Strategies for a Successful Anatomic Pathology Subspecialty Workgroup: The 26-Year Collaboration of "The Elves".

From 1990 to present, 14 liver pathologists and 2 clinical hepatologists from 9 countries have met annually to hold thematic 2.5-day meetings centered on case-based discussion. The goal of these meetings has been to identify gaps in knowledge in our field and fuel scholarly effort to address these gaps. The founding principles were worldwide representation, good representation of women, compatibility of participants, commitment to stable membership and regular attendance, mutual education and friendship, and free exchange of ideas. A summary report of the 2.5-day meeting constituted an enduring document that captured the free flow of ideas discussed. These ideas were open to all participants for the pursuit of scholarship back at their home institutions. However, any idea borne out of an Elves meeting merits open invitation for other Elves to participate in, using established standards for meaningful coauthorship. Over 26 consecutive meetings (1990-2015), themes covered the breadth of liver pathology. With retirement of 2 individuals, resignation of 3, and death of 1, six new members were nominated and voted into membership. Over these same 26 years, active members published 2025 articles indexed in PubMEd Central under the topic "liver;" 3% of these articles represented collaborations between members. This international group represents a successful model in a subspecialty of anatomic pathology for open exchange of ideas, mutual education, and generation of topics worthy of scholarly investigation. We conclude that a self-selected group of subspecialty pathologists can meet successfully over 26 years, maintain a high state of engagement through each annual meeting, self-renew as a result of retirement or resignation, and provide a creative stimulus for highly productive academic careers.

Introduction

The subspecialty of liver pathology came into existence in the 1950s, concurrent with the establishment of specialized treatment units for patients with liver disease[1] and the development of safer technologies and techniques for rapid percutaneous liver biopsy.[2] In 1968, a largely European group of liver pathologists came together as an ad hoc group with the purpose of developing a consistent approach to the role of liver pathology in the management of patients with liver disease.[3] Their landmark article addressing chronic hepatitis, published in Lancet,[4] became the seventh most cited article of the 20th century on the topic of liver pathology.[5] The 15 members of this group, dubbed “The Gnomes” (after the banking “Gnomes of Zurich”) by the legendary hepatologist, Dame Sheila Sherlock, were to become highly influential scholars in the field of liver pathology. Specifically, articles published by members of this group represented 122 of the 150 most cited articles in the field of liver pathology, when assessed in 2004.[5]

The sustaining contribution of this first-generation group of liver pathologists was the inspiration for formation of a second-generation group in 1990. Under the mentorship of professor Peter J. Scheuer, 3 organizing members (N.D.T., A.P.D., and R.C.) invited 12 other young liver pathologists to assemble in London in July 1990 for an initial convening. In a business meeting at the close of 2.5 days of case-based discussion, the decision was unanimously made to continue forward as the “International Liver Pathology Study Group.” Given the “Gnomes” moniker of the first-generation group of liver pathologists, light-hearted but inconclusive discussion was given to potential nicknames for this second-generation group. The following year’s 1991 meeting, held in Boston, Massachusetts, was at the dawn of the facsimile technology for telecommunication. The host and organizer of this meeting (J.M.C.) started all of his fax communications with “Dear Elves,” and the name stuck. This is a report of the 26-year experience of “The Elves.”

The membership and home city of the founding group in 1990, and that of the group that convened in 2015, is given in Table 1. Notably, the invitations to the founding 16 members intentionally included 2 practicing hepatologists (C.B. and D.v.L.); their perspectives on the clinical care of patients with liver disease were to prove invaluable contributions to our annual discussions. Although 4 of the founding members retired from their clinical posts (P.J.S. 1992; C.B. 2014; L.D.F. 2015; Y.N. 2014; and B.P. 2006); only 1 member stepped away completely (B.P. 2005); 2 continued on as active participating members (L.D.F. and Y.N.); and 2 remained in contact with the annual meetings in an emeritus nonparticipating role (C.B. and P.J.S.), until the untimely death of 1 (P.J.S.) in 2006. Owing to competing career pressures, 3 members resigned (K.B. 2005; R.C. 2006; and J.R. 2005), essentially after completion of the first 15-year cycle. Most of the members remained in 1 academic institution for all 26 years; 2 (J.M.C. and D.v.L.) each journeyed through 4 academic institutions during these years.

Table 1.

Membership.

1990	2015
Peter Scheuer (London, United Kingdom)*,†	Venancio Alves (Sao Paolo, Brazil)
Charles Balabaud (Bordeaux, France)*	Prithi Bhattal (Melbourne, Australia)
Krystof Bardadin (Warsaw, Poland)‡	Paulette Bioulac-Sage (Bordeaux, France)
Paulette Bioulac-Sage (Bordeaux, France)	James Crawford (Manhasset, New York)
Romano Colombari (Verona, Italy)‡	Amar Paul Dhillon (London, United Kingdom)
James Crawford (Boston, Massachusetts)	Linda Ferrell (San Francisco, California)
Amar Paul Dhillon (London, United Kingdom)	Maria Guido (Padova, Italy)
Linda Ferrell (San Francisco, California)*	Prodromos Hytiroglou (Thessaloniki, Greece)
Yasuni Nakanuma (Kanazawa, Japan)*	Yasuni Nakanuma (Kanazawa, Japan)
Bernard Portmann (London, United Kingdom)*	Valarie Paradis (Paris, France)
Jurgen Rode (Darwin, Australia)‡	Alberto Quaglia (London, United Kingdom)
Dale Snover (Minneapolis, Minnesota)	Dale Snover (Minneapolis, Minnesota)
Neil Theise (New York, New York)	Neil Theise (New York, New York)
Swan Thung (New York, New York)	Swan Thung (New York, New York)
Wilson Tsui (Kowloon, Hong Kong, China)	Wilson Tsui (Kowloon, Hong Kong, China)
Dirk van Leeuwen (Amsterdam, the Netherlands)	Dirk van Leeuwen (Amsterdam, Netherlands)

*Retired.

†Deceased.

‡Resigned.

With each vacancy in membership, the group elected to conduct open recruitment, rather than acquiesce to replacement of a senior individual with a more junior colleague from the same institution. This group chose not to bring candidates to an annual meeting on a provisional basis. Instead, at the business meeting of the immediate next annual convening, candidates were presented in absentia by nominating sponsors, and vote taken, with the intent that the selected candidate be invited to the following year’s meeting. In no instance was an invitation declined.

Recognizing that the membership of the group was by invitation at the outset, and through self-governance thereafter, it is important to note that the founding 1990 membership included 3 women from 2 countries (France and United States), and the 2015 membership included 5 women from 3 countries (France, Italy, and United States). Excluding the founding mentorship of professor Peter J. Scheuer, the age range of the initial 1990 membership was 29 to 45 years of age and of the 2015 membership 46 to 73 years of age.

The 1990 invitation from the 3 organizers was for prospective attendees to submit a single histology H&E-stained slide, a single unstained glass slide, and clinical histories from 3 interesting cases on the ab initio topic of “Nodules in Nodules.” The initial 2.5-day meeting was case-based discussion of these cases, using the third morning for a summary discussion. The key event of the 1990 meeting was the closing business meeting, which established the founding principles of the group (Table 2). Critically important was the decision that a primary purpose of the group was education and friendship. The inclusion of friendship as a linked primary purpose was commitment that openness and trust in the free-ranging discussion was to be the fundamental culture of this group. Scholarship was relegated to secondary status, since each member would be conducting their own scholarship in the normal course of her or his professional career. We thought that placing scholarship as a primary purpose would be a constraint on the otherwise free discussion that we sought during our meetings, owing to the potentially burdensome requirement that there be a publishable product out of any given meeting.

Table 2.

Founding Principles.

Operational principles	Worldwide geographic distribution
	Good representation of women
	Compatibility of members
	No further additions, except as vacancies occur
	Primary mission: Education and Friendship
	Secondary mission: Scholarship
	Three absences would be reason for resignation
Mission	Free exchange of crazy ideas (sic)
	Extend our horizons
	Learn from one another
Meeting format	A thematic topic is chosen the year before
	Each member sends out:
	Two thematic cases
	One “great case”
	Diagnoses are submitted to the year’s host
	The host compiles all submitted diagnoses in a notebook organized by originating institution
	The host selects the case discussion order based on thematic sequence of the submitted cases
	The meeting consists of:
	Day 1: Case discussion
	Day 2: Case discussion and social program
	Day 3: Business meeting and summary discussion
Financial support	Travel and accommodations: responsibility of members
	Meeting site: almost always the home department, no cost
	Social program: responsibility of the host

The 2.5-day, case-based meeting format has been followed for all 26 years. Members submit their diagnoses on “unknown cases” to the meeting host, who then compiles these unknown diagnoses—and the submitted “correct diagnoses”—into a meeting notebook organized by source institution and case. The chronological sequence of case discussion was at the host’s discretion, with the goal of clustering similar cases together, regardless of source institution. A wrinkle introduced by this second-generation group was that only 2 of the submitted cases from any given member would be thematic; the third case would be a “great case” on any topic in liver pathology. These “great cases” generated as much vigorous discussion as the thematic cases (see subsequently) and extended the horizons of the group far beyond the constraints of the annual theme.

In the founding business meeting, specific consideration was given to intellectual property. Open discussion was to be encouraged, meaning that members would be likely presenting not only potentially publishable case material but also their most advanced thinking on the thematic topics under discussion. Moreover, the meeting itself was intended to be a creative, generative process, with the goal of prompting scholarly work by members in follow-up to the meeting. Without precedent to guide the discussion at the 1990 business meeting, the principles of intellectual property were agreed upon (Table 3). These were designed both to encourage members to present their extant creative scholarly efforts to their colleagues at any given meeting and to encourage the generation of new scholarship as a result of the meeting. On the latter point, any idea generated during the annual meeting was fair game for a member to initiate a scholarly project upon return back home. The principle of “open invitation for collaboration” ensured that any other members who wanted also to pursue such scholarship could do so. These principles were reaffirmed in the 1995 business meeting. This principle has served the group extraordinarily well over 26 years; in no instance do we recall strife between members over intellectual property.

Table 3.

Intellectual Property.

Preexisting ideas

• Members can present incomplete or nascent scholarly effort relevant to their submitted case, without fear of other attending members surreptitiously pursuing similar effort

• If appropriate, follow-on collaborative multi-institutional studies can be considered

Ideas developed in the course of an annual meeting

• Ideas exchanged and generated during the meeting are open to all participants to pursue

• These ideas can be “worked” back home in any member’s institution

• However, an idea borne out of an Elves meeting merits open invitation to Elves to participate at the start of project. Whoever joins in (and contributes in a meaningful fashion) earns coauthorship.

A separate consideration was financial support of each annual meeting. First, members were individually responsible for their travel and accommodation costs. Second, since most meetings were held in the host’s home department of pathology, costs for the actual meeting site could be avoided. The ancillary meeting costs were most often supported by the host department. In 3 instances, the host organized a preceding symposium for continuing medical education (CME) to raise funds for the Elves meeting and to take advantage of the convening of 15 world experts in liver pathology in their host city. In 1 instance, the members made donations to the host, so as to collectively cover the costs of the meeting.

The group was successful in holding to a well-distributed rotation (Table 4). Owing to injection of new membership for the second cycle, new host cities appeared in the second cycle. There was full attendance at about half of the meetings or absence of only 1 or at most 2 members. The thematic topics were selected on the basis of pressing issues of the day pertaining to specific disease entities (eg, the discovery of hepatitis C virus in 1991 and the 1991 theme of “chronic hepatitis”); 2-year sequences to further pursue a specific theme (eg, 1992, bile duct diseases; 1993, bile ducts and their microenvironments); and a trend in later years to explore pathobiology as a thematic topic (eg, 2006, centrilobular injury). Disease conditions were revisited in the second cycle, given progress in the interim (eg, 1998 and 2014, steatosis and the cirrhotic liver). Only once was pediatric liver disease considered (1996, metabolic diseases), not repeated owing to the difficulty of most submitting members to obtain case material on the topic.

Table 4.

Meetings and Themes.

Year	City	Theme
1990	London, United Kingdom	Nodules-in-nodules (hepatocellular neoplasia)
1991	Boston, Massachusetts	Chronic hepatitis
1992	Amsterdam, the Netherlands	Bile duct diseases
1993	San Francisco, California	Bile ducts and their microenvironments
1994	Verona, Italy	Vascular and sinusoidal diseases
1995	Bordeaux, France	Liver toxicity
1996	Hong Kong	Metabolic diseases
1997	Kanazawa, Japan	Biliary neoplasia and preneoplasia
1998	Warsaw, Poland	Steatosis and the cirrhotic liver
1999	Darwin, Australia	Hepatocellular carcinoma
2000	New York, New York	Necrosis and vascular injury
2001	Jakarta, Indonesia	Patterns of fibrosis
2002	London, United Kingdom	Hepatitis
2003	Melbourne, Australia	Fibrosis
2004	Minneapolis, Minnesota	Vascular lesions
2005	Bordeaux, France	Primary biliary cirrhosis
2006	Gainesville, Florida	Centrilobular injury
2007	Hanover, New Hampshire	Periportal pathology
2008	Kanazawa, Japan	Diseases of the sinusoid
2009	San Francisco, California	Cirrhosis and portal hypertension
2010	London, United Kingdom	On-beyond-cirrhosis (to include regression)
2011	Hong Kong	Biliary neoplasia
2012	London, United Kingdom	Atypia and dysplasia of small bile ducts and glands
2013	Thessaloniki, Greece	Cholangiocarcinoma
2014	Sao Paolo, Brazil	Steatosis and the cirrhotic liver
2015	Padova, Italy	Vascular disease

Given the founding principle of education, the comprehensive scope of these meeting themes was a powerful driver of knowledge for the membership. Both for the thematic cases and the “great cases,” members acquired working knowledge of a breadth of liver pathology far beyond what they might have previously encountered in their own institutions. Each member can cite numerous examples of diagnostic acumen back home, thanks to case experience obtained through the Elves. Moreover, the assembled case collections as the years accumulated became invaluable teaching resources for each member’s home institution.

In recent years, case submissions became approximately two-thirds “glass” and one-third digital—both by submission of compact discs (CDs) or by authorized access to hosted digital sites for whole-slide imaging. Although this drift toward digital submissions expanded the ability of members to submit cases with limited source tissue, the enduring record of case material is partially dissembled, owing both to the less permanent nature of CDs and their enabling software and the only temporary availability of hosted websites for whole-slide imaging.

With the host both knowing the “correct diagnosis” on each case, as provided under separate cover by the submitting member, and having organized the submitted cases into a thematic sequence for the meeting, the annual host was empowered to serve as moderator of the discussion. Quite by circumstance, an assiduous note-taker (J.M.C.) was pressed into action in 1991 both as “recording secretary” and to provide a summary of meeting proceedings on the third morning. While at first this was through use of a chalk board or flip charts, digital projection slides soon became the standard format. The format of the summary discussion is given in Table 5 and has consistently formed the basis for a vigorous discussion on the third morning. Besides consolidation of learning, a critical outcome of the summary discussion was declaration of what prospective scholarly research might be of merit and what membership was interested in collaboration on such projects. Although initially the summary discussion was typed up for subsequent distribution, the dawn of digital technologies enabled the immediate distribution of the summary discussion “slide deck” to all members. This slide deck serves as an enduring record of the ideas exchanged during the meeting and as a resource to every member to inspire scholarship and teaching back at their home institutions. This tradition has held to the present time.

Table 5.

Summary Discussion.

Topic	Comment
Meeting metrics	Times of case discussion
Vocabulary terms of note	Formal or whimsical
Truisms	Profound observations, epigrams, including whimsical
Points of agreement	Generally few in number
Points of disagreement	Generally great in number
Points of discussion over 2 days	Wide-ranging, extensive, with many inflection points
Action items	Callouts during the 2-day discussion for scholarly work

Starting in 2009, the recording secretary started documenting the duration of each case discussion. Figure 1 shows the time, in fractions of an hour over 2 days of discussion, for each sequentially discussed case for the 2014 annual meeting on the topic of “steatosis and the cirrhotic liver.” The thematic sequence of cases from nonalcoholic steatohepatitis, to alcoholic steatohepatitis, to tumors arising in steatotic livers, to the “great cases,” is shown. This time chart documents that the case discussion is vigorous over the duration of the meeting, across many topic areas including the “great cases.” The chart provides assurances that neither jet lag nor discussion fatigue substantively affect the case sequence. Importantly, the chart also demonstrates that the discussion remains strong through multiple sequential cases presented on the same topic.

Figure 1.

Time of case discussion, 2014 annual meeting. The start time and end time of each case were recorded, exclusive of midsession breaks or meal breaks. The x-axis denotes the chronological sequence of cases discussed over the course of 2 days; the y-axis denotes the fractional hours for each case discussed. The sequence of thematic topics for this meeting on “steatosis and the cirrhotic liver” is shown, including the “great cases” discussed at the end of the sequence. NASH indicates nonalcoholic steatohepatitis; ASH, alcoholic steatohepatitis; N-ASH, both nonalcoholic and alcoholic steatohepatitis.

Figure 2 shows the case discussion times for each year, 2009 to 2015, as a function of sequential case number. The number of cases submitted and discussed ranged from 35 to 43. The data from these 7 years indicate that case discussions average 20 ± 1 minutes each (average ± standard error of the mean). Within a broad range of individual case discussion times, the same principles are evident year to year: consistent and strong case discussions for the duration of the meeting, inclusive of all portions of the thematic and “great cases” sequence. This is valuable information for host/moderators in their management of the meeting sessions.

Figure 2.

Compiled case discussion times, 2009 to 2015. Using the same methodology as in Figure 1, the times of case discussions over 7 consecutive years are shown.

Scholarship

A final consideration is scholarship. Figure 3 shows the total annual scholarly productivity of active membership in the field of liver pathology and pathophysiology, for the 10 years prior to formation of this group (1980-1989); the first 15-year cycle (1990-2004); and the first 11 years of the second 15-year cycle. Prior to formation of the Elves, total annual scholarly productivity of the founding membership was 33 ± 12 publications indexed in PubMEd Central per year (average ± std dev). Although the correlation may be spurious, the formation of the Elves was concurrent with the founding membership publishing a total of 66 ± 9 publications per year. With rotation to a second cycle of membership with 6 new members, total annual productivity increased further to 95 ± 14 publications. These latter data provide indication that the selection of energetic new membership was successful and that the concept of group renewal through generational rollover is valid. Over the 26 years of the group’s existence (1990-2015), active members published 2025 articles listed in PubMed Central in the field of liver pathology and pathobiology.

Figure 3.

Academic productivity in the field of liver disease of active membership. PubMEd Central was searched for all publications by active membership, under the topic of “liver.” Publications by active membership on topics elsewhere in the alimentary tract or otherwise unrelated topics were excluded. Every citation was verified for authorship and relevance to the topic of liver disease. For the years 1980 to 1989 (“before” the group was formed), the indexed authors searched were of the founding 1990 membership. For all subsequent years, the indexed authors were those actively involved with the Elves during that year. In this stacked histogram, the lowest part of each bar (in red) is published papers involving more than 1 member of the Elves. The total number of publications, inclusive of collaborative papers, is the total height of each bar. Publications by the mentor for this group, professor Peter J. Scheuer, are excluded.

The stacked histogram of Figure 3 also shows that the number of publications involving collaboration between membership remained low; 62 articles in all, on average 3 ± 2 joint publications per year (3% of total publications, 1990-2015). The majority of these collaborations constitute original scholarship; in recent years, a pair of consensus papers have been published on the topic of cirrhosis.[6,7] These data support the premise that the membership retained extensive freedom in pursuit of their own scholarly work, taking advantage of collaborations through the Elves as opportunity permitted. The unanimous opinion of the membership was that the annual Elves meetings were of high value in stimulating creative thought and serving as a springboard for subsequent scholarly work.

Discussion

The purpose of this report is to demonstrate how a self-selected group of subspecialty pathologists can meet successfully over 26 years, maintain a high state of engagement through each annual meeting, self-renew as a result of retirement or resignation, and provide a creative foundation for highly productive academic careers. The organizing principles, particularly as regards generation of intellectual ideas for the purposes of subsequent scholarship, proved to be successful. The particulars of meeting format and member interaction served this subspecialty group well, specifically the case-based discussions followed by summary discussion.

The formation of small subspecialty groups in the field of anatomic pathology is well established. Even within the sector of alimentary tract pathology, groups of expert pathologists have coalesced to establish standards for the practice of transplantation pathology[8] and diagnostic evaluation of steatotic liver disease,[9] inflammatory bowel disease,[10] dysplasia in Barrett esophagus,[11] and chronic gastritis.[12] Within the field of liver pathology, the liver pathologists known as the “Gnomes” are the longest lived: Dating back to their formation in 1968, they have long since undergone their own successful second-generation renewal. A third group of liver pathologists known as the “Laennec Society” has been meeting for over 15 years[13]; this is a larger group, sharing some membership with both the Gnomes and the Elves. Collectively, these many groups have been highly impactful in their own fields of endeavor, both through creation of shared works and through the individual scholarship of their members. Importantly, the annual meetings of these small groups constitute an attractive forum for high-quality education, complementary to society meetings whose attendance is measured in the thousands. We submit that within the field of anatomic pathology, the premise of founding a small, self-selected, and closed subspecialty group is sound. In our case, the founding members of the Elves were in the first half of their careers, in some instances in the very first years following completion of their postgraduate training. The compatibility of the group was high, and the group has remained cohesive throughout the 26 years of its existence.

A peculiarity of each of these groups, and including the Elves, is that with rare exception the membership is by invitation only, and membership is closed. Aspiring nonmembers might petition the group for membership when openings occur, but the prospects for admission to membership are limited. An answer to this dilemma is for like-minded individuals to form their own new subspecialty group. Particularly for younger academic pathologists, the academic stature of the prospective membership is less important than the academic potential of the membership. It is the very formation of such a subspecialty group that can help drive the academic productivity and career progress of the membership. Although the Elves are only one of any number of successful subspecialty groups, the information provided in this report may be of value to individuals who are contemplating formation of such a group.

Finally, this report is written for chairs and division directors of departments of academic pathology. The participation of their faculty in national or international subspecialty groups might be of inestimable value both to the progression of their own careers and also to the prestige of the home department and institution. Engagement of their faculty in such groups at an early point in their academic careers can serve as a multiplier of their academic activity and productivity, with dividends realized through the duration of an academic career.