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Maesha Deheragoda - Full Transcript

Maesha DeheragodaSpecialist Registrar at University College Hospital, London

Interview location: Wellcome Trust Building, Euston Road, London
Interview date: 24th April 2009

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SECTION 1

SA:  Maesha, tell me first a little bit about your family background.  Where are you from? I was trying to think from your name.

MD:  It’s a very long name... It’s from Sri Lanka.  I was actually born there and I came with my family to the UK when I was very young.  My father had a post sorted out – he’s a dentist, as is my mother.  My father had a job arranged here, initially, a training post.  And we joined him about a year later.  We were initially in Cardiff.

SA:  So you were a kid when you came here?

MD:  I was three years old, yes.  

SA:  So you don’t remember much of Sri Lanka?

MD:  I don’t remember it at all.  The first time I went back was eight years later – we used to spend out summer holidays there and it was lovely!  It was really incredible.

SA:  So do you now feel that you are British?

MD:  Increasingly I do, yes.  I really do.  I think because I was at school here, and university here.  I’ve never really lived for a long period overseas.

SA:  But was there a cultural difference – as a kid going to school were there cultural adjustments to make?

There was a lot of racismMD:  Oh absolutely.  Hugely.  I was at school in Doncaster, South Yorkshire, and myself and my sister were probably the only Asian people in school.  In the early 70s there was a huge wave of immigration to the UK and there was a lot of racism and I was very much exposed to that. You know, name calling all the time.  Constantly.  So it was really quite tough.  And my parents found it very hard as well because there wasn’t a huge Sri Lankan community.  A lot of Indian people came over, but our culture was so different that my parents were very, very isolated.  So there was literally our family in this town with nobody else!  And yes, it was difficult.

SA:  In those days was there protection from it?  Was bullying something that was recognised, and could your parents go to the school authorities and say, “This is just not on”?

MD:  Most certainly they could do.  But there’s only so much that can be done within the school building.  If your family and all your friends that you spend time with beyond school, and all the adult influences beyond the teachers, are strongly saying, “No, that’s okay for you to go and do that,” then of course it’s going to still happen.

SA:  How did you cope? Did you make good friends at school?

MD:  I did make good friends at school.  I think I was always quite fortunate because I actually think being female was an advantage -- you didn’t tend to succumb to the bullying as much because you have close female friends who form a little group around you, whereas I think if I was male it may have been more difficult.  

Of course in the 1980s there was an evident cultural change.  So I think that as we grew up, the 80s and early 90s at school were actually fine.  But I do remember those early days as being very hard.

“I’d love to be a doctor” 

SA:  So how did you go into medicine?  Did you not think of becoming a dentist?

MD:  I think my father would have quite liked me to go into dentistry, but I just did not find it interesting.  I used to help out in the summer holidays and things like that.  I always managed to get people’s tongues caught in the aspirator and it was just a nightmare!

Then I went to university to study natural sciences.  Again, that was a very cultural thing with my school because it was a state school and they had a history of not sending students on to higher education – certainly not to medicine.

SA:  Really?  It was just not on?

MD:  Oh absolutely.  It was all very working-class school; a lot of working-class families whose parents had no higher education.  So from about the age of 12 I desperately wanted to be a vet, to be honest with you – I love animals.  But that was just virtually banished from my thinking.  I was very much told, “If you want to go to university, do a science degree.”  No one from our school goes and does any of the professions, so...

SA:  And did you ‘absorb’ that, or did you think to yourself, “I’m not going to take that; I’m not going to have the lid put on me”?

MD:  I didn’t have the lid put on me.  At home my dad would say, “No, no you must go and do medicine.”  So at school I had, “No you can’t do it”, and at home, “You must do it.”  I think suddenly my father was horrified that I would waste potential, as he saw it, and it almost went the other way, because all I heard was “No, you’ve got to do medicine,” so I decided not to do it!  [Laughs]  It was classical teenage rebellion.  Having done my GCSEs I thought, “I’m going to be a scientist.”  I really didn’t want to be a doctor, I wanted to be a vet, and I thought I’d go and do a natural science degree at Cambridge, which is where I ended up going.

I actually went to school in Sheffield for two years because my father was so upset by this whole thing of school saying “absolutely no” to university.  So we went to a school where there was a tradition of sending children to higher education, which was tremendous.  Suddenly I started thinking, “Oh yeah, everybody’s doing medicine here!” and here was I who had got this place to do natural sciences.

[At Cambridge] I started seeing research as a scientist for the first time, and I realised that I was actually quite keen on the research, but I wanted to do it with humans rather than looking at biological systems.  We used to share lectures with the medics who were there, and they just did the most interesting things, wonderful things!  So I learnt about anatomy, and physiology... It was just so applied -- to human nature and the human condition -- and I thought, “I’d love to be a doctor.”  It was there that I really started thinking about it.  

I looked into changing over my degree.  But to be honest, Cambridge was very beautiful, but quite dull outside the University walls.  There’s a huge amount going on for the students, but if you went beyond the campus the actual city wasn’t vibrant.  I thought, “If I do medicine I’d love to do it in London or another big city”, so I applied in the final year of my degree and I came down to Barts and the London to do medicine, and I’ve been in London ever since.  I love London!

SECTION 2

SA:  And did you think right from the beginning that pathology was the area you’d go into or what?

I had some very inspirational teachersMD:  I had some very inspirational teachers.  I don’t know if you’ve met Paola Domizio? She’s wonderful, absolutely amazing!  I did look up to her as a heroine and think, “I’d love to do that sort of job.”

SA:  What was so special about the way she taught?

MD:  She was just very interactive.  A lot of people give their lectures and they just sort of talk at you, whereas Paola used to get the audience involved.  You have tutorials with her and you actually used to think... And she’s incredibly glamorous, of course, which always helps!  And beautiful, and I used to just think, “I’d so love to be like her.”  Everybody wanted to be Paola. [Laughs]  All the men wanted to marry someone like Paola!  She was just this amazing icon.  And she also made it very real. You could see what she was talking about; you could see why she was getting excited about the things that she was teaching us.  I think that really made me think pathology...I really wanted to do it.

I thought I would miss the patientsBut then I started getting very keen on the clinical side and I thought the drawback with pathology was that I would miss the patients, miss people.  So I didn’t go into pathology straight away.  I went into paediatrics for three years.  It was whilst I was in paediatrics that I thought, “Actually I do really love pathology.”  I used to look at my peers – as you do when you’re a trainee – and they were so loving what they were doing as paediatricians and I thought, “I just don’t have this love for the subject”, whereas I really did have a love for pathology.  And I thought, “If you are going to do something for the rest of your life it’s important to love it.”

I never looked backSo I applied for pathology at that point and I went back to Barts and The London.  And it was wonderful, I just never looked back.

SECTION 3

The modern face of pathology

SA:  Most of the people I have interviewed so far are much older and they were trained in a very different way.  So I’m wondering how things are now, because I know that since the Alder Hey debacle the rates of autopsy and so on have gone down very greatly, and yet you have to have a critical mass of postmortems in order to qualify.  So how has training changed over the years?  What is modern training like and how good do you think it is?

Training’s changed hugelyMD:  I think training’s changed hugely.  In fact even for us it’s changed just within the last three years or so.  When I entered I was probably the last year of people going in and doing... Basically your training was made up of an apprenticeship at the hospital you choose to train at and your learning curve was based on the numbers of cases you saw.  It was very much up to you to learn, and having good trainers around you to learn from.  As you say, the autopsy numbers were relatively low so you did what you could, and you were meant to make up your training by going to other places where they see a lot more.

SA:  How many did you have to do to be able to qualify as a pathologist?

MD:  Twenty per year for four and a half years – or the equivalent of four and a half years.  So that’s the quota that you need to reach.  What’s happened now is that, across the board, medical careers are changing, and with MMC (Modernising Medical Careers) coming in, we now have an SHO (Senior House Officer) school -- which I think is a wonderful idea.  All the SHOs get together and, rather than being based at one hospital, you are based at different hospitals but you have all your teaching centrally as a group of SHOs.  You’re taught all about the body systems... I almost get envious sometimes when I see the SHOs today because I think, “I’d love to go to that as well.”  Everybody, no matter where they work, gets this sort of basic core training.  

That’s how it’s changed.  And it’s changed to workplace-based assessments, so [today’s trainees] are assessed on the everyday job that they do, whereas  for the next two years or so, until my sort of dinosaur age is gone, we are assessed every year on our surgical pathology, our cytopathology, and our autopsy pathology by the consultants who see us.  It’s in the form of a sort of tick-list, a scoring system of different attributes we are supposed to have acquired over the year as they train us.

SA:  So it’s their responsibility to see that you get the skills that you need?

MD:  Yes, absolutely.

SA:  So it’s quite dependent on how committed the consultant is to teaching?

MD:  It most certainly is, yes.  So it is very variable across the board.  I think there are certain objectives -- in order for them to have trainees at a centre they have to demonstrate that they have achieved these training objectives, and these trainers’ training objectives as well.  But you’re right; it is very dependent on where you are.  I guess it’s the same in any specialty – [it depends on] the things you’re exposed to, the work load you’re exposed to, the number of other trainees around you, the attitudes of the consultants and the time that they have.

SA:  And how’s it been for you?

MD:  Wonderful!  I’ve just loved it.  I’ve been very fortunate; I’ve been so inspired by so many people to do what I do.   There are obviously times when I get very tired, but then everybody’s the same. 

From microscope to computer

SA:   So how much is pathology microscope-based these days?  Or is a lot of stuff done on computers and things?

MD:  Virtually 100% of it is still microscope-based.  We are bringing in some systems to use microscope scanning of slides – we’ve just got it at UCH, a new system whereby we can scan a slide in and then you can move it to different positions on the screen and magnify it.  We’re using that mainly as a teaching tool at the moment.  And again, it’s just being brought in gradually.  But everything at the moment, all our teaching sessions, is done over a microscope.

SA:  And how good to do you think the scanning of slides is?  How appealing is the technology?

The systems I’ve seen are amazingMD:   I think it’s pretty good actually.  The systems I’ve seen are amazing – you can zoom in to such high power, and you can actually navigate your way around the screen.  So you have not just the image that you’re trying to look at but you know exactly where you are on the slide and it’s wonderful.  So many different people can see it at one time, and there are amazing advantages. Once the slide is scanned in you don’t actually need the microscope there.  It’s just linked in to different computers so you’re literally sitting at a computer, the map of the slide is at the side and you can just use your keyboard to move around in.

SA:  So you could share it with anyone anywhere, worldwide?

MD:  Absolutely.  Which is the way the world is going, actually – all health care.  I think it’s wonderful.  It’ll be great – I can’t wait to use it!  

SA:  I was over in Belfast earlier in the week with Peter Hamilton of iPath...

MD:  Oh yes, well it’s his system we’re using.  It’s brilliant.  He came and demonstrated it to us and everyone’s just loving it.  The consultants love it because they can teach with it; and we’re really liking the idea of it because we’re seeing things that otherwise... You know, if you’re on an attachment you might see an interesting slide, or if you’re there for a teaching session you might see it, whereas everyone will now have [access to] this library of images that you can go to -- for exam revision, and just for general teaching.  It’s incredible.

“A very visual field”

SA:  One thing that has come up strongly in my interviews is that, okay, some people are fascinated by the processes of disease, but they have to have certain attributes to become a good pathologist – visual sense and that sort of thing.  What are your interests outside of science and do you think you are a visual person as well?

MD:  Oh hugely.  Absolutely.  It’s interesting because when people meet you they always assume you are going to be ‘a scientist’.  But as I said to you, I always wanted to be a vet.  That was my main thing, and really my sort of interest comprised animal-related pastimes and art, really.

SA:  Are you an artist, a painter?

Many pathologists are very good artistsMD:  I am indeed, and I love it.  I go to exhibitions.   I like design in all its aspects.  Beautiful furniture and things like that.  Our home is filled with canvasses.  We have many friends who own art galleries, and we’re always there looking at work and getting interested in new artists.  We’re very interested in some of the artists coming out of Asia at the moment.  Some of their work, and some of the experiences they’ve been through and that they introduce into their work, is just incredible.  I think that sort of lends itself to pathology because it is a very visual field.  You’re constantly looking at patterns and colours, and the relationships of them all to make a diagnosis.  I find that many pathologists I know are very good artists or love the artistic world.

SA:  When you first looked down a microscope what was it like?

The duodenum is the prettiest part of the body! MD:  It’s very beautiful.  When I first looked down a microscope it was quite terrifying actually, because you’re there to diagnose disease correctly.  So when you’re a trainee it’s quite scary and a lot of the junior trainees I meet will say the same – you don’t see the beauty of it until you’re more relaxed, and more sure that you’re not going to mess it up.  But now I look down it and... I just think the duodenum is the prettiest part of the body!  It is just stunning.

SA:  What’s so stunning about the duodenum compared with other tissues?

MD:  It’s pink and frilly.  It’s just a beautiful organ.  It’s really amazing.  I’ve done my PhD on it, and it’s got the most interesting cells.

Respect for the dead

SA:  Let’s go back a bit.  Before we really started this interview we were beginning to talk of your first experiences of death.  When was that, and when you started in medicine, were you prepared by your tutors for facing it?



MD:  I was very fortunate, nobody around me died when I was a child, so it was only when I was at medical school and we had the old, traditional anatomy teaching where you had a cadaver.  A group of you would work on this, and we had this wonderful introduction to our cadavers.  We had this sort of ceremony... It was amazing.

SA:  What, before the whole thing started?

MD:  Yes, absolutely.

SA:  And whose idea was that?

MD:  That was Dr Whitmore who was over at Queen Mary’s Medical School. We were just introduced to the cadaver, and he read a poem which had been written by one of the family members of one of the cadavers that we had to work on.  It was really quite moving, and it made you think of that person.  Overall the theme was about respecting that person as someone who really wanted to teach us and educate us.  His – or her – own wishes (because it was anonymous) were that we would be able to learn from the body and do good in the world as a consequence.  It was really quite wonderful and moving.


SA:  And were you expecting this – was it a tradition that you knew about?

MD:  I don’t know to be honest.  I haven’t spoken about it to anyone beyond my medical school, but I thought it was wonderful.

SA:  Did you then as a group discuss it?  Because I should imagine quite a lot of youngsters were seeing this for the first time and harbouring their own anxieties...

MD:  Oh absolutely, they were.

SA:  Were you given a chance to talk about it?

MD:  We were given a chance to talk about it as groups and ask questions at that time. And then the next session we were taken in [to the dissecting room], so we had a week to digest what had been said and everything.  And it was interesting because some people actually left the course when they saw the cadavers for the first time, because it was so real I guess. It was quite surreal in many ways.

“It’s just such a privilege”

SA:  Was it?  What did you feel, and how long did it take you to develop professional distance from what you were seeing?

Poster presentation with colleagues George Webster and Nick Church at a gastroenterology conference in the USMD:  I’m quite... I wouldn’t say I’m a very emotional person, but I think my emotions are out and that’s it, it’s done.  My first time I went in there and I got on with the class, but all of the time I was very aware of that poem and that person’s wishes and I just went home and had a good old cry for about half an hour.  I thought, “This is quite overwhelming” and then I just got on with it. That’s me all over.  It’s just the way I cope with things.  But I think a lot of people were really quite affected by the whole thing.  The boys were boys, they just go in and they make jokes and they’re silly, and they also make a little bit of fun as well...  I don’t know, the boys just seem to be fine with it.  But it was an incredibly privileged experience, the whole thing.  

My partner – he’s not medical -- when he asks me about [my work] now I always say that even with living patients it’s just such a privilege to be able to do it.  I count myself very lucky.

SA:  What sort of rituals do you use now when you go to do an autopsy – do you have rituals?

It’s still very much the personMD: There are two things I always do.  One thing I learnt is that you don’t emotionally involve yourself with that person.  I learnt that because I read an obituary – or someone showed me an obituary of someone who had died and who I had to do an autopsy on and it was the worst thing in the world.  It was purely coincidental – just an actor who had died in the street, and then I was on autopsies the following week and they’d died just around the corner from the hospital I was working in.

SA:  How did you manage?

MD:  Again it’s just professionalism.  You just get on with it.  But afterwards I realised... I just didn’t enjoy the experience.  So a) just distance yourself from it in whatever way you need to; and b) always be respectful.  So even when you have people watching, my concern is always that you’ve got to be respectful to the dead person and their family and their wishes.  And at the end of the day you do a good job, because that’s what you’re there to do.

SA:  To what extent do you feel this is just the shell of a person who has gone, and to what extent that this is still the person who lived?

You can’t divorce yourself from it allMD:  It’s still very much the person because the diagnosis, the cause of death that you’re giving, is still very relevant to their family, and so relevant to the doctors and everything.  You’re closely involved in that person’s life even though they’ve died.  So you can’t entirely say, “This is a shell”, or “It’s something empty”.  It’s something that is ongoing in many different ways, and you’re part of that ongoing process – whether it be audit of medical procedures, whether it be putting the patient’s family’s mind at ease, that’s most important.  So when you’re there doing it, you’re there on a mission.  But you do see things and you think, “Oh, that must have been so painful...”  It’s just part of being human I think, you can’t divorce yourself from it all.

SA:  And has this affected your religious outlook at all?

My family are BuddhistMD:  My family are Buddhist, and that has sort of informed my philosophy throughout my life, and I don’t really... I think it just adds to it, if anything.  But then because we’re Buddhists we don’t really have a God or anything like that.  It’s really about living your life in a good way, not harming other people by your actions.  So I think medicine, having respect for people, fits into that philosophy very well.  So I don’t really have any clashes in that way.

SECTION 4

“The pancreas...my real passion in life”

SA:  Let’s go back to your PhD...What aspect of the duodenum did you do for your PhD?

Amazing teachersMD:  Well I did the duodenum because I do think it’s just so beautiful, it really is.  But also because it comes attached to the pancreas which is my real passion in life.  I was very fortunate because I came to UCL (University College London) and I worked with Marco Novelli, who’s the professor of GI pathology over at UCL.  Marco was another person who was very inspirational to me.  He’d done his research and he was hugely respected amongst everyone in the hospital, and did really exciting stuff in his research, so I thought, “I’m going to attach myself to him and learn all about GI pathology.”    You get people who are just amazing teachers, and he’s one of them.  Also he’s an excellent pathologist.  

The survival rates are so poorSo I started doing a lot of the multidisciplinary team meetings with the clinicians with him, and one of the meetings I was at was the pancreatobiliary meeting – we do small bowel tumours, pancreatic tumours, biliary tumours, and I just found it fascinating.  I found the tumours fascinating -- pancreatic cancer is one of the most challenging cancers you can look into because the survival rates are so poor.  I was fascinated by that – all aspects.

SA:  So what questions were you asking?  What most intrigued you?

MD: Well I think what intrigued me was: are there any better ways of diagnosing it?  Better ways of treating it?  Also, there are groups of tumours which you tend to see only in women, and certain parts of the pancreas, and certain tumours that predominate in men, and I was just fascinated by this whole thing.  I’m still fascinated by it – it’s not something I’ve done a huge amount of research towards because my thesis was all about the small bowel.  

How I got into that was that one of Marco’s bosses was Sir Nicholas Wright, and Marco introduced me to him.   Nick Wright said, “What are you interested in?” and I said pancreas, or small bowel.  We had lots of patients coming in with a disease called familial adenomatous polyposis coli, FAP for short, and they develop lots of tumours, lots of polyps in their colon.  But they also develop polyps in their duodenum.  Nowadays everyone has their colon taken out to prevent the development of cancer, but they do still have duodenal disease.  So that was my research.  

We discovered that they carry a mutation in a gene called APC, and when you do get mutations in certain places in the APC gene it seems to have an effect on stem cells within the bowel.  So that was what my research was about, but I’m still writing up my thesis.

SA:  And what are you discovering about why pancreatic cancer is so serious?

MD:  In terms of pancreatic cancer, I had to leave that to do my thesis and I have only just gone back into it.  We’re just looking, at the moment, at proliferation, and preparation for proliferation, in tumours in the pancreas.  That’s really as far as I’ve got because I’ve had maybe a year out doing the small bowel stuff.  But I do hope to continue in that field.  I really do love it.

SA:  Are there still lots of things that are not understood about it?

MD:  Absolutely. Tons of things.

SA:  And have you sussed out why there should be different presentations in men and women?

MD:  No, and that’s something I’d love to look into.  There are various theories, embryological theories.  It’s not so much the main pancreatic cancers that we think about, but there are some other cystic tumours of the pancreas which I’m interested in – their progression – because some of them tend to be more prevalent in women than in men.  So it’s that sort of direction I’m wanting to look at...once I’ve done my thesis!  [Laughs]  It seems to be taking forever.  It’s actually not a difficult thing to write up, it just needs you to sit down and do it.  But I’m afraid I’ve inherited my dad’s brinkmanship – there are high levels in me!

SECTION 5

Educational outreach: enthusing the next generation

SA:  So where did you do your elective?

MD:  I went to Toronto, to the Sick Children’s Hospital there, and I did paediatric cardiology.  It was fascinating – I do love paeds.  

It’s a real passion of mineYou probably saw the article in the Bulletin [of The Royal College of Pathologists] about the schools thing?  That’s another thing I do in my free time -- a lot of work for students within inner city areas.  It’s a real passion of mine because that’s something that I can relate to so well.

SA:  What do you do?  You go voluntarily to schools to give talks?

MD:  Yeah.   I’ve always been interested in doing it, and now with the Royal College I’m trying to develop some outreach projects which are based in museums.  We’ve gone to the Hunterian Museum.  We’re looking at doing something at the Centre of the Cell at Barts and the London.  And I’ve done an outreach model which will be a huge amount of fun at the Natural History Museum.  [Developing it] was just amazing, one of the best experiences of my life!

The Black Death reappearing in LondonIn the new Darwin Centre they’ve got the David Attenborough wing and they’re going to be creating a suite for school students.  The students are going to be faced with a fictional scenario of the Black Death reappearing in London and they’re going to be asked how they’re going to prevent it and things.  So [my input] was part of the scenario.  There are different film clips: there’s a journalist being interviewed and an infectious disease expert, and then there’s this great scene, which I co-wrote with them and I had to act in as the pathologist, where the pathologist has done an autopsy on someone who’s died of Black Death.  It’ll be quite exciting – it’s going to stop there and then the students are going to be asked to discuss what their disease prevention measures would be.  If they answer correctly they’ll get this nice video clip at the end saying, “You’ve contained it.”  If it’s incorrect there’ll be masses of deaths!

SA:  So what did you, as the pathologist, bring out that informed the students?

Students love the gory sideMD:  We had to write a script which told the students of the salient features of bubonic plague; why I was particularly concerned that this could reach epidemic proportions -- because it had spread from the lymph nodes into the lungs, so the patient was likely to pass it on. So that was it really.  Of course students love the gory side – they just do, they love it.  People think they should protect their children against all this, but they love it! We had this great lymph node with pus oozing out, because we used these amazing make-up artists.  Little things like that really got them going.  It was fabulous.

SA:  These weren’t kids who were necessarily going to go into medicine?  It was just trying to interest kids generally in applied science, was it?

MD:  Yes, absolutely.

SA: What kind of impact do you think it had?   

We just wanted to get pathologists out thereMD:  They were quite keen to have a female in that role, because in my experience, when people think about pathologists, they think about forensic pathologists, or CSI nowadays, they don’t actually realise that pathologists are integral to health care in many different ways.  So I think that having someone there [of whom] people can say, “Oh, she seems really normal!”  And it was a pathologist, rather than a surgeon or a paediatrician – the glamorous specialities are always on TV doing amazing things and living incredible lives and looking great on-screen.  So we just wanted to get pathologists out there doing it so that children would see them and think “Oh, that’s a really interesting thing....”  

So I do outreach work based on trying to get the younger generation – those people who are thinking about what they want to do with their lives – to start thinking about a) going into medicine, but b) thinking about pathology.

Being a role model

SA:  Have you been to talk to inner city schools – places like your school that don’t encourage kids to go into higher education or expect much from themselves?

Were you at private school, miss?MD:  Yes, definitely.  You go to those schools that don’t have a tradition of sending people... You go and speak to them and they’re, like, “Wow, what did you do, miss?  Were you at private school, miss?”  It’s nice to be able to say, “Actually I wasn’t.  But yes, this is what I’ve done.”  With all the adversities you go through you have to have that presence of mind just to go keep going.  It’s so important for them to have someone tangible so that they can think, “Actually that person looks really normal and they’ve done it, so I can do it.”  Not models who have done all the things they should have done at school, and family who have all been there already and have the contacts.  It makes me feel a lot better, and it gives me a lot of fulfilment to be able to give something back in that way.

I also work for a company that does teaching – they go out and talk about medical careers.  That’s what really put me in touch with all the inner city schools and the students there.  It’s difficult now with all the full time clinical work, but I still try and do this.  I still advise them from time to time.  Going out to the schools is for this company, but the rest of the stuff is with the Royal College [of Pathologists].

The disease detectivesSA:  Tell me about the “disease detectives” project you did for the Royal College for National Pathology Week.

MD:  My event was “what is pathology?”  I was with this wonderful team of people and what we actually did was have all these inner city school students (again) come along to learn about a particular pathologist, present day and historical, whose research had a massive impact on society.  So we talked about people like Alexander Fleming and the discovery of penicillin and how it changed the outcome of the war, and then all the way through to Robin Warren, a modern day GI pathologist who discovered Helicobacter pylori.  

The idea was that they would go away and think about these and think about how this research worked and the impact it had had on their own lives and the lives of their friends and their families.  They had to produce a play to reflect it.  It was so much fun.  That’s the other thing I like about working with young people – they’re just so full of energy, and they teach you so much.  So it was wonderful, and they all loved the session, which was the main thing.
 

SECTION 6

A fine balance: research and clinical practice

SA:  So where do you see your career going?  Do you see it going towards laboratory research or more towards public education?

MD:  I love the public education side.  I love the research as well.  I just love everything, that’s the whole problem!  There are so many choices.  So, I love my diagnostic pathology; I love my teaching and the outreach work and the public engagement work; and I also love my research.  What I’ve actually done this year is made the decision that I’m not going to go full time into a research career, because I think it does take me away from my diagnostic and public engagement side.

So how I’m going to compromise is I want to be a consultant pathologist working in a teaching hospital, working with a team who are very interested in research, but doing collaborative work with them.  So maybe not being the primary person who’s coming out with the big ideas that are going to have huge amounts of funding behind them, but being able to contribute in a very active way to an ongoing research effort.

SA:  The big question is how possible is that?  Because various people have identified the split between research and clinical practice.

MD:  I think in fact...Nick Wright’s sort of work is very much the pure science work.  He has a huge lab that does excellent work, but his lab doesn’t do diagnostic work, and he’s very much involved in the medical school structure as well.  Whereas a lot of the pathologists I meet nowadays who have PhDs, they are diagnostic pathologists who do collaborative research.

SA:  And it works, does it?

MD:  It works, and it’s probably the norm.  The problem that others [you spoke to] were probably getting at is that nowadays in order to publish in anything, you really have to commit yourself to a research career or you’re not going to be able to do the volume of work or get the funding to enable you to publish in journals like Science and Nature.  If you want to keep a lab in a very prominent institute you need to be able to demonstrate those sorts of publications, and you can’t do that when you’ve got 50 patients waiting in clinic for their results, and you have to do that and do your research.  

The demands on you as a pathologist are enormousSo that’s where the compromise comes in.  And I think it’s inevitable.  As the NHS is going towards excellence in patient care, your amount of work in terms of admin time increases, the turnover times have to be very, very quick nowadays, so the demands on you as a pathologist in a department are enormous.  It’s the way that the healthcare system is going, so I think that divide is actually necessary now – you either do go full time into research and go down that route, or you try and combine your research, as people have been doing, but understand that you’re never going to be a ground-breaking scientist.

SA:  So what do you do?  If you say you have to have the time and the commitment to be able to publish papers in the major journals to get your funding, what can you do?  You would expect the other people you are collaborating with to put in that kind of time and effort, would you?  That’s do-able is it?

MD:  That’s do-able...

SA:  And you’d have your name on papers?

A perfect example MD:  Yes, you’d have your name on papers but you wouldn’t be the first author. So you wouldn’t be able to dictate terms and things.  And they’d be small projects that won’t be in Nature or Science, but will have an impact on patient care locally or nationally.  A perfect example of that is, before I went to do my PhD, I was involved in a collaborative research project here at UCL that has changed the way a condition called autoimmune pancreatitis [is diagnosed].  The work that we did here, which was just a very simple immunohistochemical piece of work, has really changed the way that disease has been diagnosed.

SA:  In what way?

MD:  It’s a disease in which the diagnostic criteria involved having a biopsy of the pancreas.  But people have described that you get IgG4-positive plasma cells being elevated not only in the pancreas but in other organs as well.  So our study was actually looking at biopsies of other organs to see if we could use those extra-pancreatic biopsies to diagnose autoimmune pancreatitis.  It wasn’t a novel piece of work, it was using established... The finding about raised IgG4 in other organs had been described, but had not actually been used, assessed as a diagnostic technique.  

They’re very powerful pieces of workSo things like that, they’re very powerful pieces of work, they’re small pieces of work but they do have a huge impact on patient care.  So that’s what’s satisfying for me.  I know that I’m not going to be first or last author on a Nature article any more, but it doesn’t upset me.

SA:  You’ve come to terms with that, have you?

MD:  I’ve completely come to terms with that, yes.  But having said that, there are a huge number of trainee pathologists who I’ve worked with at the Pathological Society, so people I know nationally, who are going down the route of choosing to do pure research.  And what they will do is that they will come back and do their PhDs, and then part way through their training they’ll apply for a clinician-scientist post, which will enable them to do [research].  I think it’s about a third of their time is diagnostic time and the rest of the time they can really focus on research.  

Those posts are essentialThose posts are essential for the real pathology researchers because they can then have that time to dedicate to building up a team of researchers around them, getting those papers in, writing those grants, and getting the money.  But they will have to give up a large part of their diagnostic workload.  Also their time to do activities like teaching, I imagine, will be reduced. And public engagement work will be reduced.  So for me on a very personal level I just wanted to have that human contact that, in a sense, allowed me to be flexible enough to do the outreach work.

Working in a multidisciplinary team

SA:  In your clinical work do you actually meet patients as well?  Do you have patient contact or not?

MD:  I don’t.  It doesn’t mean it’s impossible in pathology, because certainly if you go into cytopathology you can go and do clinics and sit in with the endoscopist. But to be honest, I don’t really miss it because I get so much clinical input from the team of gastroenterologists we work with.  It’s so much fun, you discuss the patients; they tell you all about the patients so that it’s almost as good as meeting them.  And I think that’s wonderful about the job...

SA:  So these multidisciplinary teams really work well?

MD:  Oh they’re fantastic, they really are.

SECTION 7

“Too friendly to be a pathologist!” 

SA:  And there’s respect from you all for your different expertise?

A real stereotype MD:  Um, yes I think so.  There’s still very much a perception that pathologists are...There’s a real stereotype around them, and it’s true to some extent, I have to say.

SA:  So what is the stereotype?

MD:  That they’re people who don’t want to be in the public eye; that they want to lock themselves away in their ivory towers.  In fact, when I was applying for a post to be a pathologist, to get an SHO post, I was told at interview that I was actually a bit too friendly to be a pathologist!  It was almost tongue-in-cheek, but there’s an element of truth in it.

SA:  How funny!

MD:  Yes, isn’t it incredible?  He thought I wouldn’t fit in because I was too outgoing!  Even my friends, the gastroenterologists that I know, who I work with and see socially, say, “Oh, some pathologists are a bit odd, aren’t they?”  And you actually think, “Well yes, they are!”  I don’t know why, but it puts us in a bad light because it makes our work look not as important as theirs, and that’s what I’d like to change, if I could change anything.

SA:  And do you feel there is a stigma within the medical profession, that you’re not the hands-on people?

There has to be a change in perceptionMD:  Yes, yes, that your job is sort of secondary.  There has to be a change in perception.

SA:  When you went into pathology did you have to overcome those kinds of prejudices for yourself?

MD:  Yes certainly.  I mean when I left paediatrics...When  I got my job as a paediatrician -- out of about 98 people I think I came number one or  two, the first or second choice, I got very much the golden rotation at Guy’s and St Thomas’ and real golden girl status: “This person’s going to make a huge name in paediatrics.”  Then I changed direction to do pathology, and suddenly overnight I became the sort of black sheep.  It was very hard.  

SA:  How did you manage it?

You grow yourself a very thick skinMD:  I think my own bloody-mindedness.   I think when you’ve been faced with adversity since a very young age you grow yourself a very thick skin and you just get on with it.  That’s what I’ve always done, so for me it was a case of just getting on with it.  But I always make those decisions in life having really thought about the outcome.  And for me the outcome of going on to something I would really enjoy, and that I could see myself doing for the rest of my life, was so much stronger than the questions, “Oh what are you doing?  It’s not necessary for you to come to this teaching session anymore because you’re leaving us.”  It goes over your head after a while.

SA:  So you were really sort of shunned for a while were you?

There’s a definite hierarchy in medicineMD:  Oh definitely.  There’s a definite hierarchy in medicine.  I mean, medicine is just one of the most hierarchical things you could go into, like the law profession in a sense.  And even within medicine there are the sorts of golden specialties that all medical students want to do, like surgery, like paediatrics.  Even within surgery there are hierarchies – everyone wants to do brain surgery.   It’s crazy.  But within medicine pathology is seen as the sort of thing you do if you can’t get a job doing something else.  And it’s shocking, it’s really shocking.

But it’s interesting, because now celebrity culture is a big thing,  everyone’s lifestyles are becoming a huge thing, and there’s a massive sea change where people are beginning to say, Everyone wants to do brain surgery“Actually I don’t want to do the really long hours it takes me to train to be a surgeon.  I would like to come into a quieter speciality.”  It’s nice for us because we are getting more people coming in.  But I’d just love it if people said, “Actually, I really love pathology,” rather than choosing it just because the hours are better.

But that’s the change we’re seeing.  It is becoming increasingly popular – a huge amount of people are applying for it, but I think some of them are applying for lifestyle reasons rather than because they are really excited by it.

Misperceptions of pathologists

SA:  I was going to ask you whether recruitment had picked up since Alder Hey.  You yourself must have come into pathology about that time?

Unfortunately it was society’s perceptionMD:  Yes, and all your friends tease you, “Oh, you’re going to be a baby killer”, because of course I was a paediatrician.  And these were doctors!  I just used to laugh and say, “Oh don’t be ridiculous.”  It was just mad.  But that was just their perception.  Unfortunately it was society’s perception, so they were a reflection of general society.

SA:  But is that changing?

MD:  I hope so.  I mean certainly among my friends—they think I do a great job.  Especially with the Natural History Museum project.  They were, “How did you do that?  A pathologist doing it!”

SA:  Is that because medical students aren’t taught much pathology nowadays?

What inspired me was pathologists like PaolaMD:  Absolutely; they don’t see it now.  I was very lucky because I had Paola Domizio teaching it, but nowadays they don’t have the formal lecture-based teaching that I used to love when I was a medical student, so a lot of people just don’t see it.  This is why I want to get out there early, before they get to medical school and are thinking about it.  They’re already thinking, “Pathology is something I need to look into”, because otherwise they don’t see it at all until they’re out on the wards.  Being asked to trace a biopsy result is probably the first time they speak to a pathologist.  I mean, they do see it in little teaching chunks in their curriculum, but really what inspired me was having pathologists like Paola out there and being able to see her as a very real icon.  Nowadays they just don’t see enough people, it’s incredibly sad.

SA:  How else can you change things?

MD:  The College is doing it through the National Pathology Week, which has really made an impact.  They had a few exercises last year which were for medical students, and were fully subscribed, where they came in and had a chance actually to see how we cut sections, why it takes so long to get certain specimens analysed and things like that.  And they got a chance to play with the microscopes and things and they really liked it.   

I’m London regional coordinator for Pathology Week this year (2009), so I’m trying to get some more exercises for medical students where they hear about the research as much as anything else and really start thinking, “Wow, that’s a field where I could make an impact.”  Because you might not see individual patients, but you certainly have the time to make an impact that affects a huge number of patients.  So it’s just getting enough keen people out there to make the difference.

SA:  Obviously your outreach work is a highlight -- but tell me about some of the memorable things that have happened in your career.

MD:  That’s a very difficult question...I think seeing things like the cystic tumours of the pancreas, that’s why I love them so much.  There was a pregnant lady who had one.  She had a tumour, a cancer, that had developed from one of these cystic tumours – because they show a range from being benign to malignant – that really interested me because it suddenly opens your eyes to, “Wow, why is this only in women?  Why is it only women of a certain age?”  That’s one thing that really got me thinking.  And certainly, “Why has no one else looked into it?”  So those things stimulate me.  

I suppose the other things in my career are doing the multidisciplinary team meetings.  I meet some really lovely clinicians who are really keen to do research, but a lot of research is tissue-based, so they need key pathologists.  And getting involved in their research projects where you’re a team but all from different disciplines has been amazing.  I think those are the main things really.

SA:  And what about your husband-to-be – what does he do?

MD:  He’s an investment banker and now runs his own private investment company.  So he’s completely non-medical, and has no family members who are medical.

SA:  But is he interested in medical things?

MD:  He’s absolutely fascinated.  And it was amazing with him, because you really do see the public perception of pathologists.  “Oh you just cut bodies up, don’t you?” That’s what I got from some of his friends when they first met me!

SA:  When you had all those kids who came to the Hunterian Museum during Pathology Week, did you find many of them saying that?

MD:  Absolutely.  “Oh you’re on CSI!”  Or, “No, I don’t know what a pathologist does.”  Or, “Yeah, you cut people up; you investigate murders.” You’re either Quincy or you’re from CSI or they have no clue what you do! [Laughs]  So there’s a lot of work to be done out there to change perceptions.  

You can’t sit in your ivory towerWhat interests me and what I really want to try and get across for National Pathology Week this year is that you can’t sit in your ivory tower anymore because the trainees who are coming up under you need to be enthusiastic about the specialty otherwise your own work is going to suffer.  So it has an impact on all of us.  It’s important for us as a profession to change those ideas.

SECTION 8   

A glass ceiling?

SA:  Tell me, one last question, as a woman have you found that there is a glass ceiling?  Have you found yourself blocked in any way?

Everyone meets stumbling blocksMD:  I think everyone meets stumbling blocks at various stages in their career which may or may not be related to gender or race, etc. To me they are crossroads as opposed to blocks.   Personally, I have always been supported by very strong women in my career.  My clinical head of department is female and she’s incredible.

SA:  And what about your mother?

MD:  Oh yes, she’s a force to be reckoned with!  She’s amazing.  And I’ve always had very supportive people.  My husband-to-be is very supportive.  My best friend is a GP but she’s always been quite a formidable person as well, incredibly motivated.  So in a sense I’ve surrounded myself with these people.  I have come across obstructions at different points in my career, but I think I’ve always managed to find support.

SA:  So where have been the obstructions?  The first was obviously at school, but was that a gender thing or not?

Quite hard to break into as a womanMD:  I don’t think that was so much a gender thing, I think that was just a race issue.  The other areas that I’ve encountered it are in the speciality – certain fields are very much a man’s field.  It’s difficult to talk form my experience because certainly the GI team that I worked with was very sort of male-dominated but they’ve accepted me quite fully and I’ve never ever had any limitations there.  But certainly things like forensic pathology are still male-dominated and are quite hard to break into as a woman, but by no means impossible.

I came to a personal crossroads at the point where I had to decide whether to pursue a research career or not. I can’t describe it as a glass ceiling as it was not a gender-based process.  It was a crossroad where I had to make a decision for the rest of my life – to pursue research and achieve highly in that field, or to have a balance between diagnostic work and research.

There are very capable female scientists and clinician scientists out there – people like Fiona Watt [deputy director of Cancer Research UK’s Cancer Research Institute] who works in Cambridge and who has a family.  There’s also Rebecca Fitzgerald in Cambridge, for whom again family is important.  They balance their careers with family very well and pursue high calibre research, demonstrating that it is not impossible.

SA:  And those are women in medicine who have said that it’s not incompatible with having a family?

The family contextMD:  Oh they feel it’s completely compatible.  Just go for it!  I think it’s [a matter of] having that conviction.  But people are so different aren’t they?  Some of the female trainees I have worked with during my time in pathology come from cultural backgrounds where their role as a female is perceived to be relatively strict – they have certain expectations that their family creates for them.  They can’t veer beyond that role, so [ideas] of doing half the things that I’ve done in my lifetime would be completely rejected by their families, by their cultures.  And they don’t push past it; they don’t want to push past it.  Maybe the family context makes it impossible for them to push past it.  

SA:  And are you wanting a family – is that part of your plan?

MD:  Maybe, but certainly lots of animals!  [Laughs] I would also like to keep up my diagnostic and outreach work and research too.  It will be tough, but I’m more than happy to take on the challenges it will bring and I’m lucky that I have very supportive parents who are also looking forward to getting involved with the challenge!  I think because I have come through from quite a tough background I would be so upset if I had to give up anything that I’ve worked for.  That’s sort of intrinsic to me.  So it’s a very personal thing that I keep contact with all of these things.  But for a lot of women it’s not the case – they don’t have the opportunity, the contacts I’ve had.  

I’m really privilegedI’m so grateful to people like Nick Wright for putting me in touch with the PathSoc.  All the people I’ve met through that... I’m lucky.  I’m really privileged in that way.  There are a lot of people who would love to have what I have, but they don’t because they haven’t had the opportunity.  

ENDS

 
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