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From: Rescuing Medical Education Conference
Stamford Sydney Airport
O'Riordan St (cnr Robey St), Mascot
18 February 2005
Professor Phillip Allen
Past President, International Academy of Pathologists
CHAIRMAN: Our next speaker is Professor Phillip Allen, Past President of the International Academy of Pathology and currently Associate Professor of Pathology at the Flinders University.
PROFESSOR PHILLIP ALLEN: Thanks Bill. There is no doubt the hospital autopsy is very close to death. The autopsy rate - the hospital autopsy rate at Flinders Medical Centre is about 1%. A few coronials increases the rate a little, whereas at the Queen Elisabeth Hospital, which is out of the centre of Adelaide, down the road, the autopsy rate in the hospital is zero. All the autopsies are transported up the Port Road to the Adelaide Hospital where they are performed there, and goodness knows what use that would be to the clinicians who are down at the Queen Elizabeth, they wouldn't have a clue what's going to happen at the autopsy. There's no feedback - absolutely useless. Well, the autopsy at the moment is close to death.
But what about this Osler, these Oslerian Principles, what's this. There's Sir William Osler, aged 63. I've got the picture from Bliss' book, William Osler, a Life in Medicine, published in 1999. Here's a short curriculum vitae. He was a son of sort of missionaries - Church of England missionaries sent out to the wilds of Tasmania - not Tasmania, of Canada, another part of the globe. Apparently it was pretty wild in those days. He was a graduate of McGill University where he became a lecturer, established a reputation, moved on to the University of Pennsylvania, then became the Professor of Medicine at John Hopkins, which was a very prestigious appointment, such was his reputation. Then his reputation improved even more and he obtained the Regis Professor of Medicine Chair at Oxford. Now this "Regis" has always puzzled me but I understand it means that you are appointed by the monarch, and the tenure is close to being absolute, which would be encouraging if it was so today.
How did he build his reputation, and here he is hard at work. He concentrated on every case, and those that died, he followed them to the mortuary - here he is in the dead house in Philadelphia - and he tried to correlate the pathological findings, the macroscopic pathological findings with the body he had seen during life, and it was very popular. Here are the students around him, and that was the basis for his reputation.
So although he was a physician he has had a profound effect on international pathology, and in particular the International Academy of Pathology. He was present at the first meeting held at the Army Medical Museum, at what is now the Armed Forces Institute of Pathology in Washington DC, of the International Association of Medical Museums. When he went to England he was appointed the Councillor for England for this international body. He had a friend called Don Smith, also known as Lord Strathconar, who controlled the finances of the Canadian Pacific Railway, and he persuaded Don to give $5,000 to the International Association of Medical Museums. Then came the First World War. The thing went into hibernation and only the $5,000 kept it going until after the Second World War, when it was reincarnated as the International Academy of Pathology, which is now the most prestigious surgical pathology - pathology - anatomic pathology professional organisation in the world. There's the seal, founded in 1906.
Well, what are Osler's principles? Pathology is the basis of clinical medicine, and this was widely accepted by everyone in my generation. Clinical teaching is best if case based. You can remember a case, you see someone, you remember that when you see them as a student, you remember them for the rest of your life. When you see someone come into your consulting room, or in the case of pathology your section, you correlate it all back to those people you've seen - individuals - they are impressed indelibly, or they should be, on your mind, and I've found that the cases --- if I'd seen a case I remembered it wonderfully well, if I read it from a book not so well, and if I heard someone talk about it, not at all.
So clinical teaching is best if case based and autopsies in Osler's day provided the final answer. Now you could quibble about that, that is no longer accurate, because there are plenty of cases that we as anatomic pathologists cannot properly diagnose at autopsy. All the electrolyte problems, conduction defects in the heart we make a terrible mess of. But the fundamental, the vast majority of diseases, autopsies give you a pretty good idea of what goes wrong. So it was a bit of an overstatement but not a lot.
So if we apply the Oslerian principles, you get clinico pathological correlations, clinico pathological conferences, pathology museums and good clinicians. If you get rid of the Oslerian principles - no autopsies, no clinico pathological correlations, no clinico pathological conferences, no pathology museums, no case based teaching and bad clinicians.
What's the reason for the decline in the autopsy? Well, it started in my view in the 70's when the physicians removed the accreditation of the six to twelve months pathology session from recognition in their physician training. So we stopped getting all those bright fellows that really invigorated the teaching hospitals in the 50's and the 60's and the 70's. All those bright sparks, the top physicians, went on to have key chairs around the country. They all went through this, they did pathology, they understood the basis, and they kept the autopsy service going. They impressed everyone on the importance of the autopsy, they told people to get autopsy requests, and the autopsy rate was about 60 or 70% as a result. That has been removed and from that date the autopsy rate started to decline.
The next fault was with the pathologists themselves, they were unenthusiastic, found increasing work loads wherever, and were less keen to do autopsies because it's hard work and smelly at that too, unpleasant. Then the hospital saw that they could get by without them and they cut the funds. Then a year or so ago we had this body parts fiasco, and the journalists got into it, and sold newspapers about a whole lot of nonsense, completely unsubstantiated, about illegal activities. Then there were the patients rights advocates as well. So these all combined to knock the autopsy on the head, as it were.
So how are we going to get these Oslerian principles back again? I think we should insist on a teaching hospital autopsy rate of around 10%, with some death reviews. It's not high. A lot of pathologists think it should be higher. Insurance people are interested in this too, to see that the quality of care in the hospital has some sort of audit, so it's important from an audit point of view. Only 10%, quite achievable, provided there are funds and staff to do them. We should encourage clinico pathological correlations which used to be the heart of the teaching medical school, the weekly clinico pathological conference, the daily demonstrations on the autopsies - some of these should come back, and we should encourage case based teaching.
We should insist that undergraduate teaching - pathology is taught by qualified pathologists and not by scientists who read up about the disease or the lecture the week before they have to present it. You might not believe this is happening but it is. We should facilitate appropriate organ tissue retention. You can't look at brains unless you fix them and take them out of the body. So neuro pathology - unless we are able to keep the brains after the body is buried - is in trouble.
And the last thing we could do is to take a leaf out of the pathologists book. Dr Jurgan Stahl(?) has just taken over the basic pathology sciences programme for the College of Pathologists, and he plans to create a basic sciences exam which is based on the first eight or nine chapters of the text book Robbins. So that the pathologists are going to have to learn what we used to learn thirty years ago in the medical schools. So they're going to be taught, and they're going to be examined on it. This will also be offered to undergraduates because they are all complaining that they are not getting enough basic pathology. So they will be able to sit for the examination conducted in basic pathology by the Royal Australian College of Pathologists. And it's possible that some of the other colleges might be interested in doing this exam too.
I think the other thing we could do is to encourage physicians and surgeons to recognise some autopsy, surgical pathology, or radiology - and I include radiology with pathology because radiology is the modern equivalent of morbid pathology. And I think there should be more closer integration, and that the trainee surgeons and physicians should spend some time in those departments, and the time should be recognised by the colleges as training time.
And the other thing we could do is to resurrect the pathology museums which are just falling apart - there are hardly any of them left - using modern technology and create an adequately documented national electronic autopsy, surgical pathology, and radiology museum using digital technology. It would cost money but it wouldn't cost a lot and it could be made available for everyone in Australia relatively cheaply.
That's all I had to say, then thinking about things in a broad general look outside pathology, the other thing that struck me was the increasing age - apart from the increasing lack of knowledge of the people coming for specialist training - the increasing age of those who are getting through, graduating from medical school. I think that's a very important point and I'm very pleased that Professor Harris made such an issue of it. It's something that we should take on board.
Thank you
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