Peer-to-Peer, Featuring Aleš Ryška

Tell us a bit about the ESP…
 

Exactly 60 years ago, the ESP was founded as a professional society to represent pathologists throughout Europe. The founders established the group in Belgium, which is unsurprising considering they all heralded from Western Europe. We must take into account that the ESP was founded in a time of political division – and it was virtually unthinkable for pathologists from Central and Eastern Europe to participate in professional life within a society based in a “capitalist Europe.” Since then, major developments have occurred – especially in the late 1980s and the millennium. Today, the ESP has more than 3500 members from 90 countries. 

97 percent of our members are pathologists and three percent are allied health care professionals, such as molecular biologists and oncologists. Considering the multidisciplinary nature of modern pathology and the multilateral collaboration of pathologists with different clinical disciplines, I see a clear space for additional growth.

In 2019, our ESP strategy meeting set out a number of goals to achieve over the next 10 years. We emphasized the importance of developing the ESP, including both face-to-face and online education. We also prioritized the support of research development and set out to improve the quality of our journal, Virchows Archiv. It is difficult to describe the entire spectrum of ESP activities, but our general vision is: “Excellence in pathology for optimal patient care.” We can summarize our agenda in three points:

1. High quality pathology diagnosis for all patients
2. Up-to-date education across Europe
3. Support cutting-edge research to understand diseases and translate science into clinical practice

When did it occur to you that you could become President of ESP? Was it a difficult process?
 

The ESP has a well-established mechanism for nominating new candidates for the presidency. A selection committee composed of all past presidents will usually first approach potential candidates. These candidates are then discussed within the ESP council and the final nominee is elected by the general assembly. When I was approached by Dina Tiniakos – who was the president in 2018 – I needed time to think through my decision. At that time, I was serving the society as the Chair of the Education Subcommittee and thought I had a clear idea of the presidential functions. In hindsight, the amount of activity that is outwardly visible is only a fraction of what the job entails. However, I have never regretted my decision to accept the nomination.

Did you propose a plan once you were President? What were your priorities?
 

The term of office for President is two years, which does not provide much room for revolutionary changes. Instead, we focus on fulfilling a long-term strategy that was set in action a decade before. Only history will judge the extent to which I have been successful. I think we have made considerable progress innovating our educational activities. We have changed the concept of the long-established European School of Pathology course system; we have finally managed to make our educational portal functional; we have witnessed significant increase in interest for the annual Pathology Progress Test; and the first ever ESP masterclass was held at the end of last year. Our Giordano Fellowships – with several bursaries that financially support young pathologists who stay at ESP Advanced Training Centres throughout Europe – have been a huge success. 

How many of the proposed aspects of your plan have been realized during your tenure? What remains to be done?
 

I started my tenure shortly after COVID-19 pandemic subsided – when we were able to resume face-to-face meetings while still enjoying the benefits of electronic communication, webinars, and virtual preceptorships. Last year we organized the first post-pandemic congress as a hybrid event and the registration numbers exceeded all our expectations. That congress in Basel was the largest ESP congress with more than 4,200 participants. Actually, it was the largest global, professional meeting of pathologists in 2022. But we are still facing some major challenges. The biggest one at hand is staff shortage because of the dramatic increase of ESP activities. Accordingly, we are currently expanding our headquarters and increasing the staffing.

What did you learn from your time as President? Do you have any advice for your successor?
 

During my tenure, I have learned how important it is to have a well functioning team. I do not hold a graduate degree in management, so I had a lot to learn. I mastered how to delegate and coordinate several projects simultaneously relatively quickly, and I consider that as my greatest personal achievement during these two years of my presidency. My successor will be Peter Schirmacher, who is the director of a large university department in Heidelberg. With his qualifications and experience, I doubt that he will need my advice, although I am ready to assist if asked.

Do you think that the ESP is a strong and solid organization that will grow and flourish?
 

Yes, indeed! I believe the numbers speak for themselves. We are continually growing and our membership has increased by more than 11 percent in the last year alone. One-third of our members are residents, which shows that young pathologists are eager to join us and feel that they are benefiting from their ESP membership.

There are several regions where we can expand further. To this end we are working with several national and international pathology societies. The national societies of European countries are represented on the ESP Advisory Board, which tries to help whenever asked to intervene by representatives of these constituent members. Many issues are common to a large number of countries, and those problems are among the highest ranked priorities that ESP must solve on a regular basis. We also have a memorandum of understanding with several multinational societies, which makes it very easy to collaborate with pathologists from various regions of Asia, America, and beyond.

What is the future of pathology in Europe? And what about current needs?
 

Europe is an extremely heterogeneous continent comprising quite a number of rich and relatively poor countries. With English as the lingua franca, it is relatively easy for pathologists to communicate among themselves and also move from one country to another. Increased mobility of pathologists that currently exists in Europe has many advantages but also causes brain drainage as pathologists from poorer countries move to the more lucrative positions in the West. The reimbursement for pathology services varies considerably from one country to another and that contributes to inequality among the European countries. Furthermore, many modern techniques such as those of molecular biology are not available in poorer regions. The ESP is trying to level out these differences and we are helping pathologists globally – particularly in economically weaker regions – to obtain these expensive tests. Another important role of the ESP is the organization of external quality assurance programs in Europe. The ESP is the founding member of the umbrella organization called International Quality Network Pathology (IQNPath), which helps us coordinate the organization of European Quality Assurance (EQA) in pathology.

Now, let's look at your career in more detail… How did your career in pathology start? Why did you choose to study in Hradec Králové? Wasn’t the “real action” at that time in Prague, the capital of the Czech Republic?
 

My path to pathology was not a straightforward one – I became a pathologist by coincidence. During my senior medical school days, my pathology teacher asked me to help him out with fine needle aspiration cytology specimens. I accepted his invitation and thus FNA became my first practical encounter with diagnostic pathology. Gradually, I delved with ins and outs of real-world pathology, which I found very interesting. I was thereafter offered a residency in the pathology department. I stayed at the same workplace where I studied, which is also the answer to why I ended up in Hradec Králové – a city with only 100,000 inhabitants. Nevertheless, our University hospital contains 1,500 beds and is one of the largest medical facilities in the country. Also, our Institute of pathology is of comparable size as other institutes in Prague. The journey from Hradec Králové to Prague only takes one hour by car, so it is not surprising that we participate in several projects with other pathology institutes in Prague. Since we are centrally located we constantly interact with other pathology departments in the Czech Republic. We also participate in several national research projects involving other Czech pathology institutes.

Which aspects of pathology attracted you the most? Who are your role models?
 

In the old days, we visited clinical wards and performed fine needle aspirations (FNAs). This contact with clinical medicine was the reason why I never saw pathology as a purely laboratory discipline. Nowadays, we no do not perform FNA on the wards since we do not have enough staff to do it. Our pathologists participate in multidisciplinary team meetings and are seen as key players in the management of patients especially those suffering from cancer. During my pathology career, I have been very fortunate to have had several outstanding mentors – from Zoltan Kerekes, who actually lured me to pathology, to my former mentor Ivo Steiner – a true British gentleman. Major European pathologists such as Manuel Sobrinho-Simoes and Fatima Carneiro of Porto, Portugal have also been great inspiration and introduced me to the challenges of international pathology. 

Is research a career prerequisite for academic pathologists in the Czech Republic?
 

The engagement of a university pathologist in the Czech Republic is based on three pillars – diagnostic service, teaching, and research. The proportion between these three activities varies from department to department. It would be naive to believe that the research opportunities for pathologists in the Czech Republic – a country with relatively limited economic resources – can be compared with top American universities and cancer centers, such as MD Anderson or Memorial Sloan Kettering. But we perform research within our league and according to our possibilities. 

I am most interested in the influence of the immune system on tumor growth and the possibilities of using predictive marker testing in the optimal selection of patients for different modalities of systemic anticancer therapy. I have also become interested in comparing the quality of various laboratory tests on an international level and improving implementation of the performance standards according to the guidelines for External Quality Assessment (EQA).

How important was subspecialty training for you? Do you encourage your junior colleagues to choose a subspecialty? Do you believe that one could still remain a general pathologist in your country? 
 

This is a very interesting question. As far as the standard diagnostic service is concerned, I believe that a pathologist in a department of our type should be able to interpret lesions from several if not all organ systems. However, the situation is completely different when it comes to expert analysis or research. Here, sub-specialization is necessary. When I became chairman of our institute, the consultants all specialized only in one particular field, which had its advantages in terms of high expertise, but, in their absence, it caused considerable problems. 

Now, each of us specialize in two specific areas, not only diagnostically, but also in terms of research. By covering several areas (for example, I am involved in the diagnosis of breast and thyroid tumors), there is an overlap and redundancy in the event of absence. In the case of controversial or diagnostically difficult lesions, we always have the option of consulting someone who specializes in that area. This system also creates greater flexibility; for example, if someone decides to change their workplace, the narrow sub-specialization is not a limiting factor. 

How many pathologists work in your department? Do you have problems in recruiting young people into pathology? 
 

Currently, there are a total of 14 consultants working in our department. Our team is relatively young; at 52 years of age, I am the second oldest consultant in my Institute. We have four residents at various stages of their specialty training. When recruiting, we try to rely on graduates who have volunteered for research activities during their undergraduate studies. This approach has proven extremely effective. 

How do you support, foster, and promote your junior faculty? What do you do to keep your department coherent?
 

At the time of my residency, formal training of young adepts was rather minimal. Most of us relied on learning on our own from literature, or from consultation about more complex cases with somewhat older colleagues. Nowadays, we hold weekly seminars to study slides from challenging cases under a multi-headed microscope. Our institute is the only department in the Czech Republic participating in the international slide-exchange project that you initiated called the Kansas Histopathology Club. Every week we have a journal club meeting that includes in extenso presentations of recent scientific papers. Finally, I should mention that our residents rotate on a regular basis from one senior consultant with special expertise to another so as to ensure that they get exposed to a full gamut of diagnostic pathology. 

Since 1998, our institute has held a regular yearly Young Pathologists Seminar. This event has garnered a lot of attention, and over 50 percent of all pathologists in the Czech Republic attend this meeting. The motto of the meeting is: “...for the young of age and/or spirit.” For the first 20 iterations of these seminars, I was in charge of their organization, but when my white hair and beard started to contradict the name of the meeting, I was pleased to hand over the organization of future seminars to younger colleagues! Since they have proven to be very popular, I hope that they will be held for many years to come.

How do you organize common tasks required from your department by the hospital or the dean and other leaders of the medical school? In the medical school curriculum, does teaching pathology weigh as much as it used to 50 years ago?
 

Covering routine diagnostics, teaching, and research remains a major challenge. Our medical school has four parallel undergraduate programs that include pathology. Namely, we teach pathology to regular students of medicine and dentistry, as well to those who take these courses in English. This means that every day there are six, sometimes nine, hours of practical classes, plus three to six hours of lectures. Such a large teaching load requires active involvement of the entire staff and that includes everyone in the department – from the residents to the head of the institute. Students are required to take two semesters of pathology, culminating in a final oral examination. We use this method of testing to ensure that our students truly understand pathology, and did not not just memorize facts from the lectures and textbooks to pass the final exam. 

Routine diagnostic services consume a lot of our time since we must take care of a huge number of cases arriving from the clinical departments. For the teaching we use a syllabus which is handed out at the beginning of the school year and accordingly these two activities of the department are well planned ahead of time. The research is less programmed but it also takes considerable time. Too many medical students and young doctors all these responsibilities seem often to be overwhelming and many of them choose, what they perceive to be, an easier life. The numbers of young physicians interested in full time daily diagnostic service and research seem to be waning. Unfortunately, this trend has been apparently noticed in many other countries and is not unique to the Czech Republic. The focus of our students on a more manageable work-life balance is a reality we must respect, but let us hope that some of them will still join our ranks.

How many students of yours choose pathology as their career? 
 

Each year, we have several outstanding students who demonstrate a deep knowledge and understanding of pathology. After the final exam I immediately offer them the opportunity to volunteer and get involved in research in our department. Every year we also get at least one or two “takers” who are willing to accept this opportunity to experience exactly what research entails, and how much pleasure one can have from studying morphology. Although some of them opt later for a clinical affiliation, according to the feedback they provide upon leaving, they still enjoy having that opportunity. Luckily for us, some of them even become our new residents and devote their life to pathology. 

In general, I think that pathology is still garnering considerable interest among our students. Every year, between 15 and 20 pathology trainees take and usually pass the Czech pathology board examinations. Yet, this number of newly certified pathologists does not seem adequate to meet our increasing routine workload requirements nationwide. One of the possible solutions would entail increasing the number of fully funded pathology positions in the country. However our health system is not responsive enough to our pleas and we are told not to expect increased staffing in pathology departments under present economic conditions. The alternative approach may be to “work smarter not harder.” Thus we are considering other measures, such as more efficient use of human resources, elimination of unnecessary bureaucracy, and the use of digital pathology and artificial intelligence (AI).

Has your career in pathology been a satisfying experience? What are you most proud of?
 

I have never regretted – not even for a single moment – my decision to pursue pathology as a career. For me, pathology is the only medical discipline able to integrate basic medical sciences, morphology and pathophysiology and understanding of disease, with cutting-edge research while also contributing significantly to patient care. Pathology is an evidence-based specialty and it relies heavily on facts despite certain subjectivity included in the microscopic evaluation of slides in our daily practice. For me, this aspect of pathology exemplifies the saying that medicine is, at the same time, a science and also an “art.”

My greatest professional joy stems from the fact that I was given the opportunity to lead one of the most modern institutes of pathology in my own country. Heading a team that provides state-of-the-art diagnostic services to our patients and at the same time is recognized by our peers as a major referral center serving as a national consultation center has been a major goal that my collaborators and I have jointly achieved. Finally we are given credit for participating in the training of hundreds of medical students every year and teaching them pathology “as the basis of their future clinical practice” in Czech or the English language. And finally, with all these daily duties we have found the time and motivation to conduct research to the best of our potential and financial conditions. I still have a couple of years of active life in front of me and all these activities can be maintained for some time. I will retire (in a few years) with the feeling that I have not wasted my time as chairman. 

Serving ESP as president has been a great honor and a privilege for which I would like to thank all my colleagues who have voted for me. I will be leaving my position at the ESP in September 2023 – shortly after the European Congress in Dublin. Although being President is extremely interesting and gratifying, I am looking forward to handing over the imaginary presidential torch to my successor, with my best wishes for an exciting period of life that is opening for him.

^{Image Credit: Aleš Ryška}