Paola 
DomizioProfessor of Pathology Education, at Barts and the London, Queen Mary's School of Medicine and Dentistry

Interview location: Pathology building at Barts and the London, Whitechapel, London
Interview date
: 9th October, 2009

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SECTION 1

PD:  Both my parents are Italian immigrants.  They came to the UK before I was born so I was born and brought up in the UK, went to school here, went to medical school here, and I've lived here all my life.

SA:  What part of Italy do they come from and what brought them here?

PD:  They come from a region called the Marche, which is central Italy.  It's a region similar to Umbria and Tuscany in that it's very hilly, lots of hilltop villages, very lovely rolling countryside and it has a coast as well on the Adriatic side.  The capital of the region, on the Adriatic, is Ancona, which looks over to Dubrovnik, ex-Yugoslavia.

SA: What brought them over here?

PD:  Well, they came after the war in the late 1950s because life in Italy at that time was pretty poor.  There was really only farming as a profession.  My grandfathers were both farmers.  One of my grandfathers actually owned his own land; the other one farmed it for a landowner, so my family background is a combination of peasant farmers and landowners.  Neither of my parents wanted to carry on being farmers so they came to the UK.

The reason they chose the UK was that my great uncle, my father's uncle, who had been an accordion tuner when he was young, had come over to England before the war.  There was a problem with a consignment of accordions that had been sent to the UK, and he was sent over to sort it out, to fix the problem, basically. He was from a small village in Italy, came to London, the big city, and decided he preferred it here, so he stayed on.  He was interned on the Isle of Man during the war, as an 'enemy alien', but he ended up staying.  So he was in the UK already.  

By the time my father wanted to come over, my great uncle had a musical instrument shop in Frith Street in the West End.  He had also opened the first Italian restaurant in London, called Pinocchio, in the late 1950s, so he was a fairly sort of well-to-do businessman.  My father came over initially to work as an accordion tuner in my uncle's shop.  But he had done national service and been in the telecommunications corps during the war, and he decided he really wanted to expand a bit, so he taught himself to repair radios and televisions.  Of course that was an expanding business in those days, so he managed to get a job quite easily.  

My mother had been a teacher in Italy, which was actually quite a prestigious job.  But when she came over here she couldn't speak English initially, and she had three children very, very quickly, so she really didn't work, and didn't use her education until much later on – until we were all at school and self-sufficient.

The path to pathology

SA:  And how did medicine come into the picture –when did you get interested in science and decide to go into that field?

PD:  Really quite late on.  I was always much better at languages and maths at school.  Because I spoke Italian, French came very easily, Latin was a doddle.  I used to get virtually 100% in my French exams, so I originally started off thinking I wanted to do something with languages.  But about halfway through my fifth year, which was just before O-levels in those days, not GCSE, I decided it wasn't really academic enough and I was quite academic, I'd always come top of my class.  The two academic subjects in those days were law and medicine, and I didn't fancy doing law so I decided to do medicine.  In fact I had to do science subjects extra -- I did physics extra as an add-on to my O-levels, because I wasn't doing it at all at the time.

I knew absolutely nothing about medicineI knew absolutely nothing about medicine when I decided.  I did, I suppose, a little bit of research, but much less than students nowadays are expected to do.  I had no contacts in medicine; I'd hardly ever been to my GP… So, I did go into it a little bit blind, I have to admit.

SA:  And what was it like?

PD:  Well, in those days our curriculum was the classical pre-clinical/clinical split, so my first two years were spent in the lecture theatre.  Nowadays of course only Cambridge and Oxford organise their curricula that way.  I did an intercalated  BSc as well, which meant I spent an extra year studying cell biology and anatomy.  I had no idea in those days that I wanted to be a pathologist, but it ended up being quite useful to me.

SA:  Why did you choose to do an intercalated degree?

It was intellectual curiosity mostlyPD:  It was intellectual curiosity mostly.  It was a scientific subject and I wanted to do something scientific rather than sociological or psychological, and that, of all the courses available, was the one that I felt would give me the most science.  It really appealed to me, and I thought it would give me a better understanding.

And I loved it, really loved it.  I really enjoyed doing the research.  Up to then we had sat in a lecture theatre and listened.  During my BSc year I actually did.  I thought for myself, did experiments, and actually produced results.  I was allowed to think and I really did enjoy that.

Then I started clinical medicine, did my three years as a medical student on the wards, and really enjoyed that.  But I was struggling to think what to I was going to do as a career.  Eventually I decided I wanted to do surgery.  Medicine, I felt, was not practical enough.  Surgery, I thought at the time (I now know differently), was more intellectual and would be more satisfying.  So I decided to embark on a career in surgery.  

I did a year of house jobs and then I applied to do a casualty job, which all surgeons had to do. I really did enjoy that and was wavering about whether I should do casualty, A&E (accident and emergency), as a full-time career, although in those days (we're talking almost 25 years ago) it wasn't really as well developed as it is now, in career terms.

But then I took a six-month job in hepato-biliary surgery at the Hammersmith Hospital, and it was the Hammersmith that effectively drove me into pathology – a little bit by accident.  The reason was that it was absolutely hellishly busy. The first ward round would be at 7.30am.  There were no phlebotomists in those days and there were no housemen, so I would have to do the houseman's job, which I'd just spent a year doing and really wanted to get away from.  So I would take the bloods from the patients, write up all the forms, go and chase the X-rays…  And I had to do all that before the ward round, so I was frequently on the ward at 6 o' clock in the morning.

And on my nights off…Because the surgeries were so long and complicated, the surgeons would come and do a ward round after they'd finished theatre, and we would have to wait for them sometimes till 7 o'clock in the evening.  By the time we'd finished the post-theatre ward round (and I'd have to do all the writing up of the notes etc) it would often be 8.30, 9 o'clock.  So on my nights off I'd be getting home 9.30 or 10 o'clock, literally just eating, going straight to bed, and getting up at 5 again to get in for 6 am.  That happened two nights out of every three.  Every third night I'd be resident in the hospital on call.  It happened that every Thursday I was on call, and one in three weekends also.  That meant that from Thursday morning till Monday night I was on call.  

I had no time to study, no time for any kind of lifeOne particular weekend that I was on call, somebody wanted to swap a Monday with me.  That was fine, but it ended up that I went into work on Thursday morning and actually left the hospital on Tuesday evening!  I don't know how many hours continuously that was on call, but it was a lot, and I just felt… I don't give up easily, and I didn't give up even at that stage, but I just couldn't study for my exams (there were surgical exams for my FRCS).  I had no time to study, no time for any kind of life, and I felt I just couldn't maintain this long term.  So I decided that I needed to take some time off and do a job that was less strenuous and less stressful, and use the extra time to study for my surgical exams.  

I didn't really know what to do, and I was looking through the BMJ (British Medical Journal) for the types of jobs that might be useful for a surgeon, but less strenuous than surgery. I saw a job advertised at Barts in pathology, as an SHO (senior house officer), for a year.  I hadn't had much exposure to pathology as a medical student and I thought: "I wonder what that would be like?"  I wasn't really sure what a pathologist did and I had no time to go and look around the department beforehand, and say, "Here I am… what's pathology all about?  Tell me about it, because there's a job advertised…" So again, just as I went into medicine a bit blind, I went into the interview for this pathology job really quite blind as to what pathology was about.  

I was honest at the interview.  I said: "Look, I don't really want to be a pathologist, I want to be a surgeon, but I feel that doing this year of pathology will make me a better surgeon.  I hope it will be useful for my career and I hope that you can take me on that basis."  And I remember the professor of pathology there, Gerry Slavin, lovely man, said to me: "Paola, we'll give you the job on one condition: that if you like the job you'll stay for two years instead of one year."  And I said, "Professor Slavin, if I like the job I'll stay for four years instead of two."  And they said, "The job's yours!"

So I started in pathology and it took me probably six months to really settle down.  It was just so different from clinical medicine.


SECTION 2

SA:  How?  What do you do when you first go into clinical pathology?

PD:  Well, in histopathology, which is my specialty, you pretty well do the same job from day one till day one million, when you retire.  You do two main things: autopsy is one large part of the work, and then the surgical pathology, which means diagnosis on tissues that have been removed from living patients – either small biopsies, or larger pieces of tissue, for example a whole stomach or a whole lung.  Usually they're removed because of cancer or some other quite nasty disease.  So I spent the first month doing autopsies.  

SA:  And what was that like at the beginning…?

The smells, and the gore and the bloodPD:  Well I was quite a gregarious person, I like speaking to people, I like speaking to patients, and suddenly going into a morgue was quite off-putting, I won't deny it.  Particularly the smells, and the gore and the blood.  I mean, doing post mortems is actually a)  upsetting, because you're making great big slices in dead people (you do get used to it, but at first it's quite upsetting); and b) very bloody, very messy, lots of organs all over the place, blood, and bits of tissue and faeces and urine everywhere.  And it can be very unpleasant, particularly if you've got a body that's died with some sort of intestinal disease and they have perforations in their bowel and all the faeces go outside – it can be very smelly.  It took quite a while to get used to that.  Obviously at first it was new to me, so the first one or two autopsies were sort of "Ooh, this is quite interesting".  But then I thought:  well, actually it's quite gory and smelly.  And quite hard work, particularly if you're a smallish woman, to try and eviscerate -- which means take out all the organs -- from a large man.  Physically it was quite hard and tough.

Working with the dead

SA:  What sort of instruments do you use?

PD:  Effectively like a butcher.  They are big knives, big scissors, bone cutters, just the same sort of thing as a butcher would use.  Because that's what you're doing, effectively -- you're cutting all the organs out of a body, you're left with a carcass, so it's really much like what a butcher would use.

SA:  Quite apart from the distasteful aspects of it, the smell and the cutting and things, what were your feelings towards the dead body, in sort of philosophical terms – what went through your mind at the beginning?

PD:  Well I'd seen dead bodies, one or two dead bodies, before, of relatives who had died.  Obviously they were quite close to me and I thought I would feel a similar sort of feeling… And of course I'd seen patients as well who had died on the wards, and it was really terribly sad.  But when I did postmortems, first of all you don't know the person.  Secondly, when they've been in a fridge for quite a while, which most of them have when you're doing hospital postmortems, they feel very stiff, very waxy, the bodies, and they don't actually feel human.  So it was easy to detach and think: "Well actually, this isn't a human being…this is just something that I have to do, and it's part of my job."  Of course it was a human being, but d'you see what I mean? One of the ways of coping with the fact that you're about to make huge big slashes and take organs out of people is to think, "Well actually, they're not very human at all."  So that was the way I coped with it. 

“An overwhelming feeling of sadness”

The first time I did an autopsy on a child was very differentI will tell you, though, that when I worked at Great Ormond Street [Children's Hospital], which I did for seven months about three years after I started in pathology, the first time I did an autopsy on a child was very different.  Because the children don't attain this rigidity and this very waxy cold feeling – I don't know why, but they don't seem to.  

SA:  Even when they've been in the fridge?

I really had to force myself to take the knife and make that cutPD:  Even when they've been in the fridge.  The first postmortem I ever did on a child was on a four-year-old girl who'd died after cardiac surgery, and she'd been dressed in her ballet tutu, a pink tutu, which was still on her when I got down to the postmortem room.  I saw this little girl with blonde curls just lying on the slab and I just wanted to jog her, and say "Little girl, wake up. Wake up and run away, don’t you know what I'm about to do to you?"  And I really had to force myself…It was horrible, I remember, I really had to force myself to take the knife and make that cut.  I was saying "I can't do this; Yes you can… I can't do this; yes you can…"  And I was struggling with myself.

SA:  So all your defences were down and you hadn't expected it?

PD:  Yup.

SA:  And how after that did you psyche yourself up to do autopsies on children?

PD:  Well I think the first one is always the worst. The second one is a little bit easier.  And then by the time… But again, children are always worse because you read the histories – often they're lovely little children, they've been ill for quite a long time, and it just feels so sad.  I think that, compared to adults, it's the overwhelming feeling of sadness.  Most of the adults that we deal with at postmortems – that I've dealt with anyway, apart from the ones with HIV – most of the others have been elderly, they've had their lives, they've maybe been ill a bit at the end, but they've not been like the children, who've had histories of being unwell -- cardiac disease or whatever – all their short lives, and they've not really managed to fulfil themselves.  So it is a much more emotional thing.

You do get used to itBut having said that, you do get used to it as well.  Because you know that the advantages at the end of the day and the benefits that it can bring – to parents, to the doctors who are looking after her, and to society in general – are actually quite great.  So you feel, "Well yes, it is quite horrible, but I am doing good by doing this postmortem, so let me just get on with it."

SA:  And do you have any sort of rituals?  I was reading about someone who said that he used to cover the face with a cloth…

PD:  No.  I never thought of doing that, actually.  And the clothes – in fact that first one was the only one that ever came dressed.  The others were always naked.  I don't know quite how that little girl in the pink tutu had slipped through. The postmortem technicians had somehow forgotten to take the clothes off, which was bad for me as it was my first child, and it did shake me for a while.  Obviously I got them to take her tutu off – I couldn't do it myself.


SECTION 3

Autopsy techniques

SA:  I know this isn't your job, but what do the technicians do?  As you say, you've done an awful lot of work on the body and yet when it goes back to the relatives for burial it's looking okay…What do they do?

PD:  They take the organs that you have eviscerated, examined, cut into, maybe taken little pieces of tissue from to look at under the microscope (obviously that's what all the trouble was about with Alder Hey), and they put them into a bag and put them back into the cavity that's been formed when we've taken everything out.  Obviously there's no possible way of putting the thoracic organs back in the thorax, or the abdominal organs back in the abdomen, because there is no way of stopping them moving around.  So they all just get put into a bag and put back into the abdominal cavity, and cotton wool is put around in order basically to reconstruct the shape of the body.  And then it's sewn up.

SA: And does it look pretty good at the end?

PD:  Well, yes, if you don't…The cut is done from here to there [indicating from throat right down the body] If you put a sort of shroud over the body so that it's covered up to the neck, all the actual cuts and stitches are covered, you can't see anything.  Now, when we take the brain out -- which is done less and less nowadays, but was done routinely when I was doing postmortems -- what you have to do is make a cut around the scalp, and reflect the skin all the way over the skull.  It actually looks quite gruesome, because you have the skin of the scalp over the face, then you have to cut with a saw – usually an electric saw – cut the skull off…

SA:  Like a boiled egg?

You cannot look at a brain properly at the time of postmortemPD:  Yes, effectively like a boiled egg…and you take the brain out and examine it.  If you examine it at the time – which, with the brain, hardly ever happens because the brain is like blancmange, it's like a jelly, you cut it and it just goes slurp, because of its content of lipids.  So what you have to do in nearly all cases is ‘fix’ the brain in formalin.  That can take days, if not weeks, which is why there's been all these problems with retaining brains -- because you cannot look at a brain properly at the time of postmortem.  You can make a couple of slices into it, and have a very quick look, but you just can't do it properly.  People who want to do their job properly, that's what they have to do -- keep the brain, fix it, and come back to it at a later date.

The decline of the postmortem

SA:  So the postmortem – do you get skilled at it?

PD:  Oh yes, oh yes.  You start off taking four hours for your first autopsy, and by the end of the first month…Those days we used to do two or three autopsies every day, and now each trainee will probably do one a month, if not less than that.  The rates of autopsy were falling anyway, but there's no doubt that Alder Hey has been a contributory factor to that drop being much more rapid.

SA:  Why were they dropping already?

In 10% of cases they're wrong, big time!PD:  They were dropping because… well, various reasons.  A) because doctors on the ward felt that their diagnostic capabilities antemortem had improved and there was no need for a postmortem.  They knew the cause of death, at least they thought they knew the cause of death.  Having said that, all the studies, even recent ones, looking at the discrepancies between antemortem diagnosis and postmortem diagnosis still show a major discrepancy rate of about 10%.  So, despite the fact that radiology is now so good, MRI and CT scans are really good, there's still a significant discrepancy between antemortem and postmortem diagnoses.  Clinicians on the wards think they know the cause of death, but actually in 10% of cases they're wrong, big time!

SA:  Why, if you can show them those sorts of figures, are they still not asking for autopsies?

PD: Well, because a) they probably don't believe you; b) they feel that perhaps resources are better spent on living patients (I mean not all doctors, but this is a fairly widely held view); c) they feel it's distasteful to come down to the postmortem room, and maybe they don't actually have time to watch the autopsies and see the results for themselves; and d) they probably think their time is better spent elsewhere.  So -- a combination of factors.  But the fact that doctors weren't asking for as many postmortems is unquestionable.  And now of course they have even less of a reason to.  Or more of a reason not to.

SA:  If you change the diagnosis afterwards, because you've found some underlying pathology too, does it actually matter?  Does it help in the management of future patients?

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PD:  Okay, let me give you an example of a case that I did.  I did a postmortem on a man who had been found wandering the streets of Hackney naked.  He was taken in to the psychiatric wards, and within a few weeks, I think, he got pneumonia and died.  Nobody really knew what was wrong with him.  His relatives hadn't been very helpful, and he couldn't really give a history – he was just sort of ‘mad’ effectively.  The clinicians knew he'd died of pneumonia, but they didn't know what the underlying cause of his ‘madness’ was.  So I did an autopsy and I found the pneumonia, which turned out to be an aspiration pneumonia, which meant that he'd been regurgitating his food and it had gone into his lungs and caused pneumonia.  Part of the reason for that was that he had a brain disease called Huntington's Corea – a disease of what we call the basal ganglia inside the brain.  

It's a hereditary disease.  It's what we call 'autosomal dominant', which means that if you have children they will definitely get the disease.  Obviously his offspring would need to be told, and I remember at the time of the postmortem we hadn't been able to find out whether or not he had children, because he was African, and we thought he might have family in Africa.  But you see what I mean?  Sometimes the results of a post mortem can be extremely important.
 

You could say, "Well, maybe his family wouldn't want to know", because the end result of this disease is that you develop dementia and there's no cure at the moment.  But it's important for the future and genetic counselling:  would you want to have children if you knew you're going to pass on a disease like this? Obviously not all postmortems are like this, but it can have very significant consequences for families.


SECTION 4

Working with the living

SA:  Okay, so after the postmortems, what did you learn?

PD:  After that we learned to do surgical pathology, and I have to say that, now, postmortems are the least favourite part of my job.  Looking at surgical pathology, looking down the microscope for diagnostic purposes, is what I do most of the time.  I started off just watching other people, observing, then doing a little bit under supervision, then a little bit on my own, then a bit more on my own, then much more on my own.  Over two or three years you gain more and more experience, and like any other skill, the more you do, the better you are at it.  It probably takes four or five years to become really competent.  I took my exam at the end of the five years -- I failed it the first time but passed it the second time.  In those days the MRCPath was basically a carte blanche to go on and become a consultant, it was your licence to become a consultant, pretty much like a driving licence -- you can go off and drive a car on your own.  Now it's changed, but in those days you could.

But in the early 90s, when I passed my exam, there was a huge shortage of consultant histopathology posts – a really massive shortage.  Since then the number of vacancies has gone right up, and about two years ago stood at about 200 vacancies -- not enough trainees.  But when I was finishing my training there was a surplus of trainees.  So I took a number of years – three -- to get a consultant post, which nowadays would be unheard of.  I spent three years as a very senior 'trainee' waiting to get a consultant post.  Because my husband was in London, we were based in London, I couldn't up sticks and go to Nuneaton, or wherever.  I was really waiting for a London post.  

Two or three came up and I didn't get them, so eventually Prof Slavin, who had initially employed me and who was still the professor, I won't say 'created' a job, but more or less engineered a job, found some funding from somewhere and wrote a job description that was tailor-made for me.  I was interviewed by a proper appointments committee, but nonetheless it wasn't really advertised, which probably wouldn't be allowed nowadays.  So I was appointed to this job in 1994, and I've been in it ever since really.

SA:  So during the years when you were still thinking that you'd go on to surgery, what sort of case book did you have, and what really started to stimulate your interest in pathology?

Struck by the variety of things I was seeingPD:  Well, later you specialise a bit, but at the beginning you see absolutely everything, and I remember being struck by the variety of things I was seeing.  In a tray of slides I would see a skin biopsy, then I would pick up some lung, then I would look at gut, then at placenta, then at a bit of bone, and then there'd be some kidney – a really huge variety of things.  And all sorts of diseases – cancer, inflammatory diseases, appendicitis, skin lumps and bumps, naevi, moles, melanomas, everything.  So I remember being really interested and struck by how wide a spectrum of disease I was seeing, which would not be the case on the wards.  

On the wards you're working for a particular consultant and you see the patients that are of interest to him.  For example, when I was working at the Hammersmith, I was seeing patients just pretty much with cancer of the liver or the pancreas, or the bile ducts -- that was it.  It was a tertiary referral centre, patients would come in from all over the world to see this particular consultant, and 90% of the patients had cancer.  So the range of patients you saw was limited.

Mistakes are inevitable

SA:  Was it interesting?

Making a mistake hits me hardPD:  Yeah, of course I enjoyed it, I really liked seeing the patients, I liked looking after them on the wards, I liked them coming in ill and going home better.  Having said that, I never saw them long term and I know that the prognosis for their particular cancer wasn't great, so I might not have liked it so much if I'd seen them die.  And also I have to say that I'm quite a sensitive person and making a mistake hits me hard.  

I've made a few mistakes in  pathology and they've hit me hard, but if I'd continued in surgery, I think it's inevitable that at some point your actions will cause the death of a patient, and I don't know how I would have taken that, really.  One always starts off thinking you'll never make mistakes, but it's impossible not to, and for various reasons not always under your own control.

SA:  I know Irene was saying that it's a huge responsibility as a pathologist, making diagnoses, and you inevitably make mistakes.  What mistakes have you made that live in your memory?

PD:  Oh gosh. Well, I've diagnosed cancer that wasn't and a patient had their stomach taken out because of that.  I've missed a diagnosis of cancer and that probably led to the patient not living as long as he might have done.  Those are the two main ones, I know about – one over-diagnosis of cancer and one under-diagnosis of cancer. 

A science and an art

SA:  And how easy is it to make a mistake?

Histopathology is not a science in the classical sensePD:  Very easy.  Because histopathology is not a science in the classical sense.  You don't get a number [read-out], and there's nothing to refer to which says if it's over this number it's X, and if it's under this number it's Y, which a lot of the blood sciences do.  In Haematology The branch of medical science concerned with the blood and blood-forming tissues;  haematopathology is concerned with diseases of., for example, if you put the blood sample into the coulter counter you get a read-out.  If the haemoglobin comes out less than 10 there's anaemia, if it's more than 10 then there's not, and so on. Histopathology is a subjective interpretation of appearances down a microscope based on your previous experience and your knowledge of the patient's history.  So if you have something with an unusual appearance that you've not seen before, or if for some reason the patient's history is atypical, or you don't know their history, or if for some reason you're lacking in concentration and you just misinterpret what you're seeing – those are all reasons for making mistakes.
 
Benign conditions can mimic malignancy, and vice versaAnd sometimes it can be very, very difficult: benign conditions can mimic malignancy, and vice versa, very strongly.  Sometimes you can give the same slide to 100 pathologists and 50 will say it's benign and 50 will say it's malignant, because it is a subjective interpretation.   So it's not as straightforward as it might appear – and as I thought it was when I was not a pathologist.  I would always think: "Well, I'm sending off the tissue to the pathologist, and they'll give me the answer.  Because it's obvious, isn't it, when you look down a microscope?"  Only when I got into pathology did I realise that actually it isn't always.  

SA:  Can you remember cases where you've looked down the microscope and thought: "There's something obviously wrong here but I haven't a clue what it is"?  

PD:  Oh yes.  Oh yes.  Most of them happen to be tumours, I have to say.  You can see there's a tumour there, you try to match it up to the books, but you just cannot find out what it is and you end up saying: "This is a malignant tumour, I don't know what it is, I'll send it around to some of my friends, but I can't guarantee that they'll know what it is either."

Recently I had a biopsy from a man, a duodenal biopsy, which is part of the small intestine just after the stomach.  The clinicians were telling me that they were convinced it was a tumour, a particular type of tumour that people from lower Mediterranean and Middle Eastern countries get. It's called a LymphomaCancer originating in lymphoid tissue, a key component of the body’s immune system.  Cancers of lymphocytes (lymphomas) and other white cells in the blood (leukaemia) together account for about 6.5% of all cancers.{, a particular type of tumour, very rare actually in the small intestine.  But they were saying: "We're absolutely sure…the radiology for this man has convinced us… really looks like it…you just have to confirm it."  So I looked at the biopsies and I thought, "Well no, actually, it isn't a lymphoma.  What it's full of is something called granulomas", which are a particular type of inflammation that you get in diseases such as tuberculosis and Crohn's disease and various other things, but they're the two main ones.  

So I said: "This patient doesn't have malignancy, but he does have these granulomas, and I think it looks like TB."  And they were saying: "No, no, it can't possibly be, this doesn't fit with the history." So they took some more biopsies, and they showed exactly the same thing.  I said, "You must treat this man with anti-TB drugs.  I don't care what you think clinically, this is what it's showing on the pathology."  And okay, I'm not usually that gung-ho because you do need clinical and pathological correlation.  It's very important in histopathology -- you can't usually be diagnostic and categorical just on the biopsy.  Similarly the clinicians can't be diagnostic and categorical just on the clinical history.  You do need some sort of liaison.  

But this man was presented at a meeting, we all discussed it, and they eventually said, "Okay, we'll treat him with TB drugs."  And in fact just on Friday I met the doctor who was looking after him and I asked how he was.  The doctor said, "Oh he's put on 15 kilos of weight, he's much better…"  They hadn't known what was wrong with this man, he couldn't eat, and he was really withering away.  So, I was really pleased with that!  I thought, this is diagnostic success: somebody's treatment being directly influenced by what the pathologist has said in spite of what the clinical picture was.

HIV enters the picture

SA:  So what about HIV, when did you start to see that, and under what kind of circumstances?

PD:  Well, the first time I ever heard of HIV was when I was a medical student in 1984.  I started in pathology in 1986 and I suppose a couple of years after that we started to see quite a bit of pathology coming from HIV-positive patients.  We had a number of deaths, and we did a fair amount of postmortems on HIV-positive patients.  Now, in the last five years, it's gone down to virtually nothing with the advent of triple-therapy.  I only remember about one autopsy in six months of an HIV-positive patient, and the number of biopsies we're getting of "What's wrong with this HIV-positive patient?" has diminished to virtually nil.

SA:  What about at the beginning, when there was this massive scare about how infectious it was – what effect did that have on people doing the autopsies?

PD:  Well first of all only those of us who were fully trained were allowed to do them.   We used to wear gowns, and we used to wear these hoods which had airflow extractors with this thing on our backs which circulated the air and prevented us breathing in any of the droplets that might come up.  We were supposed to wear chain mail gloves to stop us cutting our fingers.  But in fact I couldn't wear them, because they didn't have them small enough for my hands.  They only seemed to make them for men, and it was actually worse for me because I couldn't see the ends of my fingers – the glove ends were just all over the place!

I have to say that I did once cut myself doing a postmortem on an HIV-positive patient -- and d'you know, I've never told this to anyone before, but I was just too kind of embarrassed and worried to do anything about it! What I should have done was to go immediately to occupational health and have a blood test, and then be given the therapy straightaway.  But I didn't do anything.  This was years ago, and I've since had to have HIV tests for other reasons and I was negative, so it wasn't a problem.  But there was this sort of bizarre feeling that "this hasn't really happened" and I just got on with it.  It was only looking back, when I had to have the HIV test for another reason, that I thought, "Gosh, I wonder if that cut actually could have been infected?"

SA: Has all the paraphernalia surrounding autopsies gone now?

PD:  No, if you did a postmortem on an HIV-positive patient you'd still have to wear all that, because it is still infectious.  Hepatitis B and C are also infectious.  TB too is quite infectious, so if you know the patient has it you would be suitably dressed for all of those, and do it in a 'high risk' postmortem room area, which we now have in this building.  We didn't use to have such a place before; it would just be done to one side.  But yes, we're much more set up now to do high risk postmortems.


SECTION 5

Postmortems are not the whole story

SA:  One of the big problems, especially since Alder Hey, is that there is this massive stigma in the public mind about what pathologists do.  What you've been telling me, I find fascinating because I'm interested in medicine and things, but it still is pretty gruesome, isn't it?  What would you say to put people's minds at rest that one of their loved ones isn't going to be mutilated?

Most of pathology actually deals with the livingPD:  To be honest, what I would say -- and it's what the Royal College of Pathologists is trying to say a lot of the time -- is that most of pathology actually deals with the living.  It makes diagnoses on living people and helps the living in ways that I've been telling you. The image of the pathologist that has been portrayed by the media is mostly forensic pathology, and I'm sure that even now, if you asked a member of the general public, "What does a pathologist do?" they'd say "Well, they do postmortems.  They do what CSIs [crime scene investigators] do!  They go off and solve crimes and run after criminals." Which of course couldn't be further from the truth.  

70% of diagnoses in the health service depend on a pathologistI would say that most pathologists make diagnoses, and in fact 70% of diagnoses in the health service depend on a pathologist.  Now whether that's histopathology or the blood sciences, or microbiology (you know, pathology actually encompasses much more than just histopathology) can be debated.  But there's no question that pathologists are the people who make the diagnoses in most cases, and who therefore form the platform on which subsequent management of the patient occurs, and on which prognosis can be given to the patient.  So we are a very important part of the multi-disciplinary team, and without us I think the clinical doctors would flounder in a lot of cases.

SA:  So why are medical students, and even some medics, so unaware?  I mean, you said that you, as a trained doctor, didn't know what it was you were going into until you started in pathology?  This is dire isn’t it?  Why are you lot so unknown and so faceless?

PD:  Because we're not up front with the patients.  Because we don't see patients…

SA: ...you're the backroom boys and girls.

Pathology in the curriculum

PD:  Exactly.  Pathology, in terms of the educational aspect of it and obviously this is something which interests me a lot… Pathology, at the beginning of the twentieth century and up to about the 1960s, was really strong in curricula.  It was felt really important for doctors to know the pathological basis of disease.  It was felt they needed to know the structure of tissues and organs, how they worked and what happened when they went wrong.  Much like a mechanic has to learn about how bits of the car are put together before they can diagnose what goes wrong, it was felt really important for doctors to understand how the body works.  So pathology was a really, really big subject.  A slow but definite sea change

Then medical education started to change in the early 1970s.  It was a slow but definite sea change.  It was felt that doctors needed to know more about how to communicate with people, more about ethics and psychology – that they were overloaded with facts.  Pathology was considered to be a factual, science-based subject, much like anatomy, physiology and biochemistry, so that was the target for fact-cutting in many curricula.

SA:  So what was supposed to be the basis of medicine?  I mean okay you can be empathetic, but what if you don’t know what somebody is sick from?

PD:  Well, it was felt that maybe they didn't really need to know so much about what was wrong with the structure of the organs and things, they just needed to know the diagnosis, and that could be told by pathologists.  To be honest, I think a lot of people are now realising that the pendulum has swung too far, and that students are qualifying as doctors without any proper understanding of disease processes, and without the knowledge to interpret test results and institute basic management plans.  

There's the beginning of a groundswell to put back some of the basic sciencesSo there's the beginning of a groundswell to say that, well, we actually need to put back some of the basic sciences into the curricula. I mean, we're not saying they need to know the minutiae of rare diseases, but certainly when you can't understand how the fluid balance of a patient should work because you don't know anything about the fluid inside the body and where it goes – very, very basic aspects of pathology -- when you don't understand those then how can you ever think to treat patients?  It's inconceivable to us, but…

SA:  So when you, as a professor of pathology education, teach your students, how do you teach them to face death?  I don't know if in your day there was any discussion before you went into the morgue, or whether you just went in unprepared in any way.  And do you teach anything like that now?

PD:  No, I have to say, not really.  Nowadays we do teach students more about what a postmortem involves, and how to take consent, which we never used to do.  But most of our teaching is based still on the facts of what goes wrong in tissues and organs when they become diseased.  Predominantly because we don't have enough time to do anything else.  

SA:  Okay, but when they start to do practicals themselves, do they just have to face it and work it out for themselves or is there somebody to teach them the 'emotional intelligence' as well?

PD:  No, I don't think there is actually.  No, but perhaps there should be!  Perhaps we ought to go back and think about that one.  Obviously as trainees there are people we can talk to, but I don't remember ever having anybody say to me: "This will be difficult for you."  And I don't remember ever having said it to anybody else.  But you're probably right, we need to share our experiences and confront these things.

SA:  Tell me a bit about the history of pathology – when did it start? Give me a sort of potted history.

PD:  Goodness me, I'd have swotted up if I'd known I was going to be asked that!  Well, pathology as a science didn't actually start till probably the early twentieth century.  There were pathologists before then looking down a microscope – Van Leeuwenhoek in the 1670s, I think, developed the first microscope, and people like Louis Pasteur looked down microscopes in the late 1800s.  But there wasn't, as far as I'm aware, a science called pathology.  In fact even in the early part of the twentieth century, physicians and surgeons used to do their own postmortems and used to look at the specimens removed at surgery.  Turnbull, one of the first professors of pathology here, was appointed in 1920 something, I think. Then the speciality of pathology began to develop, and it started to be taught as a science subject as well in medical curricula.  Again, it probably depends on what you call pathology, because pathology to us encompasses all the major specialties including microbiology, Haematology The branch of medical science concerned with the blood and blood-forming tissues;  haematopathology is concerned with diseases of. etc.  There were bacteriologists before histopathologists, so histopathology is a relatively new specialty, from early 1900s.

SA:  And what about the relationship between anatomy and pathology?

PD:  Well, it's always been relatively close because obviously when you do a postmortem on a body you have to know about anatomy.  Having said that, in general anatomy is the realm of surgeons and not pathologists.  Although I would argue that there's quite a significant overlap between the two, and anatomy has suffered the same sort of reduction in curriculum time as pathology has.  But as pathologists we don't teach anatomy, and we're not directly involved in it.

“Compatible with a normal life”

SA:  So when you decided you weren't going to go on to surgery, you were going to carry on in pathology, what most appealed to you to make you change your mind?

PD:  Well, as I've said, the variety.  And also I have to say, the lifestyle was attractive and appealing.  I knew that if I carried on in surgery I'd have ten years or so in front of me of really very, very stressful long hours.  I might not necessarily have found that a problem, but having experienced pathology I thought: "Well actually, it is compatible with a normal life."  It's 9 to 5 if you want it to be, but most of us work 8 till 6 or even longer, but you don't get woken up at night, usually, and you can pretty much plan your day.

SA:  What about being a woman in pathology – has there ever been any sort of glass ceiling?

PD:  No.  In fact in pathology, as you've probably noticed, there are as many women as men, if not more so, because of this fact that it's compatible with a normal life.  I don't have children, but if I did, I'd be very grateful to have a 9 to 5 job and not to have to organise childcare for my 'on call' nights etc etc.  (And you don't need the incredible stamina that you do in surgery.)

So yes, I'm a woman, but in my entire medical career I've never been aware of being a woman and therefore being different from men doing the same job.  Really, it's never ever been a conscious thing with me.


SECTION 6

SA:  So tell me a bit about your family life.  There was an anecdote I heard about when you gave your first paper at the Pathological Society – can you tell it to me yourself?

With twins Aron and Sasha at the officePD:  Well, it was just before New Year's Eve 1990, and I was due to give a paper at Path Soc on about 4th January 1991, my very first paper at Path Soc, and I was very nervous about it.  My boyfriend at the time was in the Territorial Army and on the 27th December he was called up to fight in the first Gulf War.  Obviously I was devastated about that, and on 28th December we decided that we'd get married.  So on 29th December we went to Islington Registry Office to ask if we could do that in two days' time, because he was leaving on 1st January to go to the Gulf, and one didn't know what was going to happen.  They were very accommodating and arranged for a special licence.  

We managed to get round the red tape somehow, and we got married on New Year's Eve 1990, with just three days' notice.  We couldn't have a proper celebration -- there was no time, so we just had our parents and a couple of friends.  

We'd already arranged to go to a party on New Year's Eve, so we did.  It was actually our wedding night, but we went along to the party, and I ate something dodgy, which meant that the following day, which was the day he was leaving, I was in bed with food poisoning!  So that was my goodbye to my husband – I was in bed feeling really sick.  And on the following day I had to get up and go to Path Soc!

I was still feeling really unwell, and obviously I was feeling miserable because my new husband had just gone to the Gulf.  I thought I'd have time to practise my talk, but I didn't because I was feeling too miserable and too ill.  The Path Soc meeting was in Cambridge and they put us up in a Cambridge College which was absolutely freezing.  I cope really badly if I'm cold and trying to sleep.  Everything I had with me I had on, including shoes!  I had the electric fire on at the end of the room, and every blanket, and I still couldn't sleep.  

I slept not a wink that night, and my talk was due the following morning.  I got up still feeling the after-effects of this food poisoning, still feeling miserable, but somehow the adrenaline kicked in at the right moment, and I managed to get through my talk – not only that, I got compliments!  People said it was a really good talk, and I thought: "If only they knew!" I have never again, to this day, given a talk feeling so bad for so many different reasons!  [We both laugh]

Awareness of mortality

SA:  Oh dear!  But tell me, what has this job, where you're confronting death so often, done to your attitude to life, your philosophy?

PD:  Well, you see so much disease in so many different patients, I think it's made me a little more philosophical about what's going to happen to my own parents, and myself really.  I have had two very close cousins die of cancer, both at young ages.  And it's made me philosophical in a sense, in that I see disease in so many people, I know how widespread it is, I know that people die young, and I know that people will get sick and die and they will be gone.  It's made me a bit more accepting of the fact.

SA:  So you're very aware of mortality in a way that most people aren't until it comes close?

PD:  Yes, yes.

SA:  And what about religious beliefs – you must have been brought up a Catholic…?

PD:  Yes. I mean I don't practice as much as I used to when I was younger.  Mostly because my current husband is Jewish, so it's difficult for us to share religious experiences!  He's not religious, but he does the usual things like not eating pork, and what have you.  But he doesn't very often go to synagogue.  So I don't go to church very often any more.  I used to when I was younger, and certainly in my first marriage we used to go to church quite a bit.  It doesn't mean that I have stopped having faith…

SA:  Really?  Because there's this huge debate at the moment about whether science and religion are incompatible, and I think this kind of work very often does throw up issues of living and dying and religion…Has it for you?

PD:  [reflects] Well, I think medicine in general does, I'm not sure that pathology would affect it any more than doing medicine and doing science has.  But I personally don't think the two are completely incompatible.  I do wonder sometimes what there is after life.  But at the same time I think, well, surely there has to be a point to all this.  I can't imagine that there isn't some reason for us as a species, as a globe, as a world, being here…

Because I'm a scientist I like to find reasons for thingsBecause I'm a scientist I like to find reasons for things -- scientists do want to know why things are there, why things are happening, and it's the same for me, I can't see any reason for us having developed other than that there is somewhere a god, and there is somewhere a separate life on a separate sphere.  Perhaps not as we know it, but in some way that gives a purpose to our life on earth.

“Larger than life” mentors

SA:  What about mentors and inspirers throughout your career?

PD:  Well, the professor I mentioned who gave me the job right at the beginning, Gerry Slavin, I don't know about him being a mentor, but he was always the sort of person that I aspired to. There's another consultant at Barts, David Lowe, who's retired now – well both of them have retired – but both of them were atypical pathologists in the sense that they were… Many pathologists are quite reserved, quite quiet, they like being on their own, that's part of the job, you know, it's you and your microscope sitting in a room without that much interaction.  David Lowe and Gerry Slavin were both much larger than life characters, very extrovert, very open, almost bonkers in a way.  

They weren't really bonkers, but that's the sort of impression they gave to medical students.  And I'm a bit like that, sort of quite extrovert and I like to sort of communicate with people.  I like standing up in front of students and acting a bit silly and making them enjoy it and making them laugh.  So they were both role models in the sense that I wanted to be like them.  The students loved them, and they really enjoyed the way that they taught.  So they've been my role models in the way that I teach students, and in the way that I'm perhaps a slightly atypical pathologist as well.  

Mentors?  Again Gerry Slavin was the one who gave me the first job, who created the senior lecture post and my first consultant job, so I suppose he's the one that I have to be the most grateful to.  Sometimes he used to drive me nuts.  He'd come down and say to me: "Paola, I can't do this lecture tomorrow.  You'll do it for me won't you?  Good girl; good girl!"  He was very good to me but at the same time he used to dump me in it quite a bit!

SA:  And what about inspiration – what most inspires you in your job?

PD:  Well, in the two aspects of my job, the teaching and the diagnostic work, I suppose it's easier to be inspired in the teaching, because you can see the students progressing.  The other thing I am, apart from a teacher, I'm what we call a senior tutor to a number of medical students here, and some of them have particular problems and you have to follow them quite closely, and they struggle throughout their medical career, some of them are ill, and following those and getting them to qualify is really…makes the job worthwhile to me, inspires me in the sense of I feel that it's a good job to have and it's good to have got these young people through who might otherwise not have.  

So I'm inspired by the students learning, I'm inspired by the fact that they seem to enjoy it, I'm inspired by getting the problem students through…


SECTION 7

Attributes of a good pathologist

SA:  Okay, so what makes a good pathologist?

You have to be good at pattern recognitionPD:  What makes a good pathologist?  First of all, I think you have to be good at pattern recognition; you have to see what you're seeing down the microscope and remember it from the time before.  You have to be thorough  in your thinking, "Well, if I haven't seen this before, what must I do to try and make the diagnosis?  Must I do some more special stains?  Must I show it to somebody else?  Must I read up in the books about it?"  And you have to be quite determined to find out.

You should be able to picture what the pathologist  is seeingYou have to be good at written communication, believe it or not, because your way of communicating what you think about a particular case is through the written word.  When you read a report you should be able to picture what the pathologist who's written that report is seeing, and agree with their interpretation.  And actually not all histopathologists are very good at that.  I read some reports and I haven't got a clue what the pathologist was seeing or what they were thinking about when they wrote it.

So I feel you have to have a skill in putting what you're seeing down the microscope into words.   

SA:  So when people come to you to study pathology, how do you recognise someone who is not going to make it?

PD:  Well, somebody who, first of all, is not thorough enough.  Who, for example, shows me a slide, hasn't bothered to look out the previous slides on the case, hasn't bothered to find out the history of the patient, hasn't bothered to think about what extra stains or what extra things they might do.  I think that's probably the most serious fault, if you like, in a potential pathologist -- it's not being thorough enough.  

I'll give you an anecdote of a case I had many years ago now [to illustrate the importance of being thorough].  I looked at some placental tissue, some products of conception, from a young girl, and I wrote my report, a reasonable report. It turned out that that girl was educationally subnormal and had been raped by her father and had become pregnant, and what I was looking at was the scraping of the womb, basically an abortion.  The case went to court because the father was being tried for rape, and for some reason they thought that the specimen I'd reported was important to the case.  So here was my report being shown to the courts; a report of a case which I normally wouldn't think twice about.  But it just happened that it was central to the case -- proving that there was conception, so obviously there had been intercourse.  

And another anecdote, about a gall bladder.  Removal of the gall bladder is fairly routine, and most of the time when you send it to the pathology department you don't expect anything to be wrong with it.  You hardly look at the report.  But this particular case we just had the gall bladder, did the report (which again was reasonably thorough), and it turned out that the woman had died post-operatively from complications of the surgery, and what was wrong with the gall bladder was important to the case.  The doctor who had done the surgery was sued for negligence or something like that, and the gall bladder report was central, was one of the important factors in the case.

SA:  And did you know that beforehand?

You never know when a report might come back to haunt youPD:  No, not at all.  So I'm extremely thorough with every single case.  If there are six pieces of tissue, I make sure that the report says six pieces.  And I try to instil that in all the trainees: "You've got to be thorough; you've got to do this properly; you've got to make sure there are no spelling mistakes in every single report.  Because you never know when a report might come back to haunt you."  

SA:  You were saying that you think the tide is turning again, and you feel pathology may be being recognised as central to medicine again.  Is that happening?

PD:  In medical education?  Not quite yet.  But there's the beginnings of a groundswell.  People are beginning to realise, let's put it that way.  The publication from the GMC (General Medical Council), Tomorrow's Doctors, was the sort of bible on which many of the major curriculum changes made by medical schools were based.   The first edition was 1993 (although even before that a lot of the changes were being considered) and now they're on their third edition and the Royal College of Pathologists is in dialogue with the GMC.  In fact we had Graeme Catto, President of the GMC to dinner at the Royal College the other day and one of the things we talked about was the new edition of Tomorrow's Doctors, and how important we felt it was that pathology be included... because the two previous editions didn't make a single mention of it.

Relationship with clinicians

SA:  So in your time as a pathologist, what has been the relationship between you and the rest of the clinical team, and have you seen that change too, from a moment when you were seen very much as the lynchpin of the team?

We've become more important on the clinical teams againPD:  Well, it's gone full circle in a way.  Again, it's probably before my time, but pathologists were one of the main specialties in a hospital along with medicine and surgery.  Pathologists were really prominent and the professor of pathology was one of the most important doctors in the hospital.  Then it changed to being ‘the backroom boys’ and nobody taking any notice of you.  Now, the fact that the Cancer Plan has insisted that multi-disciplinary meetings occur for each patient with cancer, we've become more important on the clinical teams again.  If the pathologist isn’t there at one of the meetings it gets recorded.  It's one of the standards by which the multidisciplinary teams are assessed – the presence of a pathologist.

That's yet to translate itself into medical educationThat's one of the reasons why the number of pathology posts in hospitals increased again in the late 1990s, early 2000s, and why the number of vacancies went up so much – people retiring early, new posts being created, and not enough trainees to fill them.  So we've become important again to the cancer teams and to the multidisciplinary teams, but that's yet to translate itself into medical education and being important in teaching students again.


SECTION 8

High points and achievements

SA:  Okay, one final question.  Tell me about the high points in your career.  What really stands out?

PD:  Well, I suppose all the jobs I've done.  Every time I've been promoted has been good.  Becoming involved in the Royal College of Pathologists – I'm now Registrar for the College and that's quite prestigious.  Being appointed as a professor was obviously nice – particularly for my parents, who were both from a farming background.  No one's ever been to university in their respective families, ever.   I gave my inaugural lecture about four months ago.  Even though I've been a professor for about four years, for various reasons my inaugural lecture was delayed until March, and that went very well.  My parents were at it.
 
It was a bit about my history in pathology, some of the problems I've been talking about in pathology education, and what we can do about the future.  And then I actually did a magic trick at the end!  A card trick.  It was linked in with how teachers have to be entertainers as well.  I had a friend who used to be one of our trainees, went off to the States to be magician full time!  He always was an amateur magician but he decided he wanted to jack pathology in and become a professional magician, which he did very successfully.  He taught me how to do a card trick, and that went down very well.

I wanted my talk to be understandable, because I've been to a lot of inaugural lectures where people have talked about their research a lot and I haven't understood a word because it wasn't my field.  So I wanted it to be completely understandable to even non-medics like my parents.  And I wanted them to be entertained as well.  

SA:  How much of an influence have your parents had on you, would you say?  Your mother was a teacher, did that influence you towards teaching?

My parents' philosophy in life has always been my guiding lightPD:  When we were younger my mother always sat over us when we did our homework, was always helpful in that way.  She was never a teacher in the UK; it was when she was much younger in Italy.  But I think my parents' philosophy in life has always been my guiding light, as it were.  You know: working hard, being good academically.  Even though my father left school at 13 with not a single qualification, he taught himself how to repair TVs and radios etc.  So even he has been an influence on me – the fact that if you work hard, if you go to school and you're good at it, then you can overcome all the problems.  

I mean you know, the problems we had when I was growing up…I never had any money, ever.  They were both starting off; they had nothing, my parents.  We had an outside toilet, we were in a flat above a butcher's shop, we had a bath in the kitchen – it was real sort of slum poverty.  But they had this sort of 'get over this' attitude.  You know: "You will get over this, you will do better, you will succeed if you work hard."  

SA:  And did you want to get away from it – growing up in that sort of environment, were you ambitious to move on?

PD:  Oh yes.  Absolutely.  I was driven when I was at school.  Part of it obviously comes from within, but part of it also has to do with respect for your parents, respect for what they've gone through and for what they've given up to get you to where you are.  But I think undoubtedly the ambition came from me to do well at school.  My thought was, if I do well, I'll get a good job and I'll earn lots of money.  And, I don’t know, maybe some of that has been lost from modern society – I think today's children are perhaps a bit too spoiled, they don't have to work for anything…

SA:  And were your peers also from backgrounds as poor as that, or were you remarkable in your school, in your community?

PD:  I grew up in Islington, which now is an affluent, yuppified area, but in my day was very poor.  My school was a state school but it was quite a good school.  Most of the students there were better off than me but I wouldn't say 'middle class'.  I would say working class, most of the other students I went with, but not as working class as we were! For example, they used to go on school trips, but I couldn't because we couldn't afford it.  They used to get new trainers, new shoes, but I had the same pair pretty well all the way through school.  They used to buy school uniform; my mum used to make mine, etc.

SA:  And how did you feel about that?  

PD:  Well that was what… I was driven.  I thought, "Right, I'm going to do well at school and get a good job and get out of this."

SA:  Did you ever resent your parents, or did you just resent the poverty?

PD:  No, I didn't resent my parents.  If I'd grown up in Italy I don't know what we'd have been.  We certainly wouldn't have had the academic opportunities that we had in the UK.  All my family in Italy have jobs in factories, none of them have gone to university, and they married young and had children.  They would not have had the academic opportunities that we had in England.  So I didn't resent my parents.  In fact I almost thanked them in a way.  It was strange…I thanked them for that, but at the same time they were strict.  I had a lot of battles to fight.  I was the oldest of three children, so I had a lot of battles to fight when I was young – in terms of going out in the evenings, having a boyfriend, going away to university – they were against all of that.

I applied to Cambridge and Oxford, didn't get in, and in the end went to UCL (University College London), which was actually down the road from my home – not because I wanted to but because I didn't have any choice.  And I had to go on living at home.  That was a bit tough because, you know, all my friends at university were going out, doing what they liked, and I couldn't do that.  I think it cramped my style a bit.  Looking back on it now, I would like to have gone away to university, gone out of London.  

SA:  How easily have you moved between your Italian family back in Italy and your life here?  Have there been any problems, given that you're the first person to go to university?

PD:  Very few of them have ever come to visit us in fact, so I think it's very difficult for them to appreciate what it means.  To them I'm just the little girl who grew up in London, but I don't think they have any concept of what it's like a) to go to university, b) to be a doctor, or c) to be a professor.  I just think it's a completely alien world to them.

I used to go back every year without fail, but I realised I needed to go to other places in the world.  My parents are both now in their late 70s, and nearly all their siblings have died.  Yes, my cousins are still there, but inevitably as one grows older… the relationship isn't as close as it was when I was younger.

SA:  But your learning has distanced you from them, or from your own parents?

PD:  No, not at all.

SA:  Did you grow up in a home with books and things?

PD:  Yes, I devoured books, absolutely.  We used to go to the library all the time, and my parents encouraged that.  My mother says that I could read by the age of two, and she says I was always interested in reading. Of course in those days there weren't computer games; and we didn't have any toys because we couldn't afford them.  We had a small television that my father brought home, because he was in the business, but 7 o'clock in the evening that got switched off and we read and then went to bed.

SA:  Another final question…What does your pathology mean to you?  How much of your identity is it, your job?

I'm very aware of my background and my rootsPD:  That's a difficult question.  I don't know…I suppose the other thing that defines me is my ethnic origin.  I would say that that defines me more than the fact that I'm a pathologist.  To be honest I'm British, but I'm very aware of my ethnic origin being Italian.  I'm very aware of my background and my roots.  I'm still uncomfortable in 'high society'.  I still don't take taxis because of the way I was brought up; I still buy my clothes in the sales, even though I now have enough money to do what I want, I still find it difficult to spend money.  I think that defines me more, in a way, than being a pathologist.  The fact that I come from an immigrant family that was poor and Italian has been more of a defining feature of my life than anything that I've done since then.  

SA:  Is there anything you do spend money on?

PD:  [laughing] Football!  I'm an ardent Chelsea fan, and I've got a season ticket.  I've been interested in football since I was 10, but obviously didn't have the money to go regularly until about 10 years ago.  I've had a season ticket for 10 years.

SA:  Apart from your season ticket to Chelsea matches, can you now buy yourself something not in the sales?

PD:  Of course I can in terms of "I can afford it", but in terms of psychologically and emotionally?  Difficult.  

ENDS