We can work it out (Musings on public vs private health systems)

This blog muses on how transfusion medicine (TM) in the USA compares to the rest of the developed world, particulary Canada, in terms of overall cost, efficiencies, and clinical outcomes.

As a Canadian, monitoring the U.S. debate on health care is frustrating. Particularly annoying is hearing our system regularly trashed on U.S. cable shows, mostly be those who do not have a clue about Canadian health care, and occasionally by Canadian physicians heavily invested in private health care.

• See Canadian health care slurs dismissed as "rhetoric" (CMAJ, 13 Oct. 2009)

Of course, like any system Canada's is not perfect but it provides universal coverage (like the rest of the developed world) and we're trying to improve it.

Nonetheless, to me the lies and distortions south of the border are galling. The blog's title derives from an old Beatles tune that I hope comes true:

• We can work it out

Don't worry - This blog is not going to delve deeply into the U.S. - Canada health care debate, where views tend to be as passionately held as religious convictions.

The idea for the blog came from this journal article & news item (featured in TraQ's November newsletter):

• Schoen C, et al. A survey Of primary care physicians In eleven countries, 2009: perspectives on care, costs, and experiences. Health Affairs 2009;28(6): w1171­w1183.
• U.S. physicians lag behind those in other countries in IT use

The journal paper made me wonder if anyone had similarly researched TM in the USA and Canada, or TM in the USA vs TM in other countries with universal health care and a national blood service in which users do not pay for blood and blood products, i.e., the public pays via taxes and the burden does not fall to those unfortunate enough to get sick and require transfusion.

There have been reports published comparing such aspects between countries as blood donor screening criteria and overall structure and organization. And Vox Sang has international forums (fora for purists), which survey the basics of blood systems around the globe and international practices on just about every type of practice, e.g.,

• Autologous blood salvage
• Clinical indications for various blood components
• Hemovigilance
• Massive transfusion protocols
• Technical topics such as electronic crossmatching, routine Rh typing, hemolytic disease of the newborn serologic analysis

The types of studies I have in mind would compare TM-related costs, efficiencies, and clinical outcomes in various developed countries. Such costs are incredibly difficult to identify with validity. But in countries with national blood services, these figures should be determinable, albeit with many assumptions, provisos, limitations and perhaps even a glut of 'weasel words' as often appear in cost studies due to the many variables involved.

For example, Canadian Blood Services has only three testing facilities and 12 manufacturing facilities to serve all of Canada except Quebec. Canada is the 2nd largest country in the world, just behind Russia and just ahead of the USA in territorial size.

CBS's annual reports include an incredible amount of hard data:

• Report to Canadians (2008 - 2009)

Some tidbits from the report above:

• Whole blood collections: 915,858
• Staff costs constitute ~60% of total 'Transfusable Products' expenses
• Cost per unit* for year ending 31 Mar. 2009: $377.11
• *ratio of total expenses to shipments of all products

A few possible comparisons for international studies:

1. Relative cost of the overall blood system
We know that Canada's health system is less expensive than the U.S. system, because the administrative costs are less when there is a single payer. Indeed, The U.S. spends more per capita on health care than any comparable country. Does this apply to the blood system too?

2. Average cost per RBC transfused
In Canada, CBS and Hema Quebec collect and process all whole blood donations intended for allogeneic transfusion.What does a typical unit of RBC cost to produce in Canada and how does it compare with the same average cost in the USA, UK, Australia, etc.?

3. Utilization management of blood components and blood derivatives according to whatever clinical guidelines exist

For example, do countries with national blood services and government -supported provincial blood offices achieve equivalent or better clinical outcomes and financial savings compared to the USA? See

• BC PBCO
  
• Transfusion Ontario

ADDITIONAL MUSINGS
In the mid-1990s in Alberta, the Canadian province where I reside, the government decreased financing of the laboratory system by ~40%. Among many results, students in the MLS program where I taught had difficulty finding jobs in Canada. However, because they wrote the ASCP MT exam at the end of their program, many obtained employment in the U.S., including in transfusion service labs.

Canadian grads were amazed at the U.S. system in which an incredible amount of their time was spent on what to bill for various lab tests, something that was not required in Canada. Yet this emphasis on fees and cost did not result in more evidence-based test rationales.

Grads often reported that the U.S. labs they worked in were still routinely performing tests that had been abandoned in Canada in the 70s and 80s, tests that contributed little, if anything, to treatment or clinical outcomes.

Granted, it's a small sample, perhaps the anecdotal reports of a few dozen graduates. But even so, publicly funded TM laboratories in Canada had managed to implement evidence-based test rationalization before many American counterparts.

And government programs such as the BC PBCO have made impressive improvements in utilization management of blood and blood components.

Can a public system of transfusion medicine, and universal health care in general, possibly be equivalent, or even superior to, a private one? We can no doubt work it out, eventually.

Additional Resources
For more on health care comparisons in general, see:

• Comparing medical costs and results
• Sick Around the World - a profile of health care in 5 countries

As always, views are mine alone and comments are most welcome.

Don't ask, don't tell... Time to fold 'em or bad moon rising?

It's not every day that a national blood supplier and blood donor are involved in a lawsuit involving blood, sex, duplicity, and a constitutional challenge. That's happening now in Ottawa and generating plenty of press coverage.

In brief, CBS sued a gay blood donor, Kyle Freeman, who lied repeatedly on his blood donor screening questionnaire, and the donor subsequently sued CBS and Health Canada. This blog examines the issues involved in the dueling lawsuits.

The blog offers musings on the MSM deferral policy for blood donors. Its title is a takeoff on

• U.S. military policy on homosexuality
• Lyrics from The Gambler, a Kenny Rogers classic
• CCR ditty, Bad Moon Rising

The Controversy
The key issue involves the MSM (men who have sex with men) deferral policy for blood donors. As described on the CBS website:

• "...the policy excluding MSM is the subject of debate between the LGBTTQ (lesbian, gay, bisexual, transsexual, two-spirited, and queer) communities, who view it as a discriminatory policy and patient groups that depend on blood products, and who feel it is a critical safety measure."

In other words, is lifetime deferral for MSM scientifically justified to protect the blood supply because the incidence of HIV is much higher in men who have had sex with men than it is in individuals having exclusively heterosexual sex or is the policy discriminatory?

The controversy surrounding MSM policies has been widely reported, particularly protests on university campuses, which have tended to be full of passionate, hyperbolic political rhetoric, e.g.,

• SAQD Pamphlet (Standing Against Queer Discrimination, a group on the UWO campus)

Note: The above SAQD pamphlet refers to the 2007 McLaughlin Report. Readers are well advised to read the original report below.

BACKGROUND

CBS, like many blood services worldwide, following the dictums of its government regulator Health Canada, bans donations from men who have sex with men, the so-called MSM policy. The CBS predonation screening question on the "Record of Donation" reads,

• "Have you had sex with a man, even one time since 1977?"

Other Countries

MSM policies vary globally. From the CBS website:

• Countries requiring indefinite deferrals: USA, UK, France, Germany, Switzerland, Holland, Norway, Denmark, Sweden, Finland, Iceland and Hong Kong
• Countries with shorter deferral periods:
• 1 year - Argentina, Australia, Japan, Hungary
• 5 years - South Africa*
• 10 years - New Zealand
• Italy has a deferral based on specific activities

* According to the SA National Blood Service, the SA deferral was changed from 5 yrs to 6 mths in 2006.

The UK blood service also provides a Summary of International Policies relating to the Exclusion of Men who have Sex with Men from Blood Donation

In 2007 CBS reviewed its policy and decided to retain an indefinite deferral, effectively a permanent ban, as explained here

The UK has also recently issued a position statement on its policy:

• Exclusion of Men who have Sex with Men from Blood Donation Position Statement: 12th March 2009

THE COURT CASE

CBS's position on the lawsuit is provided on its website.

The main facts of the case as reported in the media:

• CBS accused Kyle Freeman, a gay man, of 'negligent misrepresentation' for lying on the screening form.
• Freeman then sued CBS and Health Canada for $250,000 claiming CBS violates his charter rights* and those of other gay men by asking male donors about having sex with a man.*Canada's Charter of Rights and Freedoms
• Freeman donated blood 18 times between 1990 and June 2002 but the case focuses on the 4 times he donated following the creation of CBS in 1998, i.e., between June 1998 and June 2002. (Canada's blood supplier prior to 1998 was the Canadian Red Cross.)
• In June 2002 Freeman sent CBS anonymous e-mails admitting he lied on the questionnaire.
• CBS attempted to get his Internet service provider to reveal his identity.
• Freeman's blood donor screening HIV tests were negative but he has had gonorrhea and late latent syphilis.

For more details, see TraQ's news reports.

Interested Parties

Two other organizations have weighed in on the case:

The Canadian Hemophilia Society has 'intervenor status' in the case. CHS supports the position of CBS and Health Canada in maintaining the current MSM donor deferral criteria. Individuals with hemophilia were devastated by the tainted blood scandal of the 1980s, as documented in the Krever Report and elsewhere.

The Canadian AIDS Society will appear as a 'Friend of the Court.' It contests the constitutionality of the lifetime deferral on
men who have sex with men and proposes an amendment.

THE DEBATE

Below are the arguments on both sides of the MSM policy.

USA

• Behavior-based blood donors deferrals in the era of nucleic acid testing (NAT)

This document outlines the AABB, ABC and ARC position: They believe that the deferral period for MSM should be consistent with deferrals for those judged to be at risk of infection via heterosexual routes. i.e., 12 months.

• FDA: Blood donations from men who have sex with other men: Questions and Answers
• Blood, Sex, and the FDA (Nov. 2009; The Advocate, a lesbian, gay, bisexual, transgender magazine)

CANADA

• The Reason behind CBS' MSM policy (Letter to editor of The Gazette [UWO student newspaper] by Ian Mumford, CBS CEO, 25 Jan. 2008)
• McLaughlin Report (2007): MSM Donor Deferral Risk Assessment: An Analysis using Risk Management PrinciplesA Report for CBS

UK

• Why we ask men who have sex with men not to give blood (UK Blood Transfusion & Tissue Transplantation Services)

Debate in the British Medical Journal:

• Should men who have ever had sex with men be allowed to give blood? Yes (BMJ 2009 Feb 26)
• Should men who have ever had sex with men be allowed to give blood? No (BMJ 2009 Feb 26)

BOTTOM LINE

If current blood donor screening tests for HIV and other agents leave no residual risk for transmitting infections then there would be no need for intrusive screening questions about high risk behaviors, i.e., a policy of Don't ask, don't tell.

Obviously there is some residual risk, albeit small, that make predonation questions essential.

The McLaughlin Report concludes this about MSM deferral periods:

• Available evidence strongly suggests that a 1-yr deferral would "almost certainly give rise to an incremental risk of transfusion-transmitted infection"
• Evidence is less clear for a 5- yr or 10-yr deferral partly because "current level of residual risk is so low that there are, inevitably, substantial ranges of uncertainties associated with the risk estimation."
• "...there is no firm evidence that such a change in the deferral period ...would result in an incremental level of risk, although the possibility of a small increase in risk cannot be entirely ruled out."
• "Under these circumstances, other social policy issues, relevant to the idea of changing the deferral period for MSM, become worthy of additional consideration."

This excerpt from the Report is instructive:

• Therefore, would ...changing the MSM deferral period to 5 years pass the risk hurdle successfully? In the end, this is a matter of judgment, that is, a matter on which reasonable people may disagree.
• What we can say with some assurance is that, at the very least, it may provisionally pass the risk hurdle. In other words, it is “within the ballpark” for discussion.
• As a result, it is fair to ask if there may be other types of benefits that are likely to flow from making this policy change...
• (1) ...possible impact on the size of the future donor pool, and
• (2) ...potential social benefit attendant upon reducing the perceived stigma associated with homosexuality.

So....let's shorten the deferral for MSM to potentially get more blood donors and lessen a social stigma. And this based on a judgement on which reasonable people may disagree and is within the "ball park" of acceptable risks. Hmmmm......

The McLaughlin Report says that health risk data are equivocal and constitute very small risks so let's consider other worthwhile goals.

I'm always uneasy when someone suggests blood safety changes based on cost effectiveness or on politically expedient issues such as lessening social stigmas. Despite the clear desirability of such goals, patient safety should be the overarching, if not sole, determining factor.

The Gambler's wise advice is that you got to know when to fold 'em, know when to hold 'em.

Will the FDA, Health Canada and blood suppliers like CBS decide to fold 'em and change the lifetime MSM deferral policy to a shorter period?

Ladies and gentlemen, place your bets.

I see a Bad Moon Rising if changes to blood safety policies are based on pressure from activists as opposed to evidence of no incremental risk, accepting that zero risk is impossible.

As always, comments are most welcome.

Ghostwriters in the sky and kickbacks: Through a glass darkly?

This month's blog is a takeoff on a classic 1950's song, Riders in the Sky (aka Ghost Riders in the Sky), recorded by Vaughn Monroe and more than 50 others. (Note: I recommend that you right click on all links and choose Open in new tab.)

The blog is a protest of sorts. Do you ever feel like protesting? Or are we all so cynical in the 21st century that we accept shady practice as standard practice?

The focus will be on these items in TraQ's September newsletter:

• Ghostwriting of scientific papers in industry-initiated papers
• Pfizer, the world's largest drug company, fined for illegal marketing and kickbacks to physicians

GHOSTWRITING

In its simplest form, ghostwriting occurs when someone has significantly contributed to writing a paper but is not mentioned in the paper. In universities this is know as plagiarism and can result in serious consequences, including student expulsion. In the world of medical research it seems to be business as usual.

Examples

Earlier this year Merck was accused of ghostwriting and even producing its own "medical journal".

Apparently, it is not uncommon* for drug companies to have favorable papers about their products ghostwritten internally or contracted out, then published under the names of willing physicians who receive 'honoraria': (* not uncommon, an example of a litotes, a new word I learned this year, courtesy of my pal, RMC)

• US senator presses NIH on drug company ghostwriting
• Glaxo used ghostwriters to promote antidepressant
• Medical papers by ghostwriters pushed therapy
• Wyeth ghostwriting archive
  

The Glaxo news article is instructive. The reporter writes:

• An internal company memo instructs salespeople to approach physicians and offer to help them write and publish articles about their positive experiences prescribing the drug.
• Direct quote from the memo: “Physicians will be eager to participate ... regardless of their professional stature.’’

And as the TV infomercial hucksters shout, "Wait, there's more...."

ILLEGAL MARKETING AND KICKBACKS

In a nutshell, according to news reports, Pfizer

• Pleaded guilty to promoting the painkiller Bextra (withdrawn in 2004) for uses that were not approved by regulators
• Settled civil allegations regarding kickbacks to doctors who prescribed other drugs, although Pfizer denies these charges

News Items

1. Pfizer receives biggest criminal fine in US history for mispromoting drugs & paying kickbacks
2. $2.3 billion is 4th fine of Pfizer or a subsidiary since 2002 over illegal marketing
3. Pfizer Fact Sheet (US govt)

Yes, they paid a $2.3 billion fine (that's a B for BILLION). Speculation is that the fine was so large because the practices had occurred over time with no change in behavior despite earlier fines.

THROUGH A GLASS DARKLY?
The unseen players in all of this are the physicians who lend their names to papers they never wrote and who accept kickbacks, as in this March 2009 report in the NY Times:

• Crackdown on doctors who take kickbacks

All these stories made me speculate that we may be viewing our world 'through a glass darkly' (Bible, New Testament, 1 Corinthians 13:12). Are we looking into a dark mirror that poorly reflects the true situation?

Us versus Them?

I wonder if transfusion medicine professionals have ever tried their hand at ghostwriting for so-called 'honoria' or taken kickbacks for prescribing or promoting products such as IVIG and erythropoietin?

If not blatant kickbacks, how about

• sponsorship of research?
• support for blood conservation programs?
• a consulting position?
• funds to travel to conferences, whether speaking favorably about the product or not?
• or who knows what else?

Of course, research sponsorship and other program funding are not in themselves wrong, indeed they are welcome. It's only if the support influences outcomes, which is why medical journals have moved to more transparent forms of disclosing conflicts of interest and competing interests. Readers are left to judge whether or not funding has influenced a study.

The news items above describe clear cases of unethical physician behavior that could result in a doctor losing a license to practice. But ethical lines can become very fuzzy once we accept even simple perks that slowly lead to more and more entanglement with commercial interests, no matter how seemingly benevolent at first.

Moreover, is it only 'them' or does it include 'us', members of the transfusion medicine community? Are we looking through a glass darkly?

LIGHTEN UP TIME

These current news items remind me of Sackett and Oxman's spoof on how doctors can grow rich pimping for drug companies:

• HARLOT plc: an amalgamation of the world's two oldest professions. BMJ 2003 Dec 20; 327: 1442-5.

In that vein, here's a fun ditty and a feel-good song that expresses a wish for all of us:

• Protest Song (Hugh Laurie)
• I can see clearly now (Johnny Nash)

As always, the views expressed are mine alone and comments are most welcome.

Addendum

Please see the comment below. It's satisfying to get some feedback and I encourage others to comment too.

Musings on Peter and Dilbert Principles: Thinking outside our little boxes

Last month featured a tongue-in-cheek characterization, sight unseen, of a new journal, the Journal of Blood Services Management or JBSM. This blog is a follow-up on JBSM, now that I have read the journal's first issue.

As someone who creates transfusion-related case studies, including those in soft sciences* such as management and education (e.g, Case A8: Severe hemolytic transfusion reaction involving a student), I was naturally drawn to the journal's case study.

* disciplines based on qualitative (not quantitative) analysis of data or research that uses more subjective and difficult-to-control measures and designs and depends on conjecture

Each issue JBSM will feature a fictional case based on real events with analysis by invited blood center managers and others. The purpose of the cases is to foster professional development for new and experienced managers.

"The Case of the Overworked Technical Director"
The first case—The Case of the Overworked Technical Director—illustrates the challenges that can occur when employees with technical backgrounds make the transition to management. Based on the discussion, the case could just as easily been called "The Case of the Incompetent Technical Director."

I encourage readers to obtain a copy of JBSM to review the case in depth.

In brief, CM, a lab technologist with 12 years experience at a blood center, has been in the job of Director of Technical Operations for 6 months with responsibility for four areas: testing, manufacturing, hospital services, and the reference lab. He is performing poorly. He is late with numerous managerial reports, budgets, performance evaluations, etc., and spends time on the bench after hours and on weekends helping out with three unfilled staff vacancies.

The JBSM editor invited three people** to analyse the case by responding to these questions: What do you see as the problem in this case? What advice would you give CM's immediate supervisor, the blood center Chief Operating Officer (COO)?

** two presidents & CEOs of blood centres and a member of the US Army's Medical Service Corps taking a PhD

The commentators have much to say, which can be distilled to

• set clear performance expectations and provide timely feedback for failures
• reinforce confidence in the person
• provide training, coaching, and mentoring
• reassign if performance does not improve

Musings on the JBSM Case Study

The case's commentators present the standard menu of how to improve staff performance. Moreover, they take it for granted that managers are expected to set priorities and meet deadlines regardless of events around them.

• No one questioned whether the facility was understaffed and if there were casual or part-time staff whom CM could ask to cover vacancies until they were filled.
• No one wondered whether the center's organizational chart had significant gaps at the supervisory level and whether there were supervisors between CM and the trench workers who could be asked to help prepare reports.
• No one discussed whether the COO performed incompetently by not providing adequate expectations, feedback, and training and allowing this to continue for half a year. They said that the COO "should have" set expectations, etc., but that's as far as they go. Perhaps the COO needs training?
• No one asked if the CEO knew that the COO had been ignoring a problem for 6 months.

It's somewhat ironic because blood centers must have a quality system in place whose quality system essentials include personnel, their duties, training, and competency assessment. Top managerial staff such as COOs, it seems, escape the same scrutiny that middle managers and front-line technical workers experience.

When things go wrong, those at the top often tend to focus on the failings of those at the middle and lower echelons without questioning the related performance of top managers, i.e., themselves. It's human nature but not productive. Dilbert's view:

• Who gets fired?

The commentators also tended to focus on the individual and his shortcomings rather than considering a root-cause-analysis approach to assess if there were systemic failings in the organization. In this case, it's likely that there are systemic problems.

Musings On Incompetence in General - The Peter Principle (PP)

This case models the PP developed by education professor Dr. Laurence Peter that "every employee tends to rise to his or her level of incompetence."

• Peter Principle

Peter's Corollary: The PP has a corollary, roughly stated as,

"In time, every position tends to be occupied by an employee who is incompetent to carry out duties and thus work is accomplished by those who have not yet reached their level of incompetence."

In the TM lab world the PP is seen in two areas:

1. As in this JBSM case study, technical staff who are promoted to management on the basis of longevity and a history of sound technical performance, regardless of leadership, managerial, communication, and people skills.
2. Pathologists, sometimes anatomic pathologists with little or no clinical pathology training and experience, and PhD scientists who direct and manage clinical laboratories and blood centres, regardless of any aptitude for, or education in, management and leadership.

If blood centers in the USA are a business, albeit non-profit ones, are those at the top knowledgeable about financial management, marketing of services, competing for investment capital, and other business basics as discussed at an NFB Leadership Forum in April (reported in the June 2009 issue of AABB News)?

As for management and leadership skills, think of all the pathologists and PhD level doctoral scientists that you know who direct blood centres and clinical labs. They are usually very competent physicians and researchers. But what about management skills? For example:

• Do they typically have strong interpersonal and people management skills?
• Exemplary oral and written communication skills, which includes listening not just telling?
• Are they good motivators of people?
• Team players who value the experience and expertise of other health professionals?
• Passionate about the vision they see for the organization, a vision that captures the imagination of employees?

Upper level executives need both management and leadership skills, preferably both and especially the latter. My experience is that there are a few gems out there, superstars who have all of the above and more. But many pathologists and PhD scientists in leadership positions ... not so much.

Just like technical staff, MDs and PhDs were not educated and trained in these skills and are unlikely to gain them by osmosis from merely being in the job.

BOTTOM LINE

Challenges can occur when employees with technical backgrounds make the transition to management AND also when employees with clinical and scientific backgrounds make the transition to management.

• Incompetence is an equal-opportunity failing that knows no professional boundaries.
• Our little boxes, whether technical, medical, or scientific should not constrain us from examing the big picture and critically analysing our role in contributing to any systemic management problems.

Dilbert Principle (DP)

When discussing the PP and incompetence, one cannot help but mention the DP, a satirical observation by Scott Adams that companies tend to promote least-competent employees to management to limit the damage they can do. In the Dilbert strip of February 5, 1995 Dogbert expresses the DP in its extreme:

• “Leadership is nature's way of removing morons from the productive flow.”

Just for Fun: A few of my favorite Dilbert strips

Multitasking (Aug. 3, 2009)

First human to fail the Turing Test (Mar. 30, 2008) [ Turing test ]

Passwords for morons (Jan. 17, 2007)

Joy of training (Dec. 26, 2006)

Abuse of meetings (Aug. 16, 2004)

Dealing with managers (Aug. 7, 2003)

How to thwart useless meetings (Aug. 26, 2001)

LITTLE BOXES

Finally, here's an old ditty sung by Pete Seeger, an American folk music legend.

• Little boxes

As always, the views expressed are mine alone. Comments are most welcome.

"Transfusion lite" - Back in the USSR?

This blog is a provacative sendup of a new journal affiliated with the AABB.

In the July issue of Transfusion AABB announced a new journal, The Journal of Blood Services Management, in an editorial by Paul M. Ness and Philip D. Schiff: "The Journal of Blood Services Management, a new administrative focus for TRANSFUSION":

The JBSM will include a broad spectrum of organization and management issues facing blood service managers. Topics will include financial management, supply chain management, LEAN/6 Sigma, regulatory matters, manufacturing management, donor recruitment, public relations and communications, information technology management, hospital and customer relations, governance matters, international issues, services within hospital-based blood services, tissue program management, risk management, competition, leadership, and general medical and technical service management.

I have not read the first issue because it is not available on the web and I have not yet received my paper copy of Transfusion. It's always late for some reason, maybe due to residing in Canada?

The new journal (JBSM - sorry, I could not resist the emphasis) is a collaboration between AABB and Group Services for America’s Blood Centers (GSABC).

The GSABC mission statement:

• "To create a stakeholder-driven group purchasing enterprise that more effectively serves the members of America's Blood Centers"

From JBSM overview (on the GSABC website)

• The Journal of Blood Services Management will be the premier journal for thoughtful leaders in blood center and transfusion service management.

Articles will generally fall into two broad categories:

1. Those grounded in theory and/or papers using scientific research methods....
2. Those focusing on innovative blood service management approaches that are based on well reasoned-extensions of existing research, experiential knowledge, or exemplary cases (e.g., thought pieces, case studies, top executive interviews).

The journal wants articles that are "engaging, lively, challenging, and stimulating." I particularly liked this tidbit:

We recognize that many potential authors may be intimidated at the thought of writing for a peer reviewed Journal. We wish to reassure these authors that the editorial staff is willing to assist in any way possible to help you write a paper for submission. For those who have never written a paper for peer review, you may wish to think of it as nothing more than writing a “term paper”.

"Nothing more than writing a term paper" is an interesting choice of words, given that the journal is targetted to "thoughtful leaders."

I am confident that most AABB members, including me, will thoroughly enjoy JBSM:

• I like thought pieces and approaches that use experiential knowledge, which are more or less the equivalent of blogs like this one. No need to use scientific research methods and worry about solid evidence.
• Papers will be more practically oriented, hence more relevant to those who work in the TM trenches beyond the research milieu of academia. Many Transfusion papers remain unread for various reasons, including content that is perceived, rightly or wrongly, as irrelevant to practice and content that is beyond the reader's knowledge base.

CONCERN

Despite being keen about a new transfusion journal with promising content, I cannot help but wonder if the appearance of JBSM is yet another baby step on the long journey to making financial concerns and cost efficiencies paramount in transfusion medicine.

Transfusion medicine as a business is also featured in the June 2009 issue of AABB News, which includes a report on an NFB Leadership Forum held in April in Florida:

• NBF leadership forum focuses on innovating for the future

According to the report, attendees at this private meeting discussed issues that would be at home on the programs and in the board rooms of any business or industry. Speakers included industry leaders from

• Ortho-Clinical Diagnostics
• GE Healthcare
• Haemonetics
• Fenwal
• Bay City Capital (venture capitalists)
• ITxM
• Florida Blood Services
• Puget Sound Blood Center
• AABB
• ARC

Advice included recommendations to

• Examine the potential for partnerships, mergers, and outsourcing
• Implement lean strategies to decrease waste
• Focus on productivity indicators
• Diversify income
• Centralize compatibility testing
• Compete against other health sectors for investment capital
• Develop technologies that reduce labor and reagent costs

Recommendations more clearly TM-related with direct clinical implications were to develop blood utilization programs and transfusion guidelines.

Oh, yes, "and we must remember the donors and patients because that is who we are trying to serve." (Jim AuBuchon, President and CEO of PSBC)

As has been noted in earlier blogs, as the economy has worsened, papers that promote cost analysis as a primary driver of TM policies such as donor testing have become more common. Patient safety always enters such cost-focused papers and presentations but almost always as an after-thought or a robotic mantra unrelated to the actual take-home messages.

QUARTERLY PRAVDA? (Pravda definition)

JBSM's scope fits rather nicely with the ideas expressed at the NBF leadership forum. It could serve as a propaganda arm of the GSABC, AABB, and NFB. Thought pieces and interviews on financial management, LEAN, and competition could easily promote ideas currently favoured by 'captains of industry'.

Ah, but what about peer review, you say. Well, peer review of traditional scientific papers has been criticized for years:

• How the Internet is changing journals (New Atlantis, Summer 2006)

Particulary troubling is the long trail of evidence that demonstrates that peer reviewers are often biased toward papers that affirm their own convictions.

Where does this leave peer review of non-research based papers such as thought pieces and interviews of TM bigwigs?

As a political analogy (try to jettison your own biases on this topic), think of former US VP Dick Cheney holding forth on his favorite theories and world view:

• Who among George W. Bush's cabinet, aides and other 'true believers' is going to be the bearer of bad news that the VP's views do not stand the test of evidence?
• There is Colin Powell, but we know what happened to him.

SUMMARY

JBSM promises to be an interesting addition to the transfusion literature. I could have joined the crowd and praised its appearance instead of giving it this tongue-in-cheek critique and calling it Transfusion lite and raising the possibilty of its use as a propaganda tool. But that would not have been thought-provoking or challenging, virtues praised in the new journal's overview.

FOR FUN

• Paul singing "Back in the USSR" (Red Square, 2003), only possible after the fall of the USSR
• CD has wonderful scenes of joyous Russians reacting to the once fobidden music

As always, comments are most welcome. Participate in peer review....

Addendum to last month's blog: "Plus ca change, plus c'est la meme chose (Where are the Hearts of Gold?)" (Musings on why publishers charge for celebrating the dead)

• Based on a comment by Bev, here is an example of several obituaries of TM luminaries available in the ARC journal Immunohematology 2005; 21(4): John Maxwell Bowman; Sir John V. Davies;Tibor J.Greenwalt; J.J.Van Loghem

Plus ca change, plus c'est la meme chose (Where are the Hearts of Gold?)

This blog is about how journal publishers are so concerned with the bottom line that they cannot see the forest for the trees. It's another riff on the cost of obituaries in scientific journals, i.e., musings on why publishers charge for celebrating the dead.

In Jan. 2006 I wrote a blog titled, The cost of an obituary in Transfusion. Transfusion medicine giant, JJ van Loghem of the Netherlands, died in 2005 and his obituary was featured in the Nov. 2005 Transfusion. I wanted to include van Loghem's obituary (giving full credit to Transfusion) on a website for transfusion professionals.

The publisher at the time, Blackwell Scientific, had a link to "Order permissions", which brought up the Copyright Clearance Center from which you can choose to distribute an article in several ways and get a "quick price." The CCC charged $306 US to put the obit on a website, about $355 CDN then, and $31 US to send it in an e-mail to one person. The cost for the obituary was the same as for any scientific paper.

Well, another TM giant has died, Charles Salmon of France and his obituary is in both the May 2009 issue of Vox Sanguinis (ISBT) and the June 2009 issue of Transfusion (AABB). Blackwell Scientific merged with Wiley in 2007 and Blackwell's journals are now available via Wiley Interscience.

Being an AABB member I have online access to Transfusion but, curious about the current cost of viewing an obituary, I registered as a non-subscriber at Wiley and investigated 24-hr access to the obit.

Bottom line - the cost to read the obit for personal use was ~$35 CDN. I cannot find any information on the cost of republishing it on a website.

As mentioned in the earlier blog, the Nov. 2005 Transfusion had an editorial on the movement towards open (free) access to published scientific literature and the competing reality that publishing quality journals is costly. The editorial focused on the NIH policy requesting recipients of NIH funding to deposit on PubMed Central (free access to all) the author's version of an accepted manuscript produced with NIH support within 12 months of publication and what that meant for authors submitting papers to both Transfusion and PubMed Central.

The authors ended by noting:

AABB, Blackwell Publishing, and TRANSFUSION editors have been discussing open access, and the Journal may introduce options in the future to make authors' work available in an additional open archive. Although it is clearly attractive to gain wider exposure for articles via public access, we must carefully weigh the pros and cons of such exposure to ensure that any negative effects on the Journal are minimized. We urge TRANSFUSION authors and readers to remain awareof these evolving developments and to participate in the lively dialogue that is likely to continue in the coming years.

To my knowledge, the new publisher Wiley Interscience does not make research papers from any of its journals available in an open archive. Not even celebratory obituaries.

As the French say, Plus ca change, plus c'est la meme chose.

As I wrote 3 years ago, it seems wrong to pay to provide a wider distribution to an obituary that pays tribute to a great TM pioneer. It's not as though reproducing the obituary would deprive the authors of their livelihood or impact the publisher's revenues.

Here's a short excerpt from the Charles Salmon's Transfusion obituary by Jean-Pierre Cartron and Philippe Rouger (which I believe falls under US copyright "fair use"):

At first austere, sometimes quite terrifying at some meetings, Charles Salmon was in fact a simple and very warm man. Charles Salmon has always been able to listen, advise, guide, and sometimes scold those who have had the chance to know him. We cannot name all his staff as they are numerous, but many have contributed significantly to the research he has initiated and all are deeply grateful for what he has given them and the time he spent with them. He was a demanding master, but also an example of scientific rigor.

FUN DIVERSION

A sometimes terrifying man, who was a warm man.... Reminds me once again of the cliche that you cannot judge a book by its cover.

Just for fun, an instructive example of a book cover being misleading is this comparison:

• Cry me a river - by plain Susan Boyle
• Cry me a river - By beautiful Julie London

Which song rendition of this sultry, sexy blues song is better?

BOTTOM LINE

Back to Wiley Interscience being incapable of nuance, being unable to offer an obituary of a great TM pioneer for free. Such content, celebrating a life of contributions to the field, falls outside Transfusion's aims and scope as well as those of Vox Sang.

Wouldn't it be great if young TM professionals, those unable to pay for society memberships or journal subscriptions, or not lucky enough to have free access to medical library holdings, could read about the life of such pioneers?

If freely available, other websites could link to the obituaries and create an exponential readership. Yet the publisher makes no concessions.

As Canadian Neil Young might say, it's an apparently endless search for A Heart of Gold.

As always, comments are welcome.

Sweet dreams are made of this...

This blog muses on how to access reliable information needed for professional practice.

As the old Annie Lennox song goes, Sweet Dreams are made of this .... everybody's looking for something. <8-)

After reviewing some of the more reliable resources, the blog will identify and recommend one resource that is freely available to all and offers high quality advice on an endless variety of issues by a range of international experts - la crème de la crème for practical TM advice.

Where can TM health professionals, including medical technologists, nurses, and physicians, access high quality information beyond their immediate circle of friends and colleagues, who frankly may not be the best sources? Obvious resources include

1. Transfusion-related journals, requiring subscriptions except for those on PubMed Central, including:

• Transfusion (AABB)
• Transfusion Medicine (BBTS)
• Transfusion Medicine Reviews
• Vox Sang (ISBT)

2. Published literature on PubMed, again requiring subscriptions or access via local medical libraries that offer access to health staff

3. Cochrane Library, free in many countries

4. Major TM association sites, "anchor websites" as I call them, but many resources are limited to members

• AABB
• Australia and New Zealand Society of Blood Transfusion
• British Blood Transfusion Society
• Canadian Society for Transfusion Medicine

5. Government-associated websites, inc. national blood transfusion services (small selection - many more exist)

AUSTRALIA

• Blood Matters – better safer transfusion program

CANADA

• BC PBCO and related TraQ website
• Canadian Blood Services - Educational website for hospital clients
• Transfusion Ontario

UK

• Better Blood Transfusion Toolkit

WITHER ADVICE YOU CAN COUNT ON?

But what about reliable advice related to specific issues that may not be covered in published papers or available on websites? Frankly, many if not most, of the practice-related questions that arise can only be answered by consulting colleagues with relevant experience and expertise.

So, how to access the experts? Today it's especially important to tap the knowledge that is seldom found in textbooks or research papers, including tacit knowledge that professionals may not even realize they have.

Many professional associations offer informal consultation, but only to members, via forums such as the

• AABB Forums
• BBTS Special Interest Groups (SIGs)

Several mailing lists exist, such as two that I manage:

• "transfusion" (moderated bilingual list of Canada's TSOs)
• MEDLAB-L, the largest English language mailing list for lab professionals in all disciplines, which is semi-moderated and has many subscribers who specialize in transfusion medicine

There are also independent start-ups such as Blood Bank Talk (unmoderated)

Crème de la Crème

In my view the best resource currently available for TM professionals to obtain high quality advice is the

• CBBS e-Network Forum, available since 1998.

Editor and Moderator is Ira A. Shulman, MD, with help from Assistant Editor and Moderator W. Tait Stevens, MD.

Anyone can subscribe to the e-Network Forum newsletter, which alerts subscribers to new discussion topics.

So what makes the CBBS e-Network Forum such a valuable resource? In my view its key strengths include

• Submissions are edited and moderated by TM experts, resulting in a high signal to noise ratio, which is critical to busy professionals
• Moderator Ira Shulman, who was an early adopter of Internet technology as a tool for TM professional development and has a built-in heat seeking missile for "spotting a rat at 50 paces"
• Range of worldwide experts who subscribe to the e-Network Forum and respond to question - Subscribers include Yanks, Canucks, Brits, Kiwis, Aussies, and more, including some of the "leading lights"
• Participants may be identified or anonymous, but if the latter, enough information is divulged to specify location at a minimum, and often more such as profession and position
• Easy to use interface, with an effective search utility

As the Annie Lennox "Sweet Dreams" lyrics go,

Sweet dreams are made of this.
Who am I to disagree?
I travel the world and the seven seas
Everybody's looking for something.

Some of them want to use you.
Some of them want to get used by you.
Some of them want to abuse you.
Some of them want to be abused.

If you subscribe to the CBBS e-Network Forum newsletter, you will not be used or abused. Without subscribing you can still access a fabulous resource for your every day transfusion practice dilemmas just by visiting the website..

For interest, there is another "Sweet Dreams," this one by American country legend, Patsy Cline.

As always, comments are most welcome.