve fresh tracks through blackdiamond gullies, families looking to refine
their form in ski school and cruise the
corduroy, those wanting to get the heart
racing with off-mountain adventure or even
those just looking for retail therapy.
And New Zealand’s variety of terrain,
resort facilities and almost-mythical
scenery along with the strong Aussie dollar
are big drawcards for Australians looking
for a snow jaunt.
And to sweeten the deal, ski resorts
across New Zealand will aim bigger and
better in 2007 as they unveil improved ski
terrain, upgraded mountain grooming and
resort facilities.
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Queenstown
For an all-round ski holiday, it’s hard to
look past Queenstown – long considered
New Zealand’s adventure capital.
Nestled on the shores of the stunning
Lake Wakatipu on the South Island, with its
picture-postcard snow-capped peaks,
Queenstown has it all: great food, great bars,
great shops and access to great adventure.
The gateway to several of the South
Island’s major ski resorts – Coronet Peak,
The Remarkables and Cardrona – the town
jumps throughout winter.
Just a 25-minute shuttle ride away at
Coronet Peak, skiers and boarders of all
grades take pleasure in the wide and
rolling terrain, and excellent facilities. And
night skiing means diehards can stay on
the slopes even longer.
This year the resort has also doubled
its beginner area and expanded its
snowmaking facilities to ensure good
coverage throughout the season.
The Remarkables Ski Area, with its
eponymous mountain range, overlooks
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Page 51
PHOTO CREDIT: MARK WATSON
Above and left: In the air
and on the slopes at Treble
Cone, Wanaka
Lake Wakatipu and is a 45-minute shuttle
ride from Queenstown.
A new terrain park, new grooming
facilities and snowmaking can only
enhance the terrain, which includes gentle
slopes as well as powder bowls and
extreme runs. Snow tubing – riding a
massive tyre tube down the slope as you
would a toboggan – is also a family-friendly
way to get to the bottom of the mountain.
Heading north from Queenstown, an
unforgettable drive puts you atop the
magnificent Crown Range and the
Cardrona Ski Area.
Ideal for families, Cardrona has an
abundance of runs geared at beginner and
intermediate skiers and boarders (80% of
its mountain), specialised kids’ lessons,
and four childcare centres for the littlies.
Cardrona also boasts on-mountain
lodging – a rarity in the Southern Alps.
Come sundown, skiers and boarders
from all three resorts descend on
Queenstown’s innumerable eateries and
bars, looking to lubricate their muscles
and steel themselves for another day on
the slopes.
Queenstown also offers a bevy of
extracurricular activities, from bungy
jumping and jet-boating through canyons
to sky diving and mountain biking, which
add yet another dimension to your holiday.
The downside? Expect crowds and
hefty price tags for any activity that looks
remotely ‘extreme’. And if you’re looking
for a ski-in, ski-out lodge experience,
Queenstown is not for you.
Wanaka
Heading north from Queenstown brings
you to Wanaka, renowned for its stunning
mountains, glacier-carved lakes, alpine
meadows and impressive snowfields.
Treble Cone is one such snowfield and
demands attention. With more skiable –
and reputedly more advanced – terrain
than any other resort on the South Island,
Treble Cone is a mountain to be reckoned
with. And it’s making no apologies.
While the resort goes out of its way to
cater to intermediate skiers and boarders
like nearby Cardrona, the terrain and pitch
at ‘TC’, as the locals call it, will always
attract those who take their skiing seriously.
Applying the ‘bigger is better’ theory,
Treble Cone expanded its terrain last year
with a multi-million-dollar investment. By
adding 45 hectares to its terrain, the resort
added some serious runs to its trail map.
Treble Cone also claims the highest vertical
drop on the South Island and enjoys
plumes of powder thanks to its location.
Striving to be all things to all people,
TC guarantees your money back if you
can’t comfortably ski or board the whole
mountain after three days with the help of
ski school. New this year, the resort will
also offer on-mountain guided tours to
assure everyone a great experience.
And at Treble Cone, everyone will go
home with that unforgettable view
implanted in their minds; the majesty of
Lake Wanaka overwhelms at every turn.
While TC has no on-mountain
accommodation, skiers will find no
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PHOTO CREDIT: MARK WATSON
PathWay #12 - Text
“New Zealand’s variety of terrain, resort
facilities and almost-mythical scenery
along with the strong Aussie dollar are
big drawcards for Australians looking
for a snow jaunt.”
shortage of options at nearby Wanaka or
can day-trip from Queenstown.
If you don’t want Queenstown’s roundthe-clock activity, Wanaka’s charm ensures
those wanting refuge, fine dining, and
watering holes with live music are equally
satisfied. It’s little wonder this town is
dubbed the New Zealanders’ Queenstown.
Canterbury Plains
Not to be overlooked on the South Island
is the Canterbury region, about an hour
from Christchurch.
It’s no match to the activity of
Queenstown, but there’s plenty here for
those who care more about carving up the
mountain than après ski.
Two worlds collide here: the
patchwork quilt of the Canterbury Plains
and the wild, majestic mountains that
form the Southern Alps.
Mount Hutt, the largest and most
commercial resort in the area, offers
excellent varied terrain and facilities,
particularly after the reconfiguration of the
52_PATHWAY
mountain in 2005. The resort is also
considered the highest in the southern
hemisphere, contributing to its consistent
snow quality.
Also popular in the Canterbury region
are local ‘club fields’, which are gaining the
South Island an international reputation.
While the behemoth resorts with their
slick facilities typically win over in the
popularity stakes, the smaller fields run by
private ski clubs are making their own
mark and welcome day-trippers. Among
those developing recognition are Ohau,
Temple Basin and Craigieburn.
The proximity of Christchurch makes it
an ideal base for this region, though most
choose to stay at local accommodation
hub Methven. This is no Queenstown – but
for many, that’s the point.
At no other commercial ski area can
you ski or snowboard a semi-active
volcano or find natural half-pipes created
by lava flows.
The volcano is home to two ski resorts
– Turoa and Whakapapa – and this year, all
eyes will be on Mt Ruapehu’s massive $40
million injection including a new six-person
express chairlift and snowmaking.
Whakapapa, on the volcano’s northern
face, is the country’s largest ski area and
is popular with beginners for its dedicated
‘Happy Valley’. The resort is also known
for its expansive views of Mount
Ngauruhoe, otherwise known as Mount
Doom in The Lord of the Rings films.
Meanwhile, Turoa serves up big open
basins, natural half-pipes, steep chutes,
and fantastic off-piste glacial skiing.
Mt Ruapehu
The South Island is New Zealand’s
attention-grabber when it comes to winter
adventure, but the North Island deserves
more than a passing mention.
The downside to Mt Ruapehu? The
weather. Blasting gales can close the
whole mountain and you may have to
contend with crowds from Auckland and
Wellington.
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Getting there
Air New Zealand and Qantas
fly regularly to New Zealand
from Sydney, Melbourne,
Perth, Cairns and Adelaide.
To Christchurch or Auckland,
expect to pay about $580
return including taxes.
•
Air New Zealand and Qantas
fly non-stop to Queenstown
during winter from Sydney,
Brisbane and Melbourne.
Airfares start from $710 return
including taxes.
•
South Island resorts are
accessible from Wanaka,
Queenstown and
Christchurch airports. Mt
Ruapehu is serviced by
Hamilton, Auckland,
Palmerston North and
Wellington airports.
PHOTO CREDIT: MARK WATSON
•
Above: Treble Cone’s, Base Lodge
Left: Kiwi snowboarder Abby Lochart shows her style
Package deals
Air packages
Available from most Australian capital cities. Departing Sydney, packages
start from $AUD1065 per person including return airfares, five nights
accommodation, car hire, and multi-day ski pass. Prices are based on
twin share and include taxes. Conditions apply.
But if you’re not too fussed about
whether you ski every minute of your
holiday, brunch at Chateau Tongariro
comes highly recommended, as do the
nearby geothermal hot pools.
Whakapapa Village and Ohakune
provide plenty of accommodation and
après-ski options, with regular shuttles
servicing the ski areas.
For skiers and snowboarders thinking
of heading to any one of New Zealand’s
resorts this winter, one thing is certain: the
Kiwis do adventure as well as anyone in
the world.
It’s simply a question of what flavour of
adventure you’re after – there’s little risk of
disappointment.
Air New Zealand Holidays (1300 365 525; www.airnewzealand.com.au)
Ski Express (1300 130 524; www.skiexpress.com.au)
SKIMAX (1300 136 997; www.skimax.com.au)
Value Tours (1300 361 322; www.valuetours.com.au)
Land-only packages
Start from $AUD520 depending on the resort and typically include 5–7
nights accommodation, car rental or shuttle, multi-day ski pass plus
extras. Prices are per person, twin share and conditions apply.
Ski Express New Zealand (0800 650 333; www.skiexpress.co.nz)
SKIMAX (1300 136 997; www.skimax.com.au)
Ski New Zealand (03 353 7354; www.skideals.co.nz)
Ski New Zealand Online (03 379 1451; www.ski-newzealand.co.nz);
Australian free-call number (1800 121 029).
PATHWAY_53
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private passions
Keeping the faith
A HEART ATTACK SLOWED HIM DOWN TEMPORARILY, BUT DR JOHN BOTHMAN IS BACK TO LIVING
LIFE LIKE HIS BELOVED RACEHORSES – FAST PACED. KATRINA LOBLEY REPORTS.
decade ago, general pathologist
Dr John Bothman got a huge
wake-up call.
A
The horse-racing fanatic was 48 when
he went to the Melbourne Cup to watch
the big race before heading to Tasmania
for a well-earned fishing holiday.
As it turned out, he never got to cast
that line.
“Just after [the Cup] finished – and,
sure enough, the horse I backed was
beaten in a photo finish – I had a massive
heart attack and just collapsed to the
ground,” Dr Bothman says.
“I knew what was happening but I
couldn’t speak, I couldn’t stand up. If it
wasn’t for a couple of country blokes who
came along and picked me up and took
me to the ambulance, I don’t think I’d be
here today.”
Dr Bothman, who lives and practises
on the NSW South Coast, was rushed to
hospital but went into cardiac arrest on
the way.
chest. No-one wanted me to go – they
thought the excitement might kill me.”
Post-heart attack, he cut back to
working two to three days a week. But his
resolve to slow down didn’t last.
These days he’s working full time at
the Southern.IML Pathology practice in
Nowra. He is also chief examiner in
general pathology for the RCPA.
But as a nod to his passion, he will
take time off whenever his beloved
racehorse, Keeping the Faith, is racing.
The seven-year-old son of Leap of
Faith has clocked up five wins and 17
second-placings, earning nearly $200,000
prize money for his owners.
A pretty good return on investment,
considering he cost Dr Bothman and
another owner-breeder less than $2000.
And Dr Bothman is hoping that
Keeping the Faith’s full brother – twoyear-old gelding The Patriot – will be even
more successful.
“They had to put the paddles on and
get me going in the ambulance,” he
recalls. Before he knew it, he was being
prepped for a triple arterial bypass.
Doctors told him there was a 70% chance
he wouldn’t survive it.
Alpacas and other curiosities
“I said, ‘You’ve already told me I’m
going to die if I don’t do anything. I’m a
punter – I don’t mind those sorts of odds.
I’ll see you in about six hours.”
“I cover all sorts of odd areas – even a
bit of veterinary work,” he says.
When he’s not following the fortunes of
his racehorses or indulging in a spot of
fly-fishing in Tasmania or New Zealand, Dr
Bothman remains busy with work.
The next month, while recovering, his
low spirits were buoyed when his $500
brood mare Leap of Faith won the main
race at Kembla Grange on Boxing Day.
In fact, one of his strangest
assignments came when his neighbour, a
doctor who breeds alpacas, asked if he’d
conduct a sperm count on a new $25,000
male alpaca that had failed to impregnate
a single female alpaca.
“I was driven to the race propped up
in a friend’s car with pillows to protect my
“I said, ‘I’ll have a look’,” Dr Bothman
recalls.
54_PATHWAY
“He said, ‘Oh no, I want you to come
out and help me collect a sample. There’ll
be a bottle of red wine in it for you.’ He’s
a red wine connoisseur and I am, so I
thought, ‘Oh, I’ll try anything once’.”
He collected the sperm - “the way we
collected the sample is probably not
suitable for [publication]” – made a smear
and examined it under a microscope he’d
brought with him. Little viable sperm
could be seen. “Being a true pathologist, I
said I’ve never seen alpaca sperm before
so we’ve got to get a positive control and
compare it.”
They repeated the exercise with a
fertile male, found plenty of swimmers in
that sample, and his neighbour got his
money back.
Dr Bothman is an enthusiastic
advocate both for general pathology and
rural life.
He lives with wife Julie, a community
health nurse, on an acreage at
Cambewarra, a lush grape-growing region
north of town.
And he wants to encourage others to
follow his footsteps.
He opted for general pathology
“because I wanted to keep my clinical
skills up and that’s what my current day
entails. Unlike a lot of pathologists, I
actually do see quite a few patients.”
The practice services a private
hospital in Nowra that conducts a lot of
orthopaedic and general surgery. As many
older patients prefer to give blood preoperatively in case they need a postoperative transfusion, Dr Bothman
assesses these patients before collecting
their blood. He also carries out fine needle
biopsies and the odd bone marrow
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“Unlike a lot of pathologists, I actually do
PHOTO CREDIT: GREG TOTMAN
see quite a few patients”
biopsy, diagnoses more primary
He tours Australia and New Zealand
“It’s going to be a long, hard road –
melanomas than most of his big-city
spruiking the joys of general pathology
but I can see we’re having some
counterparts and sees malaria cases from
because “we’re all going to be extinct in
success.”
the nearby naval base. He’s even come
the next 10 years”.
across a case of leprosy.
And he’s encouraging the creation of
As for his inability to follow doctor’s
orders and take it easy, he says: “Life’s to
training positions and has had some
be enjoyed. They tell you all these things,
to stimulate more interest in general
success with both public and private
like keep fit and don’t drink too much
pathology as a career.
pathology laboratories.
wine – well, I totally ignore that.”
Dr Bothman is also helping the RCPA
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travel doc
SOUTHERN EXPOSURE
THE MAGNIFICENT ANTARCTIC WILDERNESS HAS SO ENCHANTED PROFESSOR JULIA POTTER AND
ASSOCIATE PROFESSOR PETER HICKMAN THEY’RE ALREADY ANTICIPATING THEIR THIRD VISIT.
s soon as we returned from our first
trip to Antarctica we knew we wanted
to go again. We love cold climates and
have always had an interest in this
continent. In fact, we even thought about
working in Antarctica but never managed
to do it, so actually taking that first trip
was the realisation of a long-held ambition.
A
On our second trip we travelled with
Aurora Expeditions on a route that took us
to the Falkland Islands, South Georgia
and the Antarctic Peninsula.
The journey began in Ushuaia,
Southern Argentina, and even at this point
we felt like we had reached the end of the
earth. Our ship was a Russian vessel, Polar
Pioneer, and while no luxury cruise, it was
certainly very comfortable and we were
very well looked after by captain and crew.
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The other passengers were mostly
The island of South Georgia in the
over 40 with some into their 60s and 70s,
South Atlantic Ocean was one of the
and although we all came from different
expedition’s highlights. Observing the
countries and had different backgrounds
spectacular wildlife – penguins, seals, birds
we were united in our amazement and
and whales – was a special experience.
wonder at what we saw.
It was inspiring to see some of the
We were also drawn to its isolation. A
whole day could pass without seeing
older passengers getting into the Zodiac
another vessel and the sense of quiet and
dinghies, helped by the burly Russian
appreciation of nature was extremely
crew, and then balancing on the edge with
powerful. Prion Island was also a delight –
their feet in the middle like the rest of us
here we saw pairs of nesting, wandering
as we took off across the water to explore
albatrosses. With our guide we were
the landscape.
allowed to come within 20 metres of these
It sounds a little wild but safety was
taken seriously and the crew made sure
everyone got on and off the dinghies in
one piece.
magnificent birds and no-one talked
above a whisper the entire time.
We felt so privileged – we still smile
when we think of it.
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“It’s an overwhelming
expression of nature and a
life-changing experience”
Photographs can’t do this region
justice: the pure white of the snow and
ice; the ever-changing colour of the sea;
floating clouds of plankton in the ocean;
huge boulders and glaciers; flocks of
birds in the sky; whales close by and on
the horizon; and dolphins frolicking near
the ship.
It’s an overwhelming expression of
nature and a life-changing experience.
A journey to Antarctica is challenging,
even with the comforts of our ship and
Julia Potter is the Executive Director of ACT
Pathology and Professor of Pathology at the
Australian National University Medical School.
Peter Hickman is an Associate Professor in
attentive crew, and so we often asked
Chemical Pathology at the Australian National
ourselves in wonder: just how did those
University and is the past-Chief Examiner in
original explorers survive?
Chemical Pathology for the RCPA.
PATHWAY_57
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recipe for success
Make it a double
COOKING IS A FAMILY AFFAIR FOR TOP CHEFS GREG AND PETER DOYLE, WRITES BRONWYN MCNULTY.
B
mistake people make when cooking
seafood is overdoing it.
“It’s still sort of the basis of worldwide
food these days,” Peter says.
Greg Doyle was an apprentice chef
who spent his mornings catching waves
and his afternoons in the kitchen.
“It’s very important when you are
buying seafood to buy premium product,”
he says. “Pay a little bit more and you get
a much better product.”
“When I was first cooking, there was
just iceberg lettuce. It never occurred to
me that there were other types... you
used to go to Europe just to eat an oak
leaf lettuce.”
ack in the 70s, Peter Doyle envied his
little brother.
Twenty-year-old Peter, on the other
hand, was holed up at a desk in the
government’s land tax department valuing
real estate, with only dreams of the green
room to keep him going.
“When I left school I didn’t know what I
wanted to do,” says Peter, pictured left
with Greg. “Greg was two years younger
than me, and already a cook. He was
surfing in the mornings and going to work
in the afternoons. But I was going to work
in the mornings...”
It wasn’t long before Peter headed for
the kitchen too. The brothers (no relation to
the Doyles of the Doyles seafood chain) are
now in good company as two of Australia’s
most respected and admired chefs.
“I always liked food, but I didn’t know
that much about it,” says Peter, who, 30
years later, is variously described as “a
founding father of modern Australian
cuisine”, “a home-grown legend” and “an
inspiration to the industry”.
He runs the kitchen at Est. – an elegant
fine-dining eatery at the trendy
Establishment Hotel in Sydney’s CBD –
where he specialises in produce-driven
contemporary Australian cuisine. He says
simplicity and restraint are vital ingredients
in creating a perfect meal.
Five kilometres east, at Rose Bay’s
glass-encased Pier restaurant, Greg
receives rave reviews for dishing up what
this year’s The Sydney Morning Herald
Good Food Guide describes as “arguably
the country’s best seafood”. He likes to
keep it simple, too, and says the biggest
58_PATHWAY
Greg says his early interest in food was
probably sparked by the fact that their
mother cooked meals that were ahead of
her time.
“There’s never been an industry
background for Pete and I, but mum was a
good cook,” he says. “We always had fresh
vegetables, lots of fruit... For our era I think
she did a lot of interesting stuff like fish,
fresh vegetables, pork and veal, lamb
casseroles and things like that.”
When their mum was crook, it was
Greg who stepped up to the cooker to feed
the family of five. “I don’t know why it was
me,” he laughs. “It’s about time I asked
Pete about that.”
A revolution in cooking in the late 70s –
the nouvelle cuisine movement – made it
difficult for the brothers not to get carried
along by a wave of excitement stirring up
the industry.
“When I first started my apprenticeship,
the same 20 dishes were on all over town,”
Peter says. (Think oysters kilpatrick, steak
diane.)
“It was known as ‘international cuisine’
and nearly all restaurants and hotel dining
rooms around the world served food based
on Hotel French cuisine that had become
standardised through lack of interest,
direction and experimentation.”
Not surprisingly, after three decades
of this, food had become boring. Then
the emphasis gradually shifted away from
heavy sauces masking flavours towards a
lighter approach aimed at enhancing
fresh produce.
>
Greg’s recipe
SEARED TUNA STEAK WITH
BALSAMIC-BRAISED RADICCHIO
2 baby fennel bulbs
extra virgin olive oil
4 eschallots, sliced
4 baby radicchio
2 tablespoons baby capers
aged balsamic vinegar
cracked black pepper
sea salt
4 x 180 g tuna steaks
Wash the baby fennel and slice finely (on a
mandolin is best). Bring a deep pan that
has a lid to a medium heat. Add some olive
oil and heat, and then add the thinly sliced
fennel and eschalots. Sweat these over a
low heat with the lid on. Add the radicchio
leaves and capers and sweat again until
half cooked. Deglaze with a good splash of
balsamic vinegar. Season with salt and
pepper and remove from the heat.
Heat some olive oil in a frying pan until
very hot (nearly smoking) and sear the tuna
on each side for approximately 45 seconds.
The tuna should be crisp on the outside
and raw in the centre. Place the braised
fennel and radicchio on the heat, and add a
little more olive oil and balsamic vinegar.
Place the radicchio and fennel onto one
side of the plate and add the tuna. Dress
with the pan juices.
Serves 4
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When they’re not in the kitchen, it’s a safe bet that one or
both of these brothers are out in the surf.
PHOTO CREDIT: MICHAEL AMENDOLIA
PATHWAY_59
>
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SURF N TURF
In 1978, an eight-month trip around parts
of Asia and Europe in a campervan with
wife Beverley and their nine-year-old
daughter fuelled Peter’s passion for new
cuisine. Greg and his wife Jenny joined
them for about three months.
Both brothers also worked in
restaurants to see what was happening.
Back then they thought that one day they
might run something together. But so far a
variety of other ventures has prevented that
from happening.
Peter has run a number of restaurants
since 1980, including Turrets in the city,
Reflections at Palm Beach, Le Trianon and
Cicada at Potts Point and Celsius in the
Radisson Plaza Hotel, Pitt Street. He
moved to Est. in 2003.
Greg was the chef and had a business
interest in hip 90s Darlinghurst nightclub
Rogues, then had a place called Puligny’s
in Neutral Bay, followed by Eastside Bar
and Grill in Kings Cross. He took over at
what is now Pier in 1994.
“This restaurant had been doing
seafood since the late fifties and early
sixties,” he says. “It was Dories, then
Doyles... quite a coincidence.”
PHOTO CREDIT: MICHAEL AMENDOLIA
“We just travelled around, went to the
markets every day and went surfing,”
Greg says.
Ironically, Greg is not keen on fishing,
so dinner was caught and cooked by the
boys running the boat. “We were surfing
six to eight hours a day,” he says. “The
last thing I want to do on holidays is go
into the kitchen.”
At home Greg says he will cook if they
are entertaining. Otherwise it’s up to his
wife Jenny.
“A favourite meal of ours that is really
nice and easy is stuffing some corn-fed
chickens with lemons, rosemary and garlic,
and cooking them in a bag,” Greg says.
“Then just wilt some spinach in the juices
and serve with a nice big salad.”
Peter is partial to a good dessert but
also loves slow-cooked, stewy meals, like
beef cheeks. “Because there are so many
opportunities to eat lightly it’s nice to have
something like a slow-cooked, braised meal.
And then you have an opportunity to enjoy
that nice bottle of big red you put down.”
Today both Greg and Peter find
themselves battling challenges because of
the drought and seafood shortage.
“The longer the drought goes on, the
more impact it has on fruit and veg,” Peter
says. “And fish is looking hard to source.
We are changing our menu not because
we want to but because we can’t
guarantee that we will get the same fish
each week.”
LOCUM DOCTORS
The fish shortage is also a considerable
problem for Greg.
When they’re not in the kitchen, it’s a
safe bet that one or both of these brothers
are out in the surf – although they don’t get
out together as often as they did when
they both lived in Whale Beach. Greg is still
there, but Peter now lives in Balgowlah.
When PathWay spoke to them they were
preparing to head off on a surfing safari to
the Maldives.
“And a couple of years ago we went to
the Mentawis, in Sumatra, on a surfing safari
on a boat,” Greg says. “We were surfing reef
breaks out in the middle of the ocean.”
60_PATHWAY
50_PATHWAY
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PathWay #12 - Text
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diningout
A
YEN
for
Japanese
BLENDING ELEGANCE AND SIMPLICITY WITH INGENUITY AND QUIRKINESS,
JAPANESE CUISINE HAS WON LEGIONS OF FANS. PATHWAY TRACKS DOWN
SOME OF THE BEST JAPANESE JOINTS ACROSS AUSTRALIA.
Toko
Sydneysiders are quick to embrace a new restaurant, especially when the diners have a view of
those not enjoying the new, hip place, and can be seen in return.
Toko, located in the old MG Garage/XO site in Surry Hills, will not disappoint restaurant voyeurs.
Brothers Al, Daniel and Matthew Yasbek have opened their second eatery among the hub of
restaurants in Crown and Burke Streets.
In Japanese, Toko means “room within a house to relax”, and this chic, informal style of eating is
quintessentially Sydney.
With an open kitchen, low-rise communal tables and a bar area, Toko offers several vantage points.
You can see the chefs at work and there is a large emphasis on fresh local fish – the menu has 22
sushi options alone.
The menu is extensive but not overwhelming and you will probably want to try everything.
For an entrée we tried the nigri sushi salmon ($5.20) which is what I would expect of any good
Japanese restaurant, and my tastebuds also appreciated the sashimi tuna ($18.50).
Presented on a bed of crushed ice with wasabi sauce, the tuna was cut very fine and melted in the
mouth. It was followed by a most interesting vegetarian option for a nori roll, the toko yasai makai
nori ($8.20) with asparagus, zuchinni, capsicum, shitake mushroom, avocado and miso sauce.
It was a smooth taste explosion.
Mains are served themed on the traditional lunchbox idea with salad, miso soup and rice. We tried
the tempura donburi ($23.80) – assorted tempura with sweet soy sauce and the beef steak donburi
($28.80) – chargrilled beef fillet steak with sweet sesame soy sauce.
The latter dissolved deliciously in the mouth and was so tender we almost forgot it was red meat.
The kotori ni miso zuke ($26.50) – miso-marinated baby chicken oven-baked with bok choy - was a
stunning fusion of tastes, with hints of peanut sauce and ginger - and the chicken, like the beef, was
beautifully tender.
There is no better wine to match Japanese cuisine than an elegant rosé. We chose Fonty’s Pool Rosé
2006 from Margaret River ($11.00 per glass). It had a subtle strawberry aroma and delicate salmon
colour and perfectly brought out all the flavours of the meal. It was delicate enough to enhance, not
overwhelm, the food.
To finish we took the waiter’s recommendation with a choice of 3 sorbets ($11.20) – lemongrass, lime
and coconut, and shiso (a Japanese herb).
The traditional lemongrass, lime and coconut was divine but the shiso, well, it created much
conversation. Something for you to try.
Toko is a welcome addition to the Crown St restaurant strip.
- Eve Propper
PHOTO CREDIT: NICKY RYAN
All images from Toko
Toko
490 Crown St, Surry Hills 2010 NSW
Ph: (02) 9357 6100
Web: www.toko.com.au
Open for Dinner Mon- Sat 5.30pm -11.00pm
Open for Lunch Thurs - Sat 12noon -3pm
Bookings only available for lunch | private dining room available
About $170 for 2 including drinks
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>
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diningout
PHOTO CREDIT: NICKY RYAN
Toko sushi | Kenji Ito has just opened his first restaurant
Seizan
One of the hallmarks of a good restaurant – apart from the food
and the ambience – is the way the staff handle nuisance
customers.
I fear we were unwittingly just that when four of us descended
on Seizan restaurant and were ushered to sit at the raised seats
around the large hotplate where the teppanyaki barbecue
cooking is performed.
We had inquired whether teppanyaki was available when
booking but after one look at the extensive menu, we decided
to go with sharing dishes.
Our waitress looked fleetingly taken aback and then with
consummate Japanese politeness led us to the sunken seating
typical of authentic Japanese restaurants.
We reckon we made the right decision. We shared four entrees,
all of which proved to be delicate and tasty. The most popular
was the deep-fried scallops coated with crisp rice ($10.80),
which were delectable, followed by the cooked octopus with
soya bean dressing ($6.50), which was suitably tender, and the
chicken skewer with yakitori sauce ($6).
Of our main meals, the bento box ($24) was a hit. Each of the
four delicacies – sashimi, teriyaki chicken, simmered beef and
tempura mix – was full of flavour and combined well.
Another favourite was the Tempura Moriawase ($16.80), a
combination of fresh prawn, fish and vegetable tempura served
with Japanese radish and a gingered lime sauce, which proved
an inspired choice. All the mains came with miso soup, rice and
salad.
The friendly and obliging service persisted throughout the
evening. Iced water had appeared immediately on arrival and
was topped up regularly, our courses were served at decent
intervals and drinks orders were promptly filled.
As the restaurant filled up – a good sign, especially on a
Monday night – we were relieved to see a couple had ordered
teppanyaki and were being entertained by the showmanship of
the knife-clashing, pepper-grinder-tossing chef.
62_PATHWAY
In fact, it appeared the customers had much of the menu
covered when a nearby couple ordered the Yakiniku set ($22.50
p/p), in which a griddle is brought to the table and you cook
your own tenderloin beef and vegetables.
The wine list was not extensive but the prices were reasonable.
The decor was modern and restful with several aquariums and
framed Japanese fans, and the waitresses were clad in beautiful
yukata, a summery version of the kimono.
For those of us who, after a couple of drinks, fancy imitating
Joe Cocker or Aretha Franklin, the Seizan karaoke bar is open
upstairs on Fridays and Saturdays from 7pm and Wednesdays
and Thursdays by request.
- Cathy Saunders
Seizan
566 Hay Street, Perth
Ph: (08) 9325 5980
Web: www.seizan.com.au
Open for lunch Mon–Fri 11.30am–2pm, dinner 7 nights from 5.30pm
About $60 for two plus drinks
Kenji
What happens when a highly trained Japanese-born chef,
versed in the Kyoto style of cooking, is exposed to the work of
two of South Australia’s finest regional chefs?
The answer is to be found at Kenji, on the eastern side of
central Adelaide. Owner chef Kenji Ito is a fully trained kaiseke
chef whose specialised skills have been influenced by stints
cooking at leading regional restaurants such as the Salopian Inn
and d’Arry’s Verandah in McLaren Vale.
This is Kenji’s first restaurant of his own, opened last year in
partnership with his wife, who runs the floor, and it is one of the
more interesting restaurants to open in Adelaide in recent times.
It is a reminder of the days when Adelaide was a leader in
cross-cultural cooking, with chefs such as Cheong Liew, Le Tu
Thai and Cedric Eu, except this time the underpinning influence
is Japanese.
Although this smart-looking restaurant is at the ‘difficult’ end of
Hutt Street, in a location that hasn’t worked too well in the past,
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Cooking up a storm at Seizan's teppanyaki barbecue | Beautifully presented Seizan sushi
unlike most of its predecessors Kenji is having no trouble
attracting a stream of dedicated customers.
That is, of course, until you taste acclaimed chef Hiro Nishikura’s
Kenji says his restaurant is a reflection of everything he’s ever
done, with a seasonally driven menu providing Japanese flavours
and style, with a focus on regional produce. The large menu
possibly places strains on the kitchen from time to time, but in
general Kenji’s dishes are immaculate and often quite dramatic in
presentation.
lighting become irrelevant.
Look for dishes such as slow-cooked Barossa pork belly with
hakusai cabbage rolls, duck leg poached in orange with teasmoked duck breast and fragrant red rice, or wagyu beef with
taro and ginger mash and a green chilli salsa. The plate of half-adozen mixed appetisers for two is a fine way to taste the scope
of Kenji’s skills – or simply opt for the bento box, which is a very
stylish presentation of tempura, sushi, sashimi and beef teriyaki.
Desserts can be interesting – such as frozen green tea mousse
on sweet potato purée with poached satsuma plum and white
fungi. The wine list is small, but individual, interesting and well
priced.
exquisite sushi, and suddenly the trivial details of decor and
Seated at the bar, with a bird’s eye view of Hiro at work, opt for
Omakase, a piece-by-piece selection of the best sushi of the
day. You might be offered edible wonders such as the oysters
warmed and served in a nori wrapper with a dash of Japanese
mayo and a touch of chilli, or the briefly grilled eye fillet wrapped
around a firm oblong of sushi rice. Watch Hiro put together his
extraordinary mackerel sushi, oily and sweet with miso or the
simplicity of sushi with tuna – prime slices of melt-in-the-mouth
fish with a touch of wasabi paste.
Whatever you’re served you’ll see it being freshly made in front of
you – the perfect way to whet the appetite for the next piece
coming your way.
It would be easy to just let the sushi and sashimi keep coming
but it would be a shame to miss out on Shira Nui’s wonderful
cooked dishes such as the Chirimushi, a delicate dish of
steamed fish and cabbage in broth with a mild dipping sauce, or
- Nigel Hopkins
Kenji
Shop 5, 242 Hutt Street, Adelaide
Ph: (08) 8232 0944
Open Tues–Sat from 6pm
Licensed & BYO
About $120 for two, plus drinks
Bookings recommended
Shira Nui
Located on the edge of a shopping centre in the heart of
Melbourne suburbia, Shira Nui doesn’t look much different from
other Japanese restaurants. With its decor of pale yellow walls
matched with blond wood timber, a long sushi bar and a few
ocean-themed decorations, the smallish restaurant (it only seats
35) is indistinguishable from many of the Japanese eateries to be
found throughout the city and suburbs.
the robust Nasuden, two wonderful grilled circles of eggplant,
meltingly soft and glazed with miso paste and sesame seeds.
Desserts won’t disappoint either. We couldn’t resist black
sesame seed brulée, a wonderfully creamy custard the colour of
licorice with a distinct nutty flavour. But there’s also a green tea
version I’ll be coming back to try another time.
With a handful of excellent reviews and inclusion in every
significant guide to great food in Melbourne, you’ll need to book
in advance to secure a table or a seat at the bar, but the wait will
definitely be worth it.
- Justine Costigan
Shira Nui
247 Springvale Road, Glen Waverley
Ph: (03) 9886 7755
Open for lunch Tues–Sat noon-2pm, dinner Tues–Sat 6-10pm
About $140 for two including drinks
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the good grape
HELLO MELLOW YELLOW
AUSTRALIAN WINEMAKERS ARE TURNING TO A MORE REFINED AND LESS BLOUZY BREED OF
CHARDONNAY – AND JUST IN TIME, SAYS BEN CANAIDER.
t is our most loved wine. Chardonnay.
We drink more of it than any other single
grape variety – white or red.
I
Its popularity stretches from
viticulturalists, who find it friendly and
forgiving to grow, to winemakers, who
love the tricks and artefact they can
conjure with it, and to the vast majority of
drinkers who find chardonnay’s fruit-salad
flavour reliable and reassuring.
over two decades to move on from that
As one Hardys winemaker says,
unavoidable and awful sunshine-in-a-
“altitude and latitude equal attitude”. The
bottle chardonnay flavour profile.
further south you go, or the higher up you
But finally there’s some real
go, you get grapes with one very
sophistication starting to creep in. We are
important quality – higher levels of natural
not making great Chablis or white
acidity. And acidity is the key to elegance,
burgundy yet, but that’s not really the
freshness, balance and – more
point or goal. We are now, as a
importantly, potential longevity – in wine.
winemaking nation, starting to make
balanced, elegant and very gently, subtly
But $53 is still $53. Pay that sort of
Australian chardonnay’s smell and
flavour is pleasantly – almost banally –
memorable.
stylish chardonnay. In other words, white
money and you should rightly expect to
wines that observe wine’s first and most
get a good wine – and a wine you should
important rule: it has to be a beverage,
be able to easily drink. But what about
Unlike riesling it is not too piercing;
unlike sauvignon blanc it is not too
strident; unlike viognier – the latest new
kid on the block – it is not too viscous or
alcoholic. Yet if these statistics and
general comments are true, then why is
there an ABC – Anything But Chardonnay
– Club?
not a statement – no matter how many
under $20?
Trends, fickle and sometimes
fathomless, come and go in the wine
game, as much as they do in the fashion
industry. But this can be good news, too,
because it encourages rethinking and
refinement. And that’s something the
great majority of Australian chardonnay
has needed for some time.
best wine of the show – from all classes,
2005 Gulf Station Chardonnay is around
red and white – went to Hardys Eileen
$19, and is often discounted further.
Going back nearly 30 years now,
chardonnay burst onto the local bottled
wine-drinking scene like Dolly Parton in a
hot-pink, rhinestone-encrusted rodeo
outfit – buxom, loud and very cock-ahoop.
It was a style of white wine that was
unmissable. Its flavour was big. Because
of this a newly wine-sophisticated
Australia took to it – it was a drink and a
taste that was easy to remember. We liked
that because it made us all feel like
instant wine connoisseurs.
The trouble was the long hangover –
in gustatory terms, that is. It has taken us
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meaningless wine trophies and medals
such ‘statement’ wines might win.
And maybe the wine show system is
even changing, too. At the 2007 Sydney
Royal Wine Show more chardonnays with
more elegance and breeding took out
more gold medals. Indeed, the award for
Hardy 2004 Chardonnay ($53).
This is still a wine with all the
Chardonnay has been fine-tuning itself
at this price point, too.
Leading the way with such elegance,
refinement and very drinkable – and
affordable – subtlety is the Yarra Valley’s
Steve Webber. The De Bortoli winemaker’s
It is chardonnay that is more citric and
grapefruity than tropical fruits and
winemaking bells and whistles, but the
peaches and cream. There’s some
decibel knob has been well and truly
roundness and richness from some good,
turned down. This is a new style of
unobtrusive barrel ferment, but nothing
Australian chardonnay that demures
too fancy-pants gets in the way of the
rather than bullies.
clean, pure fruit flavours.
Part of the reason for this is the fruit.
Eileen Hardy chardies of days gone by
were made from ripe, rich, heady grapes
from such places as Padthaway and
McLaren Vale. The wine was given a fair
This is a wine you can drink, and
drink. And it is a wine Webber is proud of.
Not letting the grapes get too ripe;
sourcing fruit from south-facing slopes,
whack of barrel ferment in very osmotic,
away from full sun; sorting the fruit to
toasty French and American barrels. In
guarantee the best quality; and not relying
other words, Dolly Parton.
on too much new and loud oak has
The 2004 Eileen is a different lady
altogether.
The fruit comes from Tasmania, the
enabled him to build a wine that’s
seemingly simple, yet all so satisfying.
This is the future for Australian
Yarra Valley, and from Tumbarumba, near
chardonnay. As Dolly might have said,
the Snowy Mountains.
here chardonnay comes again...
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2007
Conference Calendar
JUNE 2007
3
11th Greek Australian International
Legal & Medical Conference
14
The Adelaide Small Biopsy Course
14 - 15 July 2007
Adelaide, Australia
klebe@fmc.sa.gov.au
3 - 9 June 2007
Crete, Greece
jennycrofts@ozemail.com.au
AUGUST 2007
16
First World Congress on Pathology
Informatics (WCPI)
16 - 17 August 2007
15
AACC Annual Meeting
Brisbane, Australia
www.pathologyinformatics.org/
15 - 19 July 2007
3
17th IFCC – FESCC European
Congress of Clinical Chemistry and
Laboratory Medicine
3 - 7 June 2007
The Netherlands
5
Dermatopathy
5 - 8 June 2007
Las Vegas, USA
18
The Virology Master Class
18 - 29 June 2007
Adelaide, Australia
www.sapmea.asn.au/virology2007
23
Microbal Genomics and Secondary
Metabolites
23 June - 1 July 2007
Split, Croatia
www.jic.ac.uk/science/molmicro/
summerschool2007
JULY 2007
1
23rd International Conference on Yeast
Genetics and Molecula
1 - 6 July 2007
Melbourne, Australia
www.yeast2007.org
San Diego, USA
http://www.aacc.org/AACC/events/ann_meet/
annual2007/
20
24th World Congress of Pathology and
Laboratory Medicine
20 - 24 August 2007
16
Techniques and Application of
Molecular Biology: A Course for
Practitioners
16 - 19 July 2007
Coventry, UK
www.warwick.ac.uk/go/bioscienceshortcourses
20
Basic Pathological Sciences Seminar
2007 Program
20 - 21 July 2007
Sydney, Australia
22
4th IAS Conference on HIV
Pathogenesis, Treatment and
Prevention
22 - 25 July 2007
Sydney, Australia
www.ias2007.org
22
9th Indo-Pacific Congress on Legal
Medicine and Forensic Sciences
22 - 27 July 2007
Colombo, Sri Lanka
inpalms2007@sri.lanka.net
28
Current Issues for Legal Medicine
28 - 29 July 2007
Canberra ACT, Australia
b.hsokins@legalmedicine.com.au
Kuala Lumpur, Malaysia
acadmed@po.jaring.my
SEPTEMBER 2007
15
The Greek Conference KOS 2007
15 - 21 September 2007
Dodekanese, Greece
eugenia@greekconference.com.au
23
International Clinical Trials Symposium
23 - 26 September 2007
Sydney, Australia
www.clinicaltraials2007.com
OCTOBER 2007
10
5th Annual Pathology Refresher
Course
10 - 12 October 2007
Budapest, Hungary
www.ryalsmeet.com/meetings/ISSP101007/
main.htm
NOVEMBER 2007
2
Short Course in Forensic Pathology
2 - 4 November 2007
Hobart, Australia
evep@rcpa.edu.au
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rearview
Dark side of Venus
PINPOINTING THE TRUE ORIGINS OF SYPHILIS HAS PROVED TO BE A TRICKY HISTORICAL
TASK, WRITES DR GEORGE BIRO.
e would need the wisdom of
for Europe,” according to author Andrew
China, India, and Africa. King Charles
Solomon to resolve big questions
Nikiforuk.1
himself died of syphilis, aged only 28.
W
such as how, when and where syphilis
started in Europe – and who gave it to
whom.
The French blame the English, the
English suspect the Neapolitans, and on
it goes. So many mysteries, but no
definite answers.
Many Europeans blame the
Americans. It’s believed that men who
sailed with Christopher Columbus caught
syphilis in the West Indies in 1492–93 and
brought it back to Europe.
“Just as smallpox became the Old
World’s calamitous gift to the New,
syphilis was America’s biological surprise
Some say that Columbus himself went
mad and died of syphilis.
In the 1490s, the French army of King
Charles VIII were besieging Naples. Some
of Columbus’s sailors had joined the
Spanish defenders. The besieged men
expelled from the city the harlots they had
infected. As planned, the prostitutes in
Much later, the author Voltaire
lamented: “France didn’t lose all she had
won in this campaign. She kept the pox.”
Fifteenth-century syphilis could turn
you into a leprous-looking wreck in weeks
and bury you within a year – if the
agonising pain did not lead you to kill
yourself first. Victims were afflicted with
pustules spreading from the genitals,
turn, infected more and more of the
agonisingly swollen joints, fever, rotting
besieging army.
flesh and blindness.
Within a year, syphilis forced the
French to abandon Naples.
As they scattered, they spread syphilis
around Europe; then sailors carried it to
One man, Joseph Grunpeck, picked
up syphilis at a banquet “attended by
Venus as well as Bacchus and Ceres”. He
himself beat the odds and lived to 81, but
his fellows did not: “so filthy and
repugnant… hoped to die. Some moaned
and wept and uttered heart-rending
Syphilis does not spare
the famous
O
ne report blames Cardinal Wolsey for giving syphilis to King Henry Vlll by
whispering in his ear.
2
cries…”
One misogynist doctor insisted: “The
disease is contagious… through
copulation… with an unclean woman.”
But within 50 years after Columbus
sailed the ocean blue, the disease was
becoming less virulent, and changed from
A list of people alleged to have had syphilis reads like a historical and
artistic Who’s Who. From Russia we have Ivan the Terrible, Peter the Great
and Catherine the Great, who gave her son Paul l congenital syphilis. From
other corners of the globe we have Herod, Charlemagne, Goya, Keats,
Napoleon, Gaugin, Nietzsche, Oscar Wilde, Scott Joplin, Al Capone and
Randolph Churchill (Winston’s father).
being a lethal epidemic to a chronic
The great John Hunter (1728–93) believed that syphilis and gonorrhoea were
just one disease; in a tragic self-experiment he inoculated himself and
reportedly ended up with cerebral and cardiac syphilis. When Samuel Johnson’s
biographer, randy James Boswell (1740-1795) enjoyed women of the night, he
sometimes used “armour” (a condom of animal gut). No, he wasn’t fussed
about getting them pregnant, he was just protecting his own crown jewels.
condition”, then washed and covered with
At first the author Guy de Maupassant was proud of his syphilis, but ended
up in an asylum suffering general paralysis of the insane.
And Sir William Osler (1849–1919) taught that he who knows syphilis,
knows medicine.
infection.
The treatments were imaginative, if not
too effective. Quacks advised people with
chancres (initial syphilitic lesions) to have
them first sucked by a person of “low
a live flayed chicken. But the main remedy
was topical or oral mercury.
Wits quipped: “A night with Venus
meant a lifetime with Mercury”.
Though mercury did kill some
spirochaetes (slender, corkscrew-like
bacterial micro-organisms), it also killed
some patients. Other users went bald and
lamented their lost love life. The bark of
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PHOTO CREDIT: JEAN-LOUP CHARMET / SCIENCE PHOTO LIBRARY
PathWay #12 - Text
A 19th century illustration of an emaciated man suffering from syphilis.
“Fifteenth-century syphilis could turn you into a leprous-looking wreck in weeks and bury you
within a year – if the agonising pain did not lead you to kill yourself first.”
the ‘Holy Wood’ (guiac) from America also
had a vogue.
Around 1909, after hundreds of
failures, Dr Paul Ehrlich (1854–1915)
synthesised two arsenical compounds,
Salvarsan and then Neosalvarsan, which
proved an effective treatment. Sad to say,
he did not live to receive his Nobel Prize.
The Viennese psychiatrist Julius
Wagner von Jauregg injected syphilis
patients with malaria parasites, so causing
high fever and achieving some remissions.
Another Nobel Prize.
Nowadays penicillin is still clearly the
best treatment.
One view is that syphilis, or a closely
related disease, existed in Europe before
Columbus. Supporters cite evidence from
skeletons found in the early 1990s in an
ancient Greek cemetery in southern Italy.
Other skeletons come from the site of an
ancient friary in Hull. Both sets of
skeletons are said to predate Columbus
and to show evidence of syphilis.
So was there syphilis in Europe long
before the fifteenth century? Some
authorities read syphilis into Biblical
references, such as that of David, King of
Israel: “My wounds stink and are corrupt
because of my foolishness. My loins are
filled with a loathsome disease…”
Could the Biblical warning “The sins of
the fathers shall be visited upon the
children” refer to congenital syphilis?
Perhaps the spirochaete existed in
both the Old and New Worlds at the same
early time, and Columbus’s sailors just
brought back an unusually virulent variety.
Or perhaps what people in medieval times
called leprosy was actually syphilis or a
close relation.
Another theory involves tropical
diseases related to syphilis and also
caused by the same Treponema
spirochaete. Whereas syphilis is a venereal
disease of adults, the other three are nonvenereal diseases of children, spread via
the skin or mouth. Yaws is common in
Africa; bejel, sometimes called nonvenereal syphilis, occurs in the Near East,
and pinta is found in Central America.
Some believe that African Negroes,
who the Portuguese navigators captured
in the early 1400s, brought yaws with
them to Europe.
Then, as it infected the fully clothed
Portuguese and Spaniards, non-venereal
yaws gradually became venereal syphilis.
Some microbiologists regard the agents
causing human treponematoses as variants
of one ancestral spirochaete. So, are these
treponematoses varieties of one disease
that originated in Africa, its manifestations
varying with climate and culture?
The debate goes on.
1. The Fourth Horseman. London: Fourth
Estate, 1991.
2. Wilkins, Robert. The Fireside Book of Deadly
Diseases. London: Robert Hale, 1994.
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postscript
Nutmeg liver and sago spleen
THE CREATIVITY OF PATHOLOGY LECTURERS INJECTED SOME MUCH-NEEDED EXCITEMENT INTO
DR PAM RACHOOTIN’S MONOTONOUS MEDICAL DEGREE.
and google them to get help from sites
such as the Undiagnosed Symptoms
Support Forum.
n American humourist once said, “Our
great difficulties in life aren’t caused
by what we don’t know, but by the things
we know – and that aren’t so.”
A
In this forum a qualified medico
attempts to elicit a more meaningful
history and then provide some advice,
while a virtual community of patient
advocates comment from the sidelines
and share similar experiences.
The only lectures in medical school
that kept me awake were the stimulating
sessions presented by the real
entertainers of the medical world.
There was nothing like a seasoned
pathologist fearlessly hitting the high Cs
of clinical–pathological correlation.
The banter continues with results of
MRI scans and blood tests. Armed with
printouts of a battery of investigations
that someone else received, the now
confident patient presents to their GP,
demanding a quick confirmation.
And the story line! Who could possibly
sleep through the who-done-it suspense,
as clue accreted to clue on the troubled
road to the differential diagnosis?
What investigations would help support
or refute the various alternative hypotheses?
Forget medicine, forget science – this had
all the makings of great literature.
This message of hidden truths was
reinforced during our required attendance
at three autopsies. If one just kept
sufficiently out of the way, it was possible
to witness the careful uncovering of
discrepancies between the presumed
diseases and the actual underlying
medical conditions. The lesson: one’s
clinical judgment does not necessarily
match reality.
Alas, today’s focus on problem-based
learning puts the magic wand in the
unguided hand of the sorcerer’s fumbling
apprentice, with all the predictable results.
Sure, let’s limit student interaction with
pathologists, ban students from
autopsies, and call it a ‘new curriculum’.
That sounds modern, doesn’t it?
Through their lectures, pathologists
provided the foundations of medical
practice for me, as well as contributing to
my sense of language and aesthetics.
Their use of metaphor spiced up what
otherwise might be a dry, scientific lexicon.
If the practice of medicine has long
been recognised as an art, we owe
pathologists credit for engaging our senses
of smell and taste to bring us a more
culinary appreciation of disease and death.
68_PATHWAY
Pathologists appear to have been
salivating over their work for years.
A tantalising array of mouth-watering
pathological treats abounds – with a focus
on sweets.
They include chocolate cyst ovaries
(endometriosis), strawberry gall bladder
(cholesterolosis), sago spleen (infiltrated
with amyloid), honeycomb lung (fibrosing
interstitial disease or emphysema), and
bread-and butter serositis (pericarditis)
with icing sugar spleen (in non-specific
splenitis).
This is not to neglect the main course
– what with nutmeg liver (chronic venous
congestion), beefy lung (showing
consolidation in gross appearance),
cauliflower-shaped colonic tumours,
anchovy sauce amoebic abscess, rice
water stools (cholera), Swiss cheese
(endometrial hyperplasia), and rice or
melon seed bodies (in tuberculosis
arthritis). Did the pathologists who
popularised these descriptions lead a
double life as frustrated chefs? Or did
hunger stimulate their imaginations while
they worked through their lunch breaks?
Meanwhile, patients have embraced
their own pseudo clinical–pathological
correlations.
They have symptoms such as “attacks
of feeling off” or just plain “weirdness”
Although GPs have struggled for
years to come to terms with vague
presentations by patients, such histories
do not deter the cyber space support
network.
Take this mythical exchange between
bloggers. A blogger, who warns that she
“may be unreasonably grumpy for a few
days… having simultaneously infected
[herself] with both bronchitis and a sinus
infection” is advised to:
“Chicken soup it until it comes out of
your ears.”
Alternatively, a nurse practitioner asks,
“Have you tried pantothenic acid? It’s
been known to stop even asthma in its
tracks…”
Whereas patients may turn to advice
from anyone with an internet connection,
medicos put their trust in pathologists to
get them going in the right direction,
notwithstanding the occasional mishap.
Like the throat swab sent off for
microscopy, culture and sensitivity, with
its finding of: “Normal vaginal flora”.
Or the biopsy from a specimen
described as a “large polyp”, submitted
by a registrar performing his first
sigmoidoscopy.
The pathologist, who maintained strict
professionalism, wrote a succinct
conclusion: “Normal cervix”.