Tuesday, August 23, 2016

Who'll stop the rain (Musings on SHOT 2015's use of narrative fallacy)

Updated: 24 Aug. 2016 (tweaks +added video clip)
As last year, the August 2016 blog is stimulated by the UK's Annual SHOT Report, often featured in past blogs. SHOT has long been the best hemovigilance program anywhere and is a treasure trove of educational goodies.

This year's blog is not going to focus on the key results and recommendations of the SHOT 2015 Report but instead give a selective overview. Readers are directed to the Report for all its informative details (Further Reading). Instead the blog will feature only two pages of the 190 pp. report concerning a concept that fascinates me. The case discussed is techie-oriented but the broader lessons apply to all transfusion professionals.

EXECUTIVE SUMMARY: For eager readers who want to know the bottom line before reading further: The blog examines a thesis in the 2015 SHOT report that the narratives we construct after-the-fact to explain why events happen are often wrong and, moreover, prevent us from learning from our errors. Let's face it. SHOT's annual reports document the same and similar human errors year after year. My musings attempt to explain further some of the reasons we create narrative fallacies.

The blog's title derives from a 1970 song by John Fogerty of Creedence Clearwater Revival, rated #188 on Rolling Stone's '500 Greatest Songs of All time.'

2015 SHOT - SELECTED HIGHLIGHTS
Tidbits related to metrics:
First, for perspective, in 2014 there were 2,663,488 blood components issued in the UK (74% RBC). SHOT received reports of 3668 cases or 13.8 reports per 10,000 blood components.

By comparison, in 2015, the number of blood components issued in the UK decreased by 3.2% to 2,577,276 (73.5% RBC). SHOT received reports of 3965 cases or 15.4 reports per 10,000 blood components, an 11.6% increase. Of course, besides more events occurring, the increase could also be due to more complete reporting.

The total number of reports analysed and included in SHOT's 2015 Report is 3288 compared to 3017 reports in the 2014 SHOT Report (9% increase). 

Risk of potentially infected donation entering the blood supply (2012-14)
Hepatitis B 1 in 1.6 million
Hepatitis C 1 in 26 million
Human immunodeficiency virus  1 in 6 million

Risk of death or serious harm from transfusion per components issued (imputability 1-3*) 2015
Death 1 in 100,000
Death from error  1 in 320,000
Major morbidity  1 in 15,500

* Imputability: 1=Definitely related;2=Probably related;3=Possibly related

ERRORS (2015) 
Similar to 2014, ~78% of 3288 analysed cases were caused by error.
Human error accounted for 96.7% of serious adverse events reported to the MHPRA.

Most SHOT reports involve often multiple mistakes related to human factorsThe number of adverse reactions and events related to poor communication and poor clinical decisions are a concern.

Laboratory errors have increased and many laboratories are under pressure with vacancies (some longstanding) and increased workloads.

More than a third of NHS staff reported work-related stress in the 2015 staff survey. Emergency departments struggle: 2 in 5 new consultant physician posts were not filled. Overall funding is tight. 

DEATHS
Patient transfusion-related death is the worst adverse event. In 2015 there were 2 deaths definitely related to transfusion, 9 probably related, and 15 possibly related.

A good figure to show deaths (n=26) correlated to type of serious adverse event is Figure 3.2 on p. 10 of the SHOT Report:

Transfusion-related deaths reported in 2015 by imputability (Copyright SHOT) [Click to enlarge]


NARRATIVE FALLACY - BACKGROUND
As noted, this blog focuses on but two pages of SHOT 2015 because they interest, indeed fascinate, me. The pages appear under 'Error Reports: Human factors' (pp. 24-5) and discuss the role of narrative fallacy in explaining why people do not learn from mistakes. In particular SHOT provides a case (Case 6) that outlines how 3 narrative fallacies occurred involving only one patient's case.

Honestly, who else but the British would discuss a psychological phenomenon like narrative fallacy in a major transfusion medicine report on hemovigilance? With narrative fallacy we concoct erroneous stories to explain facts that we encounter. 

I'm pretty sure in Canada, if we had a hemovigilance system that published its finding for the public, including the transfusion community (we don't), it would deal with numbers almost exclusively, and, beyond that, propose how transfusion professionals could leverage errors into improved transfusion safety and innovate to span the translational continuum from vein-to-vein.

Narrative fallacy can be discussed on many levels (Further Reading). Political examples:

UK: Some Labour Party MPs on the losing 'remain' side in the 2016 brexit vote appear to have rationalized the 'leave' result as significantly due to the lukewarm support and effort of their leader, Jeremy Corbyn. Labour passed a no-confidence vote triggering an upcoming leadership election. It's a narrative fallacy that gives a scapegoat, always satisfying as it stops the need for more in-depth analysis and perhaps unpleasant revelations about Labour Party MPs and officials misjudging the mood of its base.

USA: Some foreign watchers of the 2016 Presidential election patronizingly see Trump supporters as mainly poorly educated bigots, a narrative fallacy that has the advantage of fitting into existing misconceptions some have about the USA. Which isn't to say that some supporters are bigots and that Trump seems happy to feed their needs. 

But Trump supporters, like all Americans, are much more diverse than that, as shown by this Pew Research Center graphic (July7, 2016):
7-7-2016 2-30-10 PM
People are not going to unravel Trump's success without fully examining the spectrum of why people vote for him. Settling on a simple narrative (fallacy) won't do it.

The same applies to the 'whys' of anything people perceive as an 'adverse event'. We need to understand before we can learn from mistakes made and identify contributing factors. Of course, in the political examples above, some may see the events as good, not bad. 

In contrast, the transfusion medicine examples from SHOT 2015 below are clearly adverse events. But I hope you will see that the narrative fallacies are analogous in that the stories used to explain them stop further investigation and work against learning from errors made.

NARRATIVE FALLACY - SHOT 2015
SHOT 2015 introduces its use of narrative fallacy as follows:
'Humans have a tendency to construct stories around facts, which serves a purpose in making sense of the world that might otherwise be seen as too complicated. The natural instinct is to make patterns in order that the world is seen as a simple place, so a narrative is often constructed to explain the facts. Humans are hard-wired to try and turn chaos into order, so they can feel in control of their world. However, this can be termed ‘narrative fallacy’ (Taleb, 2007) because these rationalisations come after the effect and are not based on empirical data. 
...Narrative fallacy means that against all logic, individuals often do not learn from adverse events. Instead of seeing the error as a learning opportunity, the event is rationalised in a more comforting way....'
'Error Reports: Human factors' (pp. 24-5) 
Case 6: Three narrative fallacies add to confusion when grouping a patient after an allogeneic haemopoietic stem cell transplant (HSCT). 

CASE SUMMARY: In brief, the patient was a known group O and, unknown to the laboratory, had received a group A HSCT. A series of ABO grouping anomalies were incorrectly explained by 3 separate narrative fallacies outlined below. 

Besides the role of narrative fallacy, the case serves to stress the importance of communication between institutions, and also between colleagues, patients, manufacturers, everyone on the health care team. I love this clip from Cool Hand Luke:
 

Non-laboratorians may also glean how complex pretransfusion testing can be and the need for well educated, experienced medical laboratory technologists/biomedical scientists. 

Readers not well versed in the technical details of blood grouping or protocols for transfusing patients with HSCT may wish to scan the nitty-gritty of fallacies and focus on [my musings in brackets] after each fallacy. 

It's not the technical details that are key, it's the way our minds work, the stories we tell ourselves, and how often we misinterpret the evidence, typically in ways that are convenient to our needs.

Narrative fallacy 1
A known group O patient's pretransfusion blood sample gave mixed field (MF) with anti-A several times on an analyser suggesting the presence of transfused group A donor rbc. 

A second analyser gave the same MF result. Because fibrin was noticed on the top of the reaction well, fibrin was removed from the sample and it was re-centrifuged, leading to a negative result with anti-A. 

Staff concluded (narrative fallacy 1) that fibrin was responsible for the initial MF because the new result now agreed with the patient’s historical group.

The patient was correctly transfused group O rbc but also group O platelets, incorrect for a group O patient receiving a group A HSCT, which the lab staff were unaware of. 

[Because fibrin is a cause of blood testing anomalies in laboratory tests, the second result which agreed with the patient's historical blood group, seemed logical. Perhaps as importantly, lab workers always prefer inconvenient, unexpected test results to disappear as it makes our life simpler. This trait surely applies to MDs and RNs too.]

Narrative fallacy 2
When it was later known that the patient was post-transplant, the analyser manufacturer was asked to explain the discrepancy of a MF group A in instrument 1, but an eventual 'normal' group O using instrument 2.

The manufacturer wrongly proposed that repeat centrifugation of the sample might have concentrated donor rbc lower in the tube, seemingly logical, because transfused rbc would usually be older and heavier than patient rbcs and be at the bottom of blood samples. 

That could cause the O grouping result if instrument 2's sampling tip was testing rbc lower in the patient's blood sample than instrument 1's, a common explanation for missing post-transfusion MF groups on analysers.

But the manufacturer's narrative does not fit the facts in any way. When disparate grouping results occurred the ‘donor’ rbc would have been from the engrafting group A HSCT and not transfused group O donor rbc, because the group O cells were the patient’s.

[My guess, a guess shaped by biases, is that manufacturers often get asked about their instruments missing MF in blood grouping tests. In this case the manufacturer may have been on auto-pilot because they gave a standard answer even knowing the patient had a stem cell transplant. 

In a way it reminds me of how physicians (indeed all health professionals) often decide and diagnose based on intuition and pattern recognition ('I've seen this before'), not on all the presenting evidence and possibilities before them, certainly not on analysis of recent research. Narrative fallacies save time for busy practitioners but occasionally may have tragic results for patients.]

Narrative fallacy 3
Three days after the first blood groupings a fresh sample was received, but laboratory staff were still unaware of the patient’s HSCT. MF again occurred with anti-A, but this time the person doing the grouping explained (narrative fallacy) that the MF result was due to group O donor rbc transfused over the weekend. 

The test result was modified to a 3+ positive, giving a group A result. However, authorisation failed, because the patient was historically group O.

A repeat sample also grouped as A with MF. Lab staff eventually discovered that the patient had received an ABO-incompatible HSCT at another Trust, which had not been communicated to them. The transplant was reason for the MF: as the transplant engrafted, transplanted donor-origin group A rbc were present along with the patient’s own group O rbc. 

This narrative fallacy could have led to the patient being mis-grouped as an A patient who was transfused with O donor rbc, instead of being a post-transplant group O patient in the process of becoming group A.

[To me, in the absence of more case details, the lab technologist concluding the patient was group A, 'modifying' (falsifying?) a blood group test result to fit the narrative that transfused group O cells caused the MF, is mind boggling. I suspect that significant contradicting evidence would need to be ignored to create this narrative fallacy. More information is needed. If you are a UK TM colleague and know more details, I'd love to hear them. 

Again, a guess about how this narrative fallacy could happen relates to something else that SHOT 2015 discusses: Laboratory errors have increased and many laboratories are under pressure with vacancies and increased workloads.]


Techie stuff - if you are so inclined: 
Unusual that a MF test result would be 'modified' to 3+ positive, as MF is nothing like a strong 3+. Wonder what 'modified' means because it suggests something totally unacceptable - recording a false result to fit a preferred narrative. Just guessing but was that because the lab's SOPs or information system (LIS) require anything less than a 3+ result in a blood group test to be investigated further? 
Regardless, in this case, the historical record (probably in the LIS) produced a failed authorisation. In general, mistyping a patient's ABO blood group, especially a group O patient, can have catastrophic consequences if they are then transfused after an electronic (non-serological) crossmatch with ABO-incompatible rbc. Of course, an ABO discrepancy, including MF in a patient's ABO group, would prevent use of the electronic crossmatch.  
Not mentioned in the SHOT report is how the patient's reverse group tested. Group O recipients would have anti-A in their serum/plasma for months, making concluding the patient is group A difficult. The patient's anti-A would be continually 'mopped up' by adsorbing to donor-produced A antigen-bearing cells, possibly creating delayed hemolysis. But immediately post-transplant the anti-A should be relatively strong, precluding transfusion with group A rbc until engraftment occurs and a serological crossmatch is compatible. 
FURTHER MUSINGS
Think back for a moment to the HIV/AIDS 'tainted blood' scandal of the 1980s and 1990s and the narrative fallacies it spawned.
At first the narrative fallacy was the disease was gay-related immune deficiency (or GRID), comforting to those who were not gay because, 'Hey, it can't affect us.' 
After it was reported in hemophiliacs and Haitians, a narrative fallacy proposed that the disease originated in Haiti. 
The Canadian Red Cross BTS and its medical experts believed that probably all hemophiliacs were already infected by FVIII concentrates made from tens of 1000s of blood donors and conveniently opted to use up its large stockpile of untreated (unsafe) FVIII concentrates.  
With these and other narrative fallacies, the transfusion medicine community took an exceedingly long time to accept the disease could be transmitted via blood transfusion.
I encourage you to think about the comforting and convenient stories we in the TM community tell ourselves, whether in the lab, on the wards, in blood donor clinics and clinician's offices, and wonder if our stories could be narrative fallacies.

Remember that grappling with complex information and mysteries strains our brains and brains like to save energy. Stories allow us to process and retain information more easily by showing a pattern that solves a mystery. Often our stories comfort us by confirming pre-existing beliefs or just making life simpler.
For techies who've stuck with the blog to the end, an inside joke: Think of all the trouble we go to in the lab to get rid of troublesome (unexplained) test results in antibody screens or antibody identification panels that don't show a pattern. The go-to narrative fallacy is ? Clinically insignificant cold agglutinins, of course. 
FOR FUN
The blog's theme reminded me of a CCR 1970 ditty, sometimes associated with opposition to the Vietnam War. SHOT 2015 discusses narrative fallacies - stories we tell ourselves - in the context of phenomena that prevent us from learning from our mistakes. 
Long as I remember the rain been comin' down.  
Clouds of mystery pourin' confusion on the ground.  
Good men through the ages tryin' to find the sun. 
And I wonder, still I wonder, who'll stop the rain

As always, comments are most welcome. 

FURTHER READING
UK SHOT website 
SHOT: 2015 Annual Report 
Miller S. Myth based medicine. Br J Gen Pract. 2015 Jun; 65(635): 313. E-pub 2015 May 26.  
Taleb NN. The Black Swan (2007) 
Related TM blog (Aug. 2015): The early days (Musings on educating young TM professionals)


Saturday, July 23, 2016

Don't worry, be happy (Musings on how TM leaders mimic politicians)

Updated: 25 July 2016 (See highlighted text under Musings)

Do you know what government politicians and transfusion medicine (TM) leaders have in common? No matter what the threat, both repeatedly assure their constituencies, 'Don't worry, be happy.' 

July's blog takes its theme from recent transfusion-transmissible disease news. The title is from a 1988 ditty by Bobby McFerrin.


For readers who choose not to read the full blog, here's the executive version. The blog's aims are to
  • Encourage readers to be skeptical about how safe our blood supply is;
  • Hold our TM leaders to the highest standard, one higher than we expect from politicians;
  • Credit us with the intelligence to understand nuance.
GOVT LEADERS
Examples of politicians assuring citizens all is okay:
  • Canada: PM Justin Trudeau reassures Canadians that the economy is in a good position to weather the storm in the wake of Britain's Brexit vote. (June 2016)
  • UK: Home Secretary Theresa May assures Brits that the UK has taken steps to amend powers and increase capabilities to deal with developing terrorist threats. (Aug. 2014)
  • USA: Obama assures Americans the highest priority is their safety following a string of terror attacks (Dec. 2015)
TM LEADERS
Similarly, all involved at top echelons of the blood industry in the developed world constantly reassure us that our blood supply is the safest it ever has been.

Unstated is the blood supply is the safest it has ever been for the KNOWN OLD infectious disease risks, the ones that figured in the so-called 'tainted blood' scandals that plagued us in past decades. Experts assure us

  • We are doing all we can to minimize risks. 
  • Donor screening, improved transmissible disease (TD) tests, and manufacturing processes for plasma-derived products pretty much eliminate the old TD risks like hepatitis B, hepatitis C, HIV. 
  • The blood supply is safe. Don't worry, be happy.  
Need a  touchstone of how TM leaders now see our blood supply as bulletproof?
  • Today western nations have pretty much all moved from a total ban on blood donation for MSM males to a 5 year deferral to a one-year deferral, providing no MSM in the past year. 
  • Blood suppliers did so influenced by nation-wide, indeed global, campaigns by gay activists and others who support their cause. They decried the ban against gay/bisexual men donating blood, including the latest one-year deferral, calling it discriminatory and unjustified based on the evidence. 
  • Some even say the ban on MSM was unjustified from the get-go:
    • 'The new policy isn't any more scientific than the old policy. It's based on the same bigotry and gay panic defence that the ban has been based on since the beginning.' 
My belief is that CBS's evolving MSM policy is motivated by activist groups and worldwide policy changes (themselves motivated by activists) but is not discriminatory. See, for example, this 2013 interview with Dana Devine:
NEWS (JUNE-JULY 2016)
Examples of news that triggered this blog:
HIV

ZIKA VIRUS
Several disconcerting anomalies exist about Zika virus transmission:

  • What the hell is going on? (Well worth a read because we still don't fully understand Zika, just as we didn't understand in the early days of HIV and HCV)
MUSINGS
TM leaders' standard response (SOP?) to blood supply risks is analogous to politicians who ensure citizens that 'all is okay'. And TM leaders are more-or-less correct, just as politicians are about their claims of relative public safety from economic disasters and terrorism. Except when the next man-made disaster strikes, as it inevitably does.

For both groups, claiming safety makes sense and often is in the public interest. The last thing citizens need is to fear for their safety, fear to travel, fear that those who are different ('the other') are somehow dangerous. Politicians who fear-monger usually do so in their own self-interest and often are despicable in spinning tragedies to their crass political benefit.

TM leaders never-ever fear monger. It's not in their best interest or ours, whether as blood donors or transfusion recipients. For the best of reasons TM leaders correctly assure us that life-saving transfusions are the safest they have ever been. Such reassurances serve the public interest because we don't want folks to fear life-saving transfusions or stop donating blood.

Yet many in the TM community come across as complacent and overly confident. I'd love to be similar, live in a bubble, sing 'Don't worry, be happy.' But, having experienced Canada's 'tainted blood' scandals, I'm skeptical. Note, skeptical, not cynical.

Partly it's because TM leaders failed us in the HIV tragedy. Out of arrogance or being true-believers matters not:

  • And the Band Played On (full movie on Youtube - it's a beauty)
  • Canadian Red Cross denies link between AIDS and blood products (two-minute video)
    • In the 1980s a Canadian Red Cross (CRC) medical director uses 'cost-benefit ratio" to determine if hemophiliacs should be transfused with potentially infected products.
    • Reality: FVIII concentrates from thousands of donors were all infected with HIV. Yet even after safer heat-treated FVIII conc. was available, untreated products were transfused. Seems likely our leaders decided to use up CRC's expensive stock pile, in the self-serving beliefs that hemophiliacs (1) were probably already infected and (2) might die if left untreated. A few physicians wisely and bravely chose to give the safer single-donor cryoprecipitate. 
    • Note: Over 1100 Canadians were infected with HIV from blood transfusions, of which 700 had hemophilia and were treated with FVIII concentrates.
The results of economic-based calculations around the globe:
Decision making in the early days of HIV was complicated because of all the players had genuine concerns, all born of self-interest (see 'The tragic history of AIDS...' above):
"Homosexuals were major blood donors in the large cities on the east and west coasts. It was thought that singling out homosexuals for exclusion would unnecessarily stigmatize them without evidence that they were indeed transmitting the disease. The blood industry, threatened by losing a large donor pool, strongly supported the position of the gay groups on this.
The hemophilia groups expressed concerns that the data showing immune suppression in hemophilic patients could have reflected the effects of prolonged use of blood products and did not necessarily mean they had the new syndrome. They also feared the stigma of having a disease associated with homosexual patients and were concerned that reducing the use of clotting factor concentrates would bring back old issues of deformities and early death, the fate of hemophilic patients before concentrate treatment."
These same forces are still at work today among all the stakeholders. CRC's successor CBS - with most of the same trench-workers (but not staff forced out for being truthful to the Krever Commission) - are even more into cost-benefit. Indeed, they've refined cost-benefit into a science. Decisions are  evidence-based, so please don't waste our time by questioning them.

CBS and others now use data - based on prevalence and disease severity - that determine whether a blood supplier implements a blood safety test or not for a given transfusion-transmissible risk. Today's blood suppliers are all about metrics and cost-savings, and they're proud of it, even crow about it.


Just like the Canadian Red Cross was when it declined to implement surrogate tests for hepatitis non-A, non-B (now hepatitis C). Seems Canada's experts judged surrogate tests to lack sufficient sensitivity and specificity. That tens of 1000s of Canadian transfusion recipients were subsequently infected with HCV is a testament to 'expert' opinion. It ain't infallible, especially if driven by cost constraints.

Today, cost-savings pretty much drive our blood system and have for awhile. The public purse is not an unlimited money pot and tough choices must be taken. Moreover, zero-risk is impossible in TM, indeed in all of medicine. 


The impossibility of zero-risk is one reason that patients sign consent to treatment forms. Despite informed consent, how much patients truly understand is debatable. My experience is the process is often rushed, matter-of-fact, with the implication being we have to do this so let's get it done quickly: Just sign this so I can get to more important tasks. Sort of like asking people how they are, expecting only, "I'm fine, thanks."

Yes, I've written variations on this theme before. But I hope readers see how true the analogy of TM leaders being the same as political leaders who constantly reassure us - as a knee-jerk reaction - that we're safe because they're doing all they can to combat the risks we face.

BOTTOM LINE
I don't want folks to become fearful of our blood supply. It's safer than ever, although not bulletproof. Rather I encourage readers to be skeptical, i.e., to have some degree of doubt regarding claims that are normally taken for granted just because they come from our leaders.

In this case, please be skeptical about what our TM 'thought leaders' tell us about blood safety, especially given the ever-evolving transfusion-transmissible threats AND the fact that commercial vested interests (Big Pharma, the diagnostic test industry) are now - more so than ever - in bed with transfusion professionals.

SIDE BAR (Food for Thought)

Let's consider the small picture of vested interests. Many experts who present at company-funded continuing education events or any CE event have strong ties to industry.

Think about the issue on a personal scale. Have you ever attended a TM talk, workshop, seminar sponsored by Big Pharma or a diagnostic test firm? If yes, have you even once heard representatives discuss anything that casts any doubt whatsoever on their products and their benefits? Suspect not. 
When attending CE events do you assess what ties the speakers have to industry? Or mostly listen in awe to the acknowledged world-renowned experts who transitioned from their original health care careers and now more or less work for profit-driven private industry?
Let's say I've built a good career on specializing in DNA genotyping of red cell antigens. What are the odds I'd be for each and every use of molecular typing in TM and a strong proponent of so-called personalized medicine?
Suppose one of my roles is as an academic whose career and advancement depend on getting my research funded and published? How likely would I be to criticize industry partners who fund my research? Or try to publish negative studies that don't support the company's products? 
Now let's return to the big picture. I'm not suggesting TM leaders are consciously influenced by commercial interests - who often just happen to be their industry partners (although they clearly are influenced in many ways) - on matters of blood safety. Rather my point is that people invariably act in their own best interests. Human nature...

Those in charge of the safety of our blood supply cannot admit the supply is unsafe, even that tiny risks exist. Just as politicians responsible for public safety cannot say citizens are unsafe. It's impossible. This means that you and I must be skeptical and not meekly accept pronouncements from on high about anything, including government and TM decisions influenced by pressure groups.


Wouldn't it be great if our TM leaders would credit the public with intelligence and consistently articulate blood safety with these six points? I challenge them to LEVERAGE our intelligence to their advantage.
  1. Our blood supply is the safest it's ever been but it's not risk-free
  2. We need to be vigilant with donor screening, both questionnaires and TD testing. Tests are not perfect and donors may lie about risk behaviors. 
  3. Hemovigilance is key to prevent and identify adverse transfusion events and because unknown risks, for which no screening exists, are certain to arise. 
  4. Human error exists despite the best education, training, and competency assurance programs.
  5. Due to cost constraints, we must prioritize blood safety measures and, accordingly, tolerate some risk (ideally rare and less serious risks), as we do in all medical fields.
  6. MSM policies evolve and will continue to do so based on considering horrific past mistakes and their victims (many now dead) and current realities of improved screening tests balanced by HIV prevalence and relative risk among different donor groups.
Instead our TM leaders (like politicians) all too often use this easy mantra, which both patronizes and disrespects and, worst of all, cuts off discussion before it even begins:
  • Our blood supply is the safest it's ever been.
  • Don't worry, be happy.
For an insight into the viewpoint of victims in the aftermath of Canada's blood scandal see
FOR FUN
The blog's theme perfectly fits this 1988 Bobby McFerrin song:

As always, comments are most welcome. 

Wednesday, June 22, 2016

If you could read my mind (Musings on blogging to share TM experiences)

Updated: 23 June 2016
June's blog is a follow-up to an article I wrote for the April issue of the BBTS magazine, BloodLines. In the BBTS piece I speculated on why so few health professionals, working or retired, blog. I'll expand on some of these ideas in the hopes that more transfusion professionals will be encouraged to give it a go and blog for CSTM or BBTS or any professional association in any country.

Now before you rapidly exit ('Blog? Not me!'), please take a chance and at least skim the blog. It's you I'm hoping to reach by planting a seed that maybe, just maybe, you could make a real difference by sharing your experiences with colleagues.

You don't need to be a 'big wheel' to blog. We tiny cogs in the wheel also have much to share. Perhaps we haven't published or presented at conferences. But we've all had unique experiences in our transfusion lives and, in years to come, no one will know if we don't tell our stories.

The blog's title comes from a 1970 song by Canada's Gordon Lightfoot, one of the most covered songs in pop music history. 

OBSTACLES
So why don't more transfusion professionals blog? There are many reasons, but here are my top three. 

1. No time
Most obviously, and likely the biggest obstacle to blogging, is lack of time. Like many continuing education opportunities these days, folks would need to blog after-hours on their own time. 

With internet and cell phones, many employees may already resent being connected 24-7. When work-life balance is out-of-whack, leisure time with friends and family, as well as time for yourself, becomes even more precious. 

And if you feel devalued by your employer, you may lose the enthusiastic puppy persona you had at the start of your career. Instead of a career, you may see your professional work as just a 9-5 job to earn money, not to gain fulfillment.

2. No incentive

Another obstacle to blogging
 is folks tend to get no credit for blogging. Indeed, blogs may even be dissed by the 'old guard' as not evidence-based, just opinion. Well, yes! Blogs offer OPINIONS on events, issues, and challenges of the day.

But blogs can offer evidence and present logical arguments. In some ways blogs are akin to editorials. Opinions by experienced health professionals can summarize issues, pro and con, and offer food for thought. 

3. Fear of ridicule
Every time you 
  • Open your mouth
  • Give a presentation
  • Put pen to paper
  • Write an e-mail message 
  • Participate in social media of any kind
you may say something silly or indefensible and risk being thought a fool. Been there, done that. Indeed, you may even open yourself up to abuse by pompous academics or online trolls.

But to me the opposite is even worse:
  • To avoid criticism, say nothing, do nothing, be nothing. (Attributed to...) 
ADVANTAGES
So, why blog, given its risks? Here's where I'll need to self-edit for brevity because I'm definitely a true believer in the merits of blogging.

Given that blogging is an enterprise done on your own time, why do it? 

Why I blog
I blog for 6 key reasons. Blogging...

1. Is a priceless opportunity to comment on issues of the day and try to shape opinion. One example from "Musings on Transfusion Medicine' - my likely futile attempt to shape opinion on paid plasma:
2. Allows us to celebrate colleagues who have made a difference and to record transfusion medicine history through the eyes of those who lived it, the good, bad, and ugly. See, for example, the Canadian Society for Transfusion Medicine (CSTM) blog series, 'I will remember you' (scroll down to see the 6 blogs to date).

About history, Australia and new Zealand offer a great example of how to preserve our past:
3. Makes you a better thinker and writer. It's simply a case of practice improves performance. As noted in my first BBTS blog, 'Born to be Wild', key points to any writing, even e-mail, include
  • Don't bury the lead - reveal blog's aim up front;
  • Make it easy to read by using bullets and short paragraphs;
  • Be as brief as possible;
  • Include a 'so what' statement.
I confess that my blogs are too long. Please don't take them as a model of suitable length. A blog can be short and deal with a single issue or experience. 

4. Creates a record of important experiences and allows others to learn from them. 
EXAMPLE:
I could write a blog about a student I once taught who, during her clinical rotation, missed adding patient plasma to an antibody screen test, causing it to be falsely negative, with the patient receiving incompatible blood by electronic crossmatch. The elderly patient suffered a severe hemolytic transfusion reaction and subsequently died.  
This true episode makes an interesting story of what happened, including the involvement of the hospital's lawyers, the reaction of the supervising technologist and transfusion service medical director. Much to be learned from a single experience, a story worth writing that would be lost forever if not recorded. 
5. Gets your name out there and furthers your career. Of course, blogging requires taking a risk, the risk of opening your mouth and being thought a fool. No big deal. I have a T-shirt from LSOFT:
  • "He Who Dares, Wins" (motto of the British Special Air Service)
6. Is great fun. Fact is, I enjoy poking the powers-that-be and sending up the absurdities in our professional lives. Someone has to do it.

SUMMARY
Expressing opinions on current issues and examining the past are valuable ways to spend one's time. So seldom today do we get the opportunity to reflect. And blogging invariably serves as informal continuing education because bloggers need to check they're not spouting total B.S.

Some claim that in today's milieu, folks no longer have the time, no longer care to spend free time on their careers. Please, let's prove this judgement wrong.

My take on blogging: It's a blast! I maintain three blogs, two professional and one personal where I pretty much rant about whatever bugs me at the time. The personal blog is therapy that keeps me sane. 

The professional blogs are my way to try to influence opinion, to motivate colleagues to think differently and challenge orthodoxies. You can too! We're here for such a short time. Why not try to make a difference?

Plus we need to create a historical record of our stories or they will be lost forever. See, for example,
Making colleagues smile also serves a valuable purpose. What struck you as silly recently? Why not blog about it? If you want to try blogging for CSTM, I'd be glad to help by offering my 2¢ worth (make that 'nickel's worth', as cent coins/pennies don't exist in Canada any more).

To inquire about blogging, please e-mail
Finally, I encourage bloggers to write their passions and will end with this quote by Canada's Margaret Laurence (click to enlarge):

Margaret Laurence quote

FOR FUN
Lightfoot's 'If You Could Read my Mind' seems right for this blog. Fact is, no one can read our minds. If we don't spill the beans and blog about our experiences, no one will ever know. 
If you could read my mind, love,
What a tale my thoughts could tell.
Just like an old time movie,
'Bout a ghost from a wishing well.
In a castle dark or a fortress strong,
With chains upon my feet.
You know that ghost is me.
And I will never be set free
As long as I'm a ghost that you can't see. 
                                        
If I could read your mind, love,
What a tale your thoughts could tell.
Just like a paperback novel,
The kind the drugstores sell...

As always, comments are most welcome.

Monday, May 23, 2016

The In Crowd (Musings on the relevance of transfusion journals)

Stay tuned because updates will occur
May's blog was stimulated a long time ago but returned to me recently when I was cleaning house and tossed out (recycled) several thick issues of the AABB journal Transfusion, which were piled on my computer desk, largely unread after scanning content indices.

The blog's title derives from a 1965 jazz instrumental by the Ramsey Lewis Trio.

Musings focus on the articles I read in Transfusion's May 2016 issue and what this says about the journal's relevance to someone with a medical laboratory technology/science background (me). For context, traditional measures of a journal's relative importance and Transfusion's top 10 cited articles are also discussed. 

The questions I hope to answer: 
  1. What value is the AABB journal to practicing transfusion professionals (as opposed to its value to authors/researchers)?
  2. Why am I (and presumably everyone) getting a paper version of the journal and not being given an option for an e-journal only?
  3. What would my AABB membership fee be if all the costs associated with a paper version of Transfusion were eliminated?
  4. What factors should affect a journal's overall relevance and importance?
The blog is written from a medical laboratory technology perspective, as that's my background, but the issues also relate to nursing and physicians. Regardless of where you live, please ask similar questions of your professional association's journal. For example, 
  • How many papers do you typically read in your transfusion-related professional journal and where - at work on breaks, at home? 
  • Do you scan titles only or a combination titles, authors and abstracts? 
  • Which criteria determine whether you will read a given article?
  • In deciding what to read, how important is an article's direct relevance to your daily work?
  • How many articles, if any, do you read just for curiosity or fun?
Sometimes I wonder of journals even matter anymore but of course they do. And I miss the days when transfusion services regularly held journal clubs during lunch hours, often based on journal articles or conferences, in which all staff participated.

To promote continuity of the blog's ideas, consider reading the blog in its entirety and then return to access linked resources. Bet you can't.

1. AABB JOURNAL 'TRANSFUSION' - BRAGGING RIGHTS

So to begin, here's how most journals measure their worth. On its homepage, Transfusion gives its ISI journal citation ranking under the medical specialty, hematology, as well as its Impact Factor. Both are intended to show the relative importance of individual journals. 

In 2014 Transfusion's ISI Journal Citation Reports© Ranking was 23/68 and its Impact Factor was 3.225. 

So what do ISI Journal Citation Reports© (JCR) Ranking and Impact Factor (IF) mean?
  • JCR Ranking claims to objectively critically evaluate the world's leading journals using statistics. Uh-oh! That's a red flag if there ever was one. Just kidding because, as with any statistical data, users need to use their noggins to assess validity. 
    • With a JCR rank of 23/68, my guess is that Transfusion ranks no. 23 of 68 journals and is in the top third of most hematology journal citations (two-thirds of similar journals have fewer overall citations, whatever complicated statistics are used).
  • Impact Factor is the average number of annual citations recent journal articles have and obviously the higher, the better. As such, it's a proxy for the relative importance of a journal in its field. 
    • With an IF of 3.225, recent Transfusion articles were cited an average of just over 3 times in a year.
But similar to surrogate tests such as elevated ALT and anti-HBc used to screen blood donors for non-A, non-B hepatitis before HCV was identified, issues exist for how well Impact Factors measure relative importance.

For interest, The Impact Factor was devised by Eugene Garfield, who explains its history in a 2006 JAMA article.
As an aside,  I love Garfield, because in my early pre-Internet years in Medical Laboratory Science, MLS subscribed to Current Contents, which I always enjoyed and looked forward to reading. If my memory is correct, each issue began with a fascinating Garfield comments/editorial. [See Further Reading]
2. TRANSFUSION'S TOP 10 CITED ARTICLES
Since 1975 I've been an AABB member and once read 90%+ of Transfusion's articles, but mostly for interest, not because they directly related to my work. 

Most reading was done because I'm curious and love transfusion medicine. After becoming an educator, motivation included the potential to discover 'juicy' tidbits that would interest or amuse students, and Transfusion's articles often did. 

In today's hectic and understaffed work environment, I wonder which of Transfusion's top 10 articles would be read during leisure time, on breaks or after hours, by 
  • Clin lab technologists/scientists in a blood supplier or transfusion service laboratory? 
  • Transfusion and blood conservation RNs?
  • Hematologists/hematopathologists?
I suspect that not many in these three professions would read 3, 7 and 9 below, which is good because only 30% un-read is excellent. As an experiment, please assess which of the following you would read. I've linked the PubMed abstract for each article. 

Please think about which criteria helped decide whether you would read an article or not.

Transfusion's Top Ten Cited Articles: [Author's work location/country]

1. Activity-based costs of blood transfusions in surgical patients at four hospitals. (Shander A, et al) 2010;50:753-65. [USA]

2. Transfusion of older stored blood and risk of death: A meta-analysis. (Wang D, et al) 2012;52:1184-95. [USA]

3. Pathogen inactivation and removal methods for plasma-derived clotting factor concentrates. (Klamroth R, et al) 2014; 54:1406-17. [Germany]

4. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. (Yang L, et al) 2012;52:1673-86. [UK]

5. Fibrinogen as a therapeutic target for bleeding: A review of critical levels and replacement therapy. (Levy JH, et al) 2014; 54:1389-1405. [USA]

6. Duration of red blood cell storage and survival of transfused patients. (Edgren G, et al) 2010;50:1185-95. [Sweden]

7. Storage lesion: Role of red blood cell breakdown (Kim-Shapiro DB et al) 2011;51:844-51. [USA]

8. The use of fresh frozen plasma in England: High levels of inappropriate use in adults and children. (Stanworth S et al) 2011;51:62-70. [UK]

9. Adoptive transfer and selective reconstitution of streptamer-selected cytomegalovirus-specific CD8+ T cells leads to virus clearance in patients after allogeneic peripheral blood stem cell transplantation. (Schmitt M et al) 2011;51:591-9. [Germany]

10. Transfusion-associated circulatory overload after plasma transfusion. (Narick C, et al) 2012;52:160-5. [USA]

So, what's your health profession and  how many of these top cited papers would you have read? Be honest. As both a lab technologist in the trenches and an educator, I'd have read all but #9.  

3. TRANSFUSION'S MAY 2016 ISSUE
Below are three papers I read in the May issue of Transfusion (Volume 56, Issue 5,pp. 1001–1249) that directly relate to my prior career as a med lab tech/scientist and educator. Yes, only three and I read them out of interest. These days,although retired from real work, my time is even more precious. 

The journal sections each paper is under are included. I've summarized each with a 'So What?' conclusion.

1. TRANSFUSION MEDICINE ILLUSTRATED (pp.1006–7)
Delayed hemolytic transfusion reaction captured by a cell phone camera.Margaret E. Gatti-Mays, S. Gerald Sandler [USA]
So what? The delayed hemolytic reaction was due to anti-Jka and shows a photo of the peripheral blood smear with multiple microspherocytes. Authors encourage physicians to use cell phone cameras to photograph peripheral blood smears and use them in clinical presentations. 
2. IMMUNOHEMATOLOGY (pp. 1182–4)
Anti-Mur as the most likely cause of mild hemolytic disease of the newborn. Sara Bakhtary, Anastasia Gikas, Bertil Glader, Jennifer Andrews [USA
So what? Full term infant had jaundice presumed to be due to anti-Mur, an antibody more commonly found in Asian patients in the USA, and one important to recognize since the Mur+ phenotype has a higher prevalence in this population.
3. LETTER TO EDITOR (pp.1247–8)
Sustained and significant increase in reporting of transfusion reactions with the implementation of an electronic reporting system. Rosanne St Bernard, Matthew Yan, Shuoyan Ning, Alioska Escorcia, Jacob M. Pendergrast, Christine Cserti-Gazdewich [Canada]
So what? In 2009 the authors transitioned from a paper-based to an electronic reporting system (ERS) for suspected transfusion reactions. The user-friendly process did not result in “junk inflations”. Instead reporter suspicions generally concurred with specialist conclusions. Accordingly, they endorse using an ERS for transfusion reaction reporting to improve hemovigilance.
ANSWERING THE QUESTIONS
Here are my answers  - conditioned by my professional experience and biases - to the questions posed about Transfusion. Your answers may differ and likely will.

Q1What value is the AABB journal to practicing transfusion professionals (as opposed to its value to authors/researchers)?
A: Transfusion has value as a good read for anyone who's curious on current 'hot' clinical issues and to educators who must keep up-to-date with the latest and greatest, including esoteric research, which may or may not ultimately translate into something useful to practitioners.
The journal's relevance to the day-to-day working lives of medical laboratory technologists/scientists in laboratories is minimal. Most papers relate to clinical practice (MDs, RNs) or research (PhDs).
Q2Why am I (and presumably everyone) getting a paper version of the journal and not being given an option for an e-journal only?
A: Transfusion is a glossy journal that costs many trees to produce, plus mailing costs, which are not insignificant. I don't need or want a paper copy.  
It's published monthly, plus has supplements of Annual Meeting abstracts and others such as conference proceedings. That's a lot of paper.
For May's issue I read only 7 of 248 pages, ~2.8%, which related directly to my work. And some issues have even fewer articles relevant to my needs and interests.
Q3What would my AABB membership fee be if all the costs associated with a paper version of Transfusion were eliminated?
A: My 2016 AABB membership cost $124 USD, which at the time I paid was $170.27 CDN. Sure, membership is a good deal, less than 50 cents/day.
But how much of this does AABB pay per member to Transfusion's publisher, Wiley? Darned if I or any member knows.
Academic publishers such as Wiley and its subsidiaries, e.g., Wiley-Blackwell,  surely make most money from advertisers and libraries. It's interesting that they've been under pressure recently for being an oligarchy that gouges cash-strapped university and college libraries. [See Further Reading]
Q4. What factors should affect a journal's overall relevance and importance?
A. To me, Transfusion's relevance should relate not only to its citation ranking or impact factor. Rather, a key factor is how many articles in each issue busy transfusion professionals will actually read because they relate to their day-to-day jobs.   
Yes, it's easy to dismiss my views because immunohematology (beloved to med lab techs/scientists) is a dying art and increasingly irrelevant. But how many papers in the 2016 May issue would time-strapped nurses and physicians read in their spare time? You decide.
Transfusion comes with AABB membership. Shouldn't its content reflect the needs of ALL members, at least according to their membership percentage?
SUMMARY
Just a few of the many issues I'd love AABB to address:

1. AABB, please allow members to opt out of receiving a paper copy of Transfusion and please decrease membership fees accordingly. 

2. AABB seems an association mainly for physicians. Is it? Why does its journal offer only continuing MEDICAL education credits for reading select articles and successfully completing a test on the content? I think I know why...

Cannot help but wonder what percentage of AABB's membership constitutes physicians vs PhD researchers vs medical lab scientists vs nurses vs administrators. Transparency please. We'd love to know.

3. Never mind med lab technologists/scientists, how about more Transfusion articles relevant to nurses? They increasingly play a key role in our profession. 

Of course, I know from experience that asking AABB or any large organization such questions is pretty much useless and akin to pissing in the wind. Would love to be proven wrong.

FOR FUN
I decided to use 'The In Crowd' in the blog's title for these reasons:

1. It's a laid-back, simple tune that's easy to listen to. Indeed, over the years I've listened to it for many hours because I bought the Ramsey Lewis album of the same name many moons ago. 
2. Although it's an instrumental version, the lyrics fit with the blog's theme of promoting a journal based on its relative ranking and impact. Hey dude, don't ya wanna publish in the 'In Crowd' journal Transfusion?
I'm in with the in crowd.
I go where the in crowd goes.
I'm in with the in crowd.
And I know what the in crowd knows.
Tidbit: I've got this album somewhere if I could only recall where I stashed the few 331⁄3 rpm vinyl records I've kept.  
  • The In Crowd (The Ramsey Lewis Trio vinyl album, recorded live at the Bohemian Caverns in Washington, D.C. in 1965)
As always, comments are most welcome. 

FURTHER READING
Academic publishers reap huge profits as libraries go broke (CBC, June 15, 2015) 
Larivière V, Haustein S, Mongeon P. The oligopoly of academic publishers in the digital era. PLoS ONE 10(6): e0127502. E-pub: June 10, 2015 (Free full text)
Just for fun
Confession: I've included these just so I have a record and can read on some long winter nights.

The writing of Eugene Garfield, including
Essays of an Information Scientist:1962 - 1973 
Essays of an Information Scientist:1974 - 1976 
Essays of an Information Scientist:1977 - 1978 
Ex:  Humor in Scientific Journals and Journals of Humor