Sebastian Lucas - Transcript Summary

Sebastian LucasProfessor of Clinical Histopathology at Guy’s,  King’s and St Thomas' Hospital

Interview location: St Thomas' Hospital, London
Interview date
: 26th July, 2007

Key Themes: Alder HeyAutopsy, International Perspective, Legislation and RegulationMentors and Influences, MotivationRelationship with clinicians


Profile | Transcript Summary | Full Transcript


Section 1

  • Talks about his path into medicine from a non-medical family.  Studied at Oxford, then moved to University College Hospital: “I've been in London, apart from spells in Africa, ever since.”
  • Discusses his decision to go into pathology, which he was finding very interesting.  He could not face the thought of “looking at chronically ill people day after day” , and wondered: “is there a bit of medicine which is problem-solving?”  Pathology was the answer.  “35 years later, that's what I still like about pathology: it's problem solving.”
  • Describes the various roles of a hospital pathologist, including diagnostic histopathology, cytology, and autopsy work.  He is very involved with autopsies, and comments: “How much contact you have with people depends what case-mix you're looking at and how interested you are in feeding back the results.” He personally makes an effort to meet relatives of the deceased: “I go to lots of inquests, and it's an absolute golden rule -- and I make sure trainees know this -- that when an inquest is over you go and shake hands with the relatives... It's the only way pathologists are ever noticed.”
  • Gives some examples of where the information he has to impart may not be what the relatives want to hear.  The other interested parties are the coroner and the patients’ doctors.  His own motivation is simply “to work out what happened and why”. 
  • Acknowledges that he is unusual in having “carte blanche to do whatever I think is required to get to the bottom of a case, without very many inhibitions, financial or ethical. I don't mean ethical in the moral sense, but in the sense that 'you can't do that because it's against the Human Tissue Act'.”
  • Talks in at some length about the different considerations in doing an autopsy.  “One has to factor in time versus depth of detail.”  Ultimately the aim is to “provide as much evidence as possible such that an objective judgement can be made”.
  • Goes on to discuss ‘consented’ autopsies requested by clinicians and his particular interest in maternal deaths.  These are extremely rare in the developed world, he points out, so “the ones that happen are going to be unusual.”  He discusses briefly the art of speaking to relatives in distressing circumstances.
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Section 2

  • Infectious diseases are another special interest, and he describes, with some specific examples, his international consultancy work in this field.  “Every week will bring in one or two real gems. And you think, ‘Wow! I'm jolly lucky to be seeing all this’."
  • He finds this work endlessly exciting:  “It's the thrill of picking up a slide and looking at...things which are either versions of a disease I know about but I've never seen that version before; or genuinely really rare things; or even things that no one else has ever seen before.”
  • Describes in detail solving the extraordinary case that “got me into infectious diseases: this actually changed my life.”   It was the death in pregnancy of a young white woman “who'd never left North London” but had contracted  “amoebiasis, which is a tropical disease.”
  • Talks briefly about his introduction to infectious diseases during his training with the “charismatic pathologist Michael Hutt”.
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Section 3

  • Describes how AIDS entered the picture, and the arrival at St Thomas’ of Terrence Higgins, one of the first people known to die of the disease in UK.  “The penny dropped that this is what we were then calling GRIDS – Gay Related Immune Deficiency Syndrome.  AIDS hadn't been officially labelled as such at that point.”  He did not recognise then that this disease would have such an impact on his professional life.  “I forgot about it. That's the relevant point.  Terrence Higgins was just another fascinating case.”
  • Describes how in 1983 he took over the work of Michael Hutt who performed pathology services for many African hospitals by post. “I saw loads of things I had never seen before; things that don't happen in Britain.”
  • Comments that this work taught him some valuable lessons:  “You learn by having a prepared mind... [And] you have to face the fact that usually the first time you see something really big and different you'll get it wrong.”
  • Describes a massive project on leprosy in Malawi.  “There was a population of about 150,000 [in the project site], and the project literally examined them all, every square inch of them within the bounds of modesty and ethics, every five years.”
  • Explains that this is when his real involvement with AIDS began.  “Among the stuff coming from overseas was a whole set of intestinal biopsies...[from Uganda’s] Makerere School of Medicine.”  These were from patients with Slim Disease: “the name given to a condition being seen [in Africa] in the early 1980s, and which is now what we call AIDS.”
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Section 4

  • Describes the history of the growing understanding of the pandemic, its reach, and its various manifestations.
  • In 1985 he attended the first international conference on AIDS in Africa, and as a result was invited out to Uganda.  He was shocked by the scale of the problem:  “I have never seen anything like it.  These are enormous wards, and every bed was occupied by a dying skeleton.”
  • This encounter “flicked a switch: this is interesting, this is worth doing, this is a disaster.”
  • He became involved in the early investigations, having suspected in 1986 that “an awful lot of what we think is HIV-related disease may well be tuberculosis -- made worse by HIV.  Which subsequently turned out to be entirely true.”  From hypothesis to proof took five years.
  • Recounts in colourful detail gathering samples from Ugandan villagers for investigation at the UK’s specialist labs at Porton Down.  “I left Kampala after two extraordinary weeks that changed my life.”
  • Explains that since there was no treatment for HIV infection, establishing exactly what the opportunistic infections were was crucial to caring for patients.
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Section 5

  • His next big overseas project was in Côte d’Ivoire in 1991.  Recounts working with friend and fellow AIDS physician Kevin de Cock on a project initiated by the US Centers for Disease Control in Abidjan.
  • He overcame his initial misgivings about working in Côte d’Ivoire – “I was appalled by the climate” – when he realised the amazing opportunity it presented.  De Cock told  him:  "Ivorian Law, Napoleonic Code, it's French.  Anyone who dies in a teaching hospital in Côte d’Ivoire can be autopsied without consent."  Nearly 500 people were autopsied in a year; this was seminal work.
  • Touches on the whole debate about where public health considerations might or might not legitimately outweigh the concerns of the individual.  In situations, such as that in Côte d’Ivoire, he believes “the public health benefits are so colossal that...they override to some extent personal objections.”
  • Describes the pathology they found, and how this is where the TB hypothesis was clinched.  “All the patients I was looking at [in the UK] were gay white middle-class men.  That's what AIDS was in London then.”  But “Africa was completely different.  The first thing that hit us in the face in Côte d’Ivoire was: actually, it's all TB.”
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Section 6

  • Returned to England and spent the next two to three years analysing the material from Côte d’Ivoire.
  • Points out that he was lucky not to get the post in Liverpool that he applied for.  “I'd have had Alder Hey to deal with, and I'd have been completely incapable of dealing with that... I'm not very good at managing people.  [And] there's no AIDS there!”
  • Moved to St Thomas’.  Returns to the story of Michael Hutt, who was so important in his own life.  Describes Hutt’s role in tropical pathology and in making Uganda’s Makerere “a  jewel” of a medical school.  It was on his return from Uganda that Hutt received Wellcome Trust funding to set up his postal pathology service for Africa.
  • Describes how Hutt was instrumental in getting Lucas sent to Nairobi in 1980.
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Section 7

  • Relates his own experience of the Alder Hey controversy.  Gives credit to the chief executive of St Thomas’, Jonathan Michael.  “He realised that organ retention was a big issue, we were vulnerable (he didn't know how vulnerable, but he found out pretty quickly!) and it had to be addressed head on, openly.  And we had to have an absolute protocol about what to do.”
  • Makes the point that “one thing that didn't happen here, and that did happen in Bristol, Alder Hey and other places, was that we didn't have a whole lot of anguished mums and relatives on our doorstep.  You might have thought we should have had, given the numbers, because we had masses of stuff.  But...patients coming to this hospital come from an enormous catchment area, so big that they never get together.”
  • Goes into some detail about the complexities of the controversy, and the role played by Dick Van Velzen.  Has misgivings about the new legislation that came in as a result, saying that things have “got more bureaucratic, but there's still a huge grey area in tissue retention... and it's not very clear.  Or it's very clear what to do if you want to stay absolutely within the letter of the law... You do nothing!  That's easy.  But the point is, to be good and to be useful for public health you need to do a bit more than that, and that's where the grey areas come in.” 
  • Discusses the value of archives, not least as a teaching tool.  “We have a fantastic series of pots of malformed fetuses...Now this is not prurient stuff... You can be lectured like mad about the importance of antenatal screening; 10 minutes in the Gordon museum and you can see why you do it.”
  • Discusses the status of pathology today.  Comments that there has been a “huge renaissance” in surgical diagnostic pathology; that reporting procedures are much improved; and that pathologists are a central part of clinical management.  “No longer are we invisible.” 
  • Nevertheless, he muses, “We don't have the full-hearted support of our clinical colleagues as absolute equals.”  Explores briefly the changeable relationship between clinicians and surgical pathologists over the past half century.
  • Concludes with a brief discussion about the reasons for and implications of the decline in consented autopsy rates.  “One a fortnight... We used to do three a day!”
  • Emphasises what he believes are serious shortcomings in the coronial autopsies system.  These have been “of very variable quality and too many clinicians have seen very bad reports which are not ‘the truth’ and don't represent what the patient had, and they have therefore been put off, thinking that all autopsies are like this... [This] is a huge problem.”



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