Tuesday, March 31, 2020

We are the world (Musings on COVID-19's impact on the world's blood supply)

Stay tuned: Revisions are sure to occur
March's blog derives from the ongoing worldwide shortage of blood due to the coronavirus (COVID-19). Of course, because this is a transfusion medicine blog, I'm preaching to the converted. But I hope it gets wider distribution among all healthcare colleagues and the public beyond. 

Specifically, I ask all transfusion heath professionals to speak to colleagues, family, friends, neighbours about the ongoing need for blood donation, made even more crucial because of the COVID-19 pandemic. 

The blog's title is based on a 1985 song written by Michael Jackson and Lionel Richie for  'USA for Africa.' 

For TraQ's newsletter, I've collated some of the ongoing blood shortages across the globe (Further Reading). Fact is, the need for blood transfusion is ongoing despite the COVID-19 pandemic. Yet blood donation has dropped off significantly in many nations for numerous reasons explained in the news items in Further Reading. 

Despite the ongoing efforts of the Transfusing Wisely initiative (Further Reading), implemented in many nations, regular need for transfusions still exits for many patients. Transfusing Wisely's general goals: Reduce the rate of unnecessary blood transfusions with the goals of lowering the risk of complications for patients and supporting the judicious use of valuable resources. 

For the general public, just some of the ongoing needs for blood transfusion include the following (not all inclusive):

Patients who need blood transfusions
  • Mothers who incur significant bleeding during delivery, including those with placenta previa
  • Gastrointestinal bleeding (if massive can be life threatening) with many causes such as hemorrhoids, peptic ulcers, tears or inflammation in the esophagus, diverticulosis and diverticulitis, ulcerative colitis and Crohn's disease, colonic polyps, or cancer in the colon, stomach or esophagus  
  • Kidney disease, sometimes secondary to type 1 diabetes, that requires dialysis
  • Any surgery that involves significant blood loss
  • Trauma patients including those in car accidents who experience blood loss and victims of knife attacks or gun shot wounds
  • Blood disorders, including
    • Thalassemia major patients need regular red blood cell transfusions to raise their hemoglobin level and deliver oxygen to body tissues
    • Sickle cell disease patients need regular red blood cell transfusions to provide normal red blood cells, lessen anemia and reduce the blood's viscosity, allowing it to flow more freely and ease disease symptoms and prevent complications
    • Leukemia patients who develop thrombocytopenia need platelet transfusions to control bleeding 
The need is real and ongoing. Please encourage colleagues, family, friends, and neighbours to donate blood and save a life. It's one thing folks can do during the pandemic. Further Reading includes questions about donating in Canada and blood systems in all nations have similar information. 

FOR FUN Naturally, I chose We Are The World, originally written for 'USA for Africa' in 1985 by Michael Jackson and Lionel Richie, produced by Quincy Jones and Michael Omartian, and sung by many fabulous American  artists.  
We are the world
We are the children
We are the ones who make a brighter day
So let's start giving...

As always, comments are most welcome and appreciated.
Australia: In the face of coronavirus pandemic, Australian Red Cross Lifeblood’s stocks are threatened (24 Mar. 2020)

Canada: Top doc says Canada still needs people to give blood amidst social distancing (17 Mar. 2020)
      Canadian Blood Services: Message by CEO Dr. Graham Sher
      CBS answers COVID-19 blood donation questions

Pakistan: Experts urge volunteers to donate blood as thalassaemia patients face shortage (22 Mar. 2020)

Spain: In COVID-19 emergency blood bank stocks in Costa Del Sol hospitals are alarmingly low (18 Mar. 2020)

UK: Blood donors needed after 15% drop, says NHS (23 Mar. 2020)

USA: Coronavirus fears threaten America's blood supply (12 Mar. 2020)

Transfusing Wisely Canada

Saturday, February 29, 2020

You don't own me (Musings on questioning Dr. orders)

 Updated: March 1, 2020
February's blog derives from another TraQ case study from decades ago that discusses a topic not often included in online transfusion medicine cases but is still relevant. This case was based on a case study used to teach nurses at the McGill University Health Centre (MUHC) in Montréal, Québec. Because of this blog, I've revised the case to update all links. 
  • The blog's title derives from a 1963 ditty first recorded by Lesley Gore.
Case Study O6: Transfusion Reaction Coincidental with Failure to Disobey Physician Orders
This case was suggested by an RN and, because I'm not a nurse, several helped me with the case, also medical laboratory technologist pals from Hamilton and a physician (whom I taught when she was in Medical Laboratory Science at the University of Alberta). 

This case study presents a scenario in which a nurse did not follow several key transfusion protocols and procedures, including adhering to the time limit for transfusing blood, monitoring vital signs throughout a transfusion, and questioning orders that contradicted hospital policies and procedures.

It began when the nurse called the attending physician to explain the situation and charted the conversation as follows:
  • The Dr. was made aware; he ordered to continue transfusion even if it takes all day.
What happened to the patient? Based on laboratory results and a multidisciplinary discussion, staff concluded that a febrile non-hemolytic reaction had likely occurred after the second PRBC and had triggered subsequent events:
  • Increased temperature and chills increased intracranial pressure (the drain had been closed the previous day), leading to
  • Seizure and convulsions (treated by medication, induced coma, and intubation)
Analysis of the incident revealed that the nurse in question required remedial training related to resolving slow running transfusions and critical thinking in general, and also required re-training for how to monitor and document transfusions.

A more systemic problem was identified regarding the responsibilities and related skills of health professionals to provide checks for patient safety as part of the healthcare team. In other words, she should have questioned the physician's orders and taken it further, though that would be difficult.

Further analysis resulted in individual re-training and a system-wide education program on responsibilities and skills for providing interdisciplinary checks to ensure patient safety.

Key learning points include:
1. Clinical staff who administer transfusions must be trained and assessed in blood administration.

2. Monitoring and documenting vital signs must be done for each blood component transfused before, during, and after transfusion according to established policies and procedures.

3. Scopes of practice ensure that health professionals have the required education, training, and professional qualifications to perform their duties competently and safely.

4. Within their respective scopes of practice, members of the health care team collaborate in providing patient care.

5. Perceived loss of autonomy is considered to be a major obstacle to collaboration and open questioning within health teams.

6. Nurses and allied health care professionals such as medical laboratory technologists have a duty to question physician orders that are inappropriate or unclear.

Yes, I'm being facetious with the title and song, having some fun, but I couldn't resist. Decided to use the version with Bette Midler, Goldie Hawn & Diane Keaton as in the 1996 film, The First Wives Club. Yep, love these actors.
As always, comments are most welcome.

Case Study O6: Transfusion Reaction Coincidental with Failure to Disobey Physician Orders (Links are fixed) 

Davies C. Getting doctors and nurses to work together. BMJ 2000 Apr 15;320:1021-2. [Changed title]

Mancini ME. Performance improvement in transfusion medicine. What do nurses need and want? Arch Pathol Lab Med 1999;123(6):496-502.

Poerto G, Lauve R. Disruptive Clinician Behavior: A Persistent Threat to Patient Safety (July /August 2006, Patient Safety & Quality Healthcare)

Salvage J, Smith R. Doctors and nurses: doing it differently. The time is ripe for a major reconstruction. BMJ. 2000 April 15; 320(7241): 1019-20.

Friday, January 31, 2020

Stand by me (Musings on transfusion medicine errors)

Updated: 1 Feb. 2020 (Learning pt. 5, Further Reading)
To begin the new decade, I'll muse on a TraQ case study from decades ago that discusses a topic not often discussed by educators in class or included in online cases* but is still relevant and merits airing. 

*Online transfusion cases often involve antibody identification or making a diagnosis using lab and other diagnostic tests, in other words, cases with clear evidence-based results: yes and no answers that require factual knowledge and experience but not much reflective thinking. You may disagree, that's okay too. 

This blog's case study involves a student whose error resulted in a patient dying prematurely but, given another patient, could easily have been THE cause of death. Frankly, I shudder to think what the headlines may have been if local media had gotten hold of the story and were anything like the UK's tabloid press. 

The blog's title derives from a 1961 ditty by Ben. E. King.

CASE A8: Severe Hemolytic Transfusion Reaction Involving a Student
This case involved me directly as I was the clinical instructor of the student and transfusion service (TS) involved. As the clinical instructor I taught the student in a 2-week student lab (involving wet laboratories and small group tutorials) followed by a 4-week internship in the clinical transfusion lab where students were supervised by medical laboratory technologists. All the details of the case are in Further Reading. 

The student was supervised by an experienced, respected technologist  who was also responsible for working on the bench and processing routine work. The TS laboratory performs antibody screens using gel technology followed by an electronic crossmatch for patients who lack clinically significant antibodies.

The lab's policy is to initially supervise students very closely and then, depending on performance (which is documented daily),  to gradually allow students to perform with less supervision. Regardless of the intensity of supervision, the policy requires that supervising technologists always read the results of student tests.

The student did gel antibody screens on a batch of 5 patients in the late afternoon.

One of the 5 patients had a positive (3+) antibody screen ("Patient A") but, because blood was not ordered and unlikely to be required for the type of surgery, the patient specimen was set aside for antibody identification the next day.

One of the 4 patients with a negative antibody screen ("Patient B" - an 70-year old male scheduled for liver resection for metastatic colorectal cancer) had an electronic crossmatch performed for 3 units of RBC.

Early the next morning Patient "B" was transfused with 2 units of RBC.
When the morning shift began in the laboratory, an antibody identification panel on Patient A was unexpectedly negative, as was the repeat antibody screen. Antibody screens were then repeated for all patients in the batch and one (Patient B) was positive. Patient B was later found to have an anti-Fya and anti-c.

Immediately upon discovering the mix-up and positive antibody screen on patient B, the ward was contacted to stop any transfusion in progress, to inquire about Patient B's condition, and to monitor him for signs of a possible hemolytic transfusion reaction (HTR). Subsequently, Patient B was found to be experiencing a severe HTR and the TS medical director was consulted to help manage it. 

The student and supervising technologist were questioned in private, both individually and together, by the medical director and laboratory supervisor. The student could not recall making an error and thought that patient plasma had been pipetted correctly for each patient. The supervising technologist recalled not seeing the student actually pipette patient plasma into the gel cards but did read the results of all indirect antiglobulin tests (IATS) in the batch.

By chance, staff were able to retrieve gel cards from the biohazard garbage and identify that Patient B had less volume than usual in the antibody screen tests, consistent with no plasma having been added. The conclusion was that there was a pipetting error in which Patient B's plasma was not added to Patient B's gel antibody screen cards but rather to Patient A's tests.

Patient B died the day following transfusion.

The hospital's Risk Management Office was contacted and the chief counsel discussed the case with the TS medical director and Patient B's physician.

A series of group meetings were held by the lawyer from Risk Management with the TS laboratory supervisor, student, supervising technologist, and TS clinical instructor (me) all being present.

The Chief Medical Examiner was notified and investigated the death.

The TS medical director openly disclosed and explained what had happened to the patient's family. We waited for 2 years suing limitation but the family never decided to sue. 

The supervising medical technologist left the lab and began a career in a related field.

My personal learning points from the case:
1. When medical technologists in a busy lab supervise students, they can't watch every student move. Student errors may happen and supervising technologists are devastated, as in this case. Suspect this may be true for other health professionals supervising students who make serious errors too. 

2. The group sessions with the hospital's Risk Management lawyer were enlightening to me. She stressed that anything said in our meetings couldn't be used in court because of attorney-client privilege.

3. Our TS medical director was exemplary in her transparency to disclose the error to the patient's family. Perhaps ahead of her time?

4. I suspect many lab errors are latent errors (aka systems errors as well documented by UK's SHOT) caused by flaws in the system, i.e., errors that lead to human (operator) errors and whose effects typically lie dormant in the system. (Further Reading) 

5.The student in Case 8 thought she'd added drops to the antibody screens correctly. Many times in the student lab when students get incorrect results they'd almost always say, 'But I did it right. I know I did.' Then I'd gently remind them that it was, of course, normal to think that.If they knew they were adding the wrong drops, following the wrong procedure, they'd not have done it. 

Being human we make all sometimes make mistakes.What's key is to learn from them and realize the clinical laboratory has a culture of no blame that enhances patient safety. The worst thing would be for them to be spooked and frightened of making mistakes in the clinical lab (self-fulfilling prophesy) where patient safety is at risk. 

6. Reminds me of the reality that transfusion med lab technologists / scientists are often the last barrier between a patients and possible death. The transfusion service is different from many other med lab departments (not all) where unusual results are often repeated before reporting. 

I knew this as early in my career I'd crossmatched group AB blood for a patient who died because she was group O and had a wrong group AB sample sent to the off-site transfusion service where I worked. 

As always comments are most welcome. 
Chose this song because I think all health professionals need to stand by colleagues and students when human or systematic errors occur because there, but for the grace of gawd, go I. 

Tuesday, December 31, 2019

Bridge over troubled water (Musings on how to prevent burnout in transfusion professionals)

Updated: 20 Feb. 2020 (Fixed typos)
As the decade comes to an end, some musings on how to be happier and prevent burnout. The idea for December's blog began this morning with a CBC radio interview with its workplace columnist. She mentioned a study of physician burnout that showed enabling Drs. to devote 20% of their work activities to the part of their practice that is especially meaningful to them had a strong inverse relationship to their risk of burnout (Shanafelt TD,et al, Further Reading).

Physician burnout is often in the news these days and spoken of as an epidemic. It made me wonder about other transfusion workers such as nurses and medical laboratory technologists/scientists. The blog's title derives from a 1970 Simon and Garfunkel ditty (changed the tune - this one fits better) .

Took a peek at some of the literature on physician burnout. Must be said up front that burnout varies by specialty (nice chart in Rothenberger DA, Further Reading), and many other factors including sex, specifically that women are more likely to experience burnout. (Further Reading)

Factors that contribute to work burnout are nicely summarized in Rothenberger's  paper (Table 2) and include
  • Work overload 
  • Lack of control 
  • Insufficient reward 
  • Lack of fairness 
  • Breakdown of community 
  • Conflicting values between job requirements and personal values 
Please consider which, if any, play a role in your workplace.

See the Engagement column of Table 2 for ideas that lessen factors that contribute burnout. Think if these are possible in your workplace and, more importantly, which, if any, you can affect positively. (Click to enlarge)

One of several scales used to assess burnout is Maslach’s triad of emotional exhaustion, de-personalization or cynicism, and feelings of diminished personal competence and accomplishment at the work. (Further Reading)

Recently, I saw burnout in a hospital where my spouse spent 33 days this summer. One of his nurses was clearly burned out. We know because my husband often talks to healthcare providers, asks them about themselves, etc. Many find this refreshing and tell him all kinds of personal things about their backgrounds. One evening one of his RNs opened up to him and mentioned that she was stressed and might leave the profession soon. That formed a bond between them. As a daily visitor, I noticed how under-staffed and over-worked nurses often were, literally run off their feet at times.

Much earlier I saw burnout among medical laboratory technologists (aka biomedical scientists) when restructuring occurred in Alberta combined with a massive laboratory budget cut. 

The powers that be wouldn't come clean about what was happening and lab staff were left feeling totally out of control. Uncertainty ruled, unproductive incessant gossip ensued.

Those staff who remained had to compete for remaining positions, setting colleague against colleague, friend against friend. Often the process was viewed as unfair by losers and the winners felt guilty. Lose-lose all around, including the organization.

Fewer jobs existed, indeed lab jobs disappeared in Alberta and those who could had to uproot and find work in the USA, NZ, etc.

With budget cuts, continuing education opportunities dried up and staff were left feeling unappreciated.

Today, more than 25 years later, something similar is happening in Alberta.  The provincial government changed and what had been planned has once again been ditched. Local lab staff experienced so much change over the years and now uncertainty reigns once again. 

For transfusion labs an added factor includes automated testing, which lessens the hands-on factor many who gravitate to serology and immunohematology love. Plus the modern computerized, high-tech work environment makes patients seem more remote and e-mail is so overused, it numbs the mind. I know of lab staff whose mailboxes are full of 100s of messages, most of them irrelevant.

Have no idea how much of this currently relates to transfusion physicians, nurses and lab staff elsewhere, but I suspect some aspects must apply. 

So....to steal from journalism, please consider the 5 Ws and one H on how to lessen burnout: 

WHO needs to act? 
All of us. It we owe it to ourselves and colleagues in our transfusion family and most of all to our patients.

WHEN should we act? 
Now, the sooner the better. Make it a New Year's resolution, if you're into that and it motivates you. 

WHERE should we act?
In our workplaces dealing with patients; in staff meetings with colleagues; at lunch, coffee breaks, other outings; training students and new staff; collaborating with administrators and  health professionals in other disciplines; representing our profession and ourselves at meeting; meeting with those we perceive as our  bosses. Bottom line: Everywhere in work related roles.

WHY should we act?
Not just to retain health professionals so the number doesn't wane with possible shortages or to recruit successfully as aging professionals retire in increasing numbers. As important, if not more crucial, is we act to keep our mental health, which affects physical health. 

Our health and attitudes affect all around us, including our family, colleagues, students, patients, and their health too. Face it, no person wants to be in the presence of negativity and with burnout we exude it. 

WHAT do we need to do?
This may seem the tough question but I see it as relatively simple. For ages I've realized that what we remember in life is a series of short interactions with others, perhaps only lasting seconds or minutes.  First, remember that every conversation you have, every word or phrase uttered, may be remembered by the recipient of the communication forever, and have an effect either as a positive force or, gawd forbid, life-defining in a negative way.

Second, respect yourself and your work (meaning do your best, especially when it's hard) because only when you feel good about yourself can you help others. It's similar to the Buddhist core concept of  self-love, whereby you must love yourself before you can extend love to others.

Third, if in any position of power, do what you can to delegate to subordinates (under supervision remote or close depending on where they're at), which will increase their self-worth and confidence. Most every health professional has some power, e.g., in training and mentoring students and staff; in influencing colleagues to be their best by being a role model. One way is not to gossip maliciously, another is to be true to those who are absent, which builds trust in all present. 

Tidbits: Genuine praise goes a long way for a job well done. If high up on the chain of command, remembering staff names is always appreciated. 

Corollary: Take every opportunity to convince those above you of ways to make the workplace better because it's win-win for them, you, the staff, and patients. If unsuccessful as will inevitably occur at times, be creative and find work-arounds to improve your work environment tangibly or spiritually. 

HOW to do it?
Have fun and be happy in your work as it's infectious and will spread to others. Give of yourself and others will pay it forward. Resolve to be the best you can according to your abilities. You owe it to yourself.

As in the research paper, one way to decrease burnout is to spend 20% doing what you best love about your job. Must admit I was very fortunate because I loved ~99% of my job, what I've always said was the best job teaching transfusion science in the world. Students were a diverse group of delightful characters, smarter than I was, had more comprehensive knowledge, and kindly tolerated me calling them 'kids', something I do to this day. Also fortunate with colleagues, who generously helped me overcome my deficiencies. 

What did I least love? Staff meetings that were not needed, and when they were, hearing 'We tried that, it didn't work', thereby shutting down discussion. 

Learning Points
If you love nil about your job, best to pack it in and try another career or retire. As someone who experiences the health system a lot, I see burnout in some health staff. Also as an educator, I've seen the rare colleague who became jaded and really needed to quit before doing more damage. 

Doing more of what you love and enjoy makes sense and helps decrease burnout. When work is fun, we stick with it and create an environment where everyone improves, including patients. Just like when learning is fun, students tend to do much better.

Wavered between 2 songs, but in the end chose a very old ditty, many will think is dated:
When you're weary, feeling small,
When tears are in your eyes, I will dry them all.
I'm on your side. When times get rough
And friends just can't be found,
Like a bridge over troubled water
I will lay me down.
As always, comments are most appreciated. 

Shanafelt TD, et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009 May 25;169(10):990-5. 

Rothenberger DA. Physician burnout and well-being: a systematic review and framework for action. Dis Colon Rectum. 2017 Jun;60(6):567-76.

CBC Edmonton AM Workplace Column: New Year at Work (31 Dec. 2019 - 7:06 mins.)

Berg S. Why women physicians are more likely to experience burnout (9 Sept. 2019, AMA)

Templeton K, et al. Gender-based differences in burnout: issues faced by women physicians (30 May 2019, NAM)

Maslach C, Jackson SE. 1981. The measurement of experienced burnout. Journal of Organization Behavior;2(2):99-113.

Saturday, November 30, 2019

I can see clearly now (Musings on using artificial intelligence in transfusion medicine)

Updated: 1 Dec. 2019 [See Addendum below.]

November's blog, similar to all recent ones, is short. Perhaps the oldster (me) has finally learned that shorter is better or is it due to neuronal changes of normal aging?

The idea for the blog was initially stimulated by an article (Artificial Intelligence: A Primer for the Laboratory Leader) in CSMLS's LabBuzz, Nov. 22. (Further Reading). Naturally, this led me to read many more AI articles, some of which are included in Further Reading below.

The title derives from a ditty composed and sung by Johnny Nash.

As someone whose career was marked by many dramatic changes, I'm interested in what the 'next big thing' is. One candidate is artificial intelligence (AI).

I was particularly struck by the authors' (of 
Artificial Intelligence: A Primer for the Laboratory Leader) choice of six 'Roles of Laboratory Managers in the Post-AI Laboratory' See the article for a description of the outcomes of each role or see the screen shot from the article:

To me, many of these roles exist in the pre-AI lab and may be fulfilled by the lab manager or medical director, depending on the laboratory. The authors mention a quote attributed to the Greek Heraclitus, who lived ~500 BC:

  • "Change is the only constant in life." 
They also mentioned the cliché used by diagnostic reps who push automated clinical instruments: it's useful to remember that new technology eliminates old jobs, but it also creates new jobs. Clinical lab reps often phrase it as eliminating boring, mundane work to do the intellectually stimulating work med lab techs/scientists were educated and trained for. Except that clinical lab reps often promote automated instruments as a way to 'decrease head count', the euphemism for axing staff, especially highly educated, well paid staff. 

Authors' learning points: Welcome all change, it's inevitable and will take us to a better and brighter future. Think, 'Robots are coming to help us' not take our jobs.

Fair enough. Change is inevitable. Not sure it's always good, though, as many technological changes are a mixed bag of pros and cons.

Sidebar: Must admit that the robot comment reminds me of Reagan's "I'm from the government and I'm here to help", a late-1970s 
cliché.  Reagan was the less-government POTUS who believed in trickle-down economics: tax breaks and benefits for corporations and the wealthy will trickle down to everyone else. Except the theory didn't work well. Reagan also opted to end federal funding for mental health programs to cut the budget. The consequences of Reagan's social policy? ~One-third of the USA's homeless suffer from severe mental illness, which puts a burden on police departments, hospitals and the penal system. 

To me, a more apt 
cliché is one prevalent in the 1990s in Alberta, Canada when government health care cuts and restructuring decimated the laboratory and broader health system. They hired consultants to do the dirty work, then leave. Many in the lab community called them 'suits.' (See Further Reading)
  • "I'm a consultant and I'm here to help."
Managerial roles pre-AI often include the manager performing the following functions:

  • Assume leadership, which includes motivating staff to achieve a common goal and being a role model for key qualities like dedication and integrity;
  • Communicate to lab staff and beyond the lab;
  • Delegate responsibilities to staff;
  • Manage projects and budgets;
  • Organise and chair meetings;
  • Comply with mandatory laboratory regulations;
  • Maintain current best practices;
  • Manage conflicts in the workplace;
  • Manage conflicting priorities;
  • Manage workplace diversity (inter-generational, ethnic,cultural);
  • Problem solve issues from technical to human resources;
  • Develop staff skills, including CE/CPD opportunities;
  • Recruit and retain talent;
  • Maintain a safe workplace. 
So can I assume that the six 'Post-AI Laboratory Roles' are just add-ons, more or less minor tweaks, to what today's managers already do versus a revolutionary change? Is artificial intelligence and machine learning that big a deal? Will it consume a manager's time as the be all and end all? Or is it just one of many changes that laboratory professionals have adapted to over the decades. Are AI roles more critical than traditional managerial roles? You tell me.

As always comments are most welcome. See below.

My reply to Anonymous's comment below, who writes, "A huge concern I have centres around the data chosen for algorithms used for AI decisions" and mentions two books:
The second book that Anonymous mentions is Machines Like Me by Ian McEwan (2019). The link is a review. The book gets a mixed review. A few quotes:
  • "The book touches on many themes:...artificial intelligence AI, ...but its real subject is moral choice
  • "The epigraph quotes Rudyard Kipling’s poem “The Secret of the Machines”, which presciently expresses the uncompromising quality of the machine mind. “We are not built to comprehend a lie,” the poem goes. 
  • "In Adam’s digital brain [he's a robot], there may be fuzzy logic, but there’s no fuzzy morality. This clarity gives him an inhuman iciness." 
Thanks, Anonymous, for much food for thought. Suspect algorithms come down to GIGO. Oh and they're highly susceptible to historical bias and... [Fill in the blank as you wish]. 

I chose a 1972 song by Johnny Nash (who often collaborated with Jamaica's Bob Marley) and admit it's somewhat tongue in cheek as I'm skeptical of AI's use in medicine, including laboratory medicine and transfusion. Admit it has much promise but has yet to deliver due to obstacles (See Artificial intelligence and digital pathology: challenges and opportunities, Further Reading).

Artificial intelligence: a primer for the laboratory leader (18 Nov. 2019)

AI can help labs manage data to improve stewardship. New artificial intelligence technologies improve patient care and lower laboratory costs (21 Nov. 2019)

8 Management skills you need to be a laboratory manager (10 Mar. 2019)

For pathologists:
Tizhoosh HR, Pantanowitz L. Artificial intelligence and digital pathology: challenges and opportunities. J Pathol Inform. 2018 Nov 14;9:38.

Making artificial intelligence real in pathology and lab medicine (Pathology Chair's blog, Lydia Howell, MD, 1 Feb. 2018)

Wednesday, October 30, 2019

I will remember you (Musings on gender in transfusion medicine)

Updated: 2 Nov. 2019

October's blog is short. The idea was initially stimulated by two 'from the archives' papers in TraQ (Further Reading). The topic of the papers was perceived gender discrimination by healthcare professionals. The initial purpose of October's blog was to get readers to assess if they perceived gender discrimination exists in their disciplines and workplaces.

After reflection, I decided to change the focus to highlighting how many great female physicians there are in transfusion medicine, many of whom I've been privileged to know personally. And, sad to report, one recently died. 

The title derives from a ditty sung by Canada's Sara McLachlan.

Historically, medicine has been male dominated, whereas both nursing and medical laboratory technology/science have been female dominated, at least in Canada. That's been my experience in transfusion medicine but it has changed significantly over the years, especially in transfusion medicine.

TIDBITS Since I moved to Edmonton in Nov. 1977 to teach in University of Alberta's Medical Laboratory Science to the present, Oct. 2019 (42 years), top jobs have been held by men: Medical Directors of UAH's Dept. Lab Medicine and Chairs of the Dept. of Lab Med and Pathol (Faculty of Medicine and Dentistry, University of Alberta).

Individual UAH lab specialties have been held by women, including I am especially pleased to say the transfusion service, which is currently headed by one of my Med Lab Sci 'kids', who also holds higher regional positions. Across Canada, many female physicians hold significant transfusion medicine positions.  

Nurses vs physicians remains an ongoing saga and perhaps sometimes it's just about power, not gender. Suspect it gets more dicey when scope of practice is involved, which also adds pharmacists to the mix.

Canada's blood suppliers are a mixed bag. CBS had had a male CEO from the get-go, though many female physicians are CBS medical directors across Canada. Héma-Québec began with a female CEO. Parts of CBS are male top-heavy

Over the years I've seen female transfusion Drs. bullied by what I perceived as pompous male colleagues in rounds and at conferences. As the cliché goes, women must be way better than male colleagues to succeed. Is it still true?

Transfusion medicine is blessed with many exemplary female physicians in top positions. Some examples of ones I've known personally and met F2F (alphabetical order):
Interesting that so many of these Canadian female transfusion medicine docs have held major positions (as above) and won awards. To name a few: 
  • CSTM Ortho award recipients:
    • 2002, Francine Décary (CEO of H-QISBT President 2004-6)
    • 2007, Heather Hume (Executive medical director, CBS)
    • 2010, Susan Nahirniak (Chair of NAC)
    • 2013, Debra Lane, Medical  Director of CBS's only joint transfusion service/ blood supplier in Canada)
    • 2014, Lucinda Whitman (Chair of NAC)
Of course, Canada has many outstanding female transfusion medicine Drs. I've never met F2F but know via social media like Twitter or via e-mail. Ex:
  • Dr. Jeannie Callum (who kindly contributed to CSTM blog on Ana Lima )
  • Dr. Yulia Lin: CSTM Ortho award recipient, 2016; 2019 AABB President's Award, 'In recognition of her role as a master educator in the field of transfusion medicine, particularly through her contributions to the education of junior doctors through the Transfusion Camp program.'
  • Dr. Elianna Saidenberg who died far too young on Oct. 20, 2019 (Further Reading) 
Special note on Elianna Saidenberg, Never met her except via her tweets, and she kindly liked many of mine.Thought she was a wonderful human being as I suspect did all who knew her up close or from afar. Clearly, Dr. Saidenberg made a difference in her all too short time on planet earth. Twitter remembers Elianna

So...what do you think? Does your country have many fabulous female transfusion medicine physicians as Canada does. Is gender an issue in transfusion medicine, whether related to physicians, nurses, medical laboratory technologists?

I've chosen Canadian Sarah McLachlan's song for this blog, one I've used before:

I will remember you 
will remember you, will you remember me? 
Don't let your life pass you by 
Weep not for the memories.
As always, comments are most welcome and there are several below you may enjoy. 

In Memoriam: Dr Elianna Saidenberg (21 Oct. 2019)

Blau G, Tatum D. Correlates of perceived gender discrimination for female versus male medical technologists. Sex roles 2000 Jul;43(1):105-18. | Related:

Blau G, Tatum DS, Ward-Cook K, Dobria L, McCoy K. Testing for time-based correlates of perceived gender discrimination. J Allied Health. 2005 Fall;34(3):130-7.

Shannon G, Jansen M, Williams K, Cáceres C, Motta A, Odhiambo A, et al. Gender equality in science, medicine, and global health: where are we at and why does it matter? Lancet. 2019 Feb 9; 393(10171):560-9.

Tuesday, October 01, 2019

Both sides now (Musings on humans vs technology in transfusion medicine)

Stay tuned: Revisions are sure to occur

There's much transfusion news these days on artificial intelligence (AI), big data, drones, innovations, new technology, precision medicine. In a way this blog is a follow-up to the prior one, 'Get back' (Musings on transfusion medicine's future).

September's blog (albeit published Oct. 1) was stimulated by a weekly feature ('Workplace column') on a local radio program I heard this morning (Further Reading). Also, because as an oldster I want a record of events I've experienced in the hope they will resonate with some and influence others to do similar. Otherwise when we oldsters croak, they're gone forever.

The blog's title derives from a song by Canada's Joni Mitchell.

As you read the blog, regardless of your health profession, please consider the challenges you faced if you have held a management position and, if not, think about the strengths and weaknesses of managers you have had. Also, consider the impact you as a manager have had on colleagues and the influence your managers have had on you and your career. 

Specifically, the radio column was on moving into management, generally viewed as a promotion with a higher salary. The columnist (@sandbaryeg) gave tips on becoming a manager for the first time. Her tips made me recall when I took a giant leap from a long career as a transfusion educator of medical laboratory technologists/biomedical scientists to become a lab manager at CBS ('assman' as the centre's QA department addressed my mail). True, I'd been lab supervisor in my 13-yr job before teaching, but with none of the responsibility the 'assman' position entailed.

Indeed, as I only learned later, although I managed the patient services lab at the blood centre, the position had been downgraded to 'assistant manager' in order for the centre (and perhaps head office?) to retain more control, especially over salaries. Also, I hadn't realized (bit stunned of me) that the person who had been an assistant to the prior manager and perhaps (just a guess) had applied for the job I was recruited for, and was the acting manager when I came. She was a prior student of mine, in fact in the first Med Lab Sci class that I taught all the way through, who I was and still am exceedingly fond and proud of.

My take on the consultant's 5 tips for new managers. How to
1. Run meetings, something many dread;
2. Give effective feedback;
3. Foster a team environment;
4. Attract & recruit the staff you need vs filling an existing job;
5. Manage your own time effectively.

Promotion: First, I'll note that in my experience (historical, I know, dating from 1960s-2000) often the folks who get promoted in the lab are ace technologists. If all factors are considered more or less equal, seniority may play a role. To me, that's not an effective process, but it's likely the easiest.

How often do fabulous footie players (soccer in NA) or hockey players become great managers? Not many. Why? Because the skills needed are quite different.

Needed skills? More recently, not only med lab techs/scientists but also physicians (perhaps nurses?) tend to get Masters of Business Administration (MBAs) as lab medicine and transfusion have become more and more a business. Presumably these degrees help in a new career as a 'suit' whose prime concern is the bottom line, though patient safety is always touted, given first place in communications.

I'll discuss the 5 tips in various ways based on my experience.

Decades ago as an educator I'd experienced many ineffective meetings, including those run by MDs at the departmental (Lab Med & Path) & Faculty of Medicine levels. Some dept. meetings were info-only unneeded sessions. Few required active participation. And often the minutes were totally useless to anyone not attending.
  • My experiences motivated me to write a resource for TraQ in 2009 on running meetings (Meetings as Time Wasters, Further Reading).
On running meetings in my brief career as 'assman' I was fortunate and smart to designate my prior student to run many meetings. She was experienced in the task and did it much better than I ever could. Only time I ran meetings was when it came to getting staff on board with changing almost all pretransfusion testing methods in the lab. That came easy as it was right up my alley as an educator.

In a similar vein, I was glad I'd insisted on a whiteboard for my 'assman' office as it was well used when meeting with supervisors in the various sections of the patient services lab.

As an educator I had to give feedback over decades and some was difficult. For example, telling foreign students (English as a second language), whose parents had struggled and worked hard to send them to Canada that they were not going to pass their clinical rotation. For such students it was a total disaster, an incredible loss of face and shame. Frankly, it broke my heart and I know that whatever I said to lesson the blow (e.g., they could have great success in another career) wasn't heard and didn't lesson their reality in any way.

In giving more routine feedback, as a med lab technologist with an MEd, I knew the characteristics of effective feedback. On a personal level I believe that often what shapes us for good and bad in life are 15-60 second interactions with others. For example, I'll never forget the powerful effect of my Dad saying, 'Pat, don't be afraid to be different.'

As a teacher of med lab students I always kept that in mind when giving feedback. Meant I treated struggling students the same as high achievers. And in retrospect I see that many of those who struggled have gone on to be high achievers, leaders in their field. Why? Suspect it's because success depends on many factors, not necessarily getting the highest grades.

A good pal is a standardized patient at the University of Alberta and they have a particular take on feedback, called CORBS (Further Reading):

CLEAR – Give information clearly and concisely
OWNED – Offer feedback as your perception, not the ultimate truth. Talk about how something made you feel. Use terms such as “I find” or “I felt” and not “You are”
REGULAR – Feedback is offered immediately, or as soon as possible after the event
BALANCED – Offer a reasonable balance of negative and positive feedback. DO NOT overload with negative feedback.
SPECIFIC – Feedback should be based on observable behavior and behaviors that can be modified.

Not much to say. Health care teams are similar to politicians kissing babies. Everybody does it as it's the reigning orthodoxy, the cliché of how we love to see ourselves. Again, University of Alberta has a course on it. INT D410 - Interprofessional Health Team Development.

Like to think I've been a member of many teams in health care (my transfusion families over the years) but must admit that many who promote it most publicly do not walk the talk.

Will only speak to my recruitment to be 'assman' 21 years ago. Fact was the job was not quite as advertised. In retrospect I thought they portrayed part of the job almost as if it was what became hospital liaison specialists. I totally dug the part about the centre being the pilot site for a new information system and found it a worthwhile challenge.Our talented team of med lab professionals did a wonderful job in implementing the new IS.

Similarly, I loved the opportunity to change outdated lab methods, though don't think they hired me for that. It was just my 'value added' to the job I held for all of 9 months. When I tendered resignation I explained why in exit interview. They understood more money wouldn't make a difference and admitted they could not change what I thought needed changing most (head office, though it's more complicated than that).

So did CBS recruit the right person for the job? Yes and no. Yes, because I led the talented patient services lab team successfully through a difficult time of incredible change. No, because after years in academia at a university where dissent and free speech are cherished, I didn't fit in a national organization where adhering to head office directives was paramount. That's what made you a valued team member.

The radio consultant pointed out that managers need to prioritize their tasks and serve as role models for staff as they cannot work to 10 pm over the long term. I don't have much to say except that you obviously cannot help others if you're exhausted. See it as a Buddhist concept that you need to love yourself, be okay with who you are, in order to love and help others. Over my entire career I was often the first in and last out daily but that's another story.

Are AI, big data,new technology, precision medicine all important to health care and more crucial than the qualities of people in leadership positions? Perhaps. But not to me. As a human being on plant earth, I'll always value the human condition over technology. See excerpt from 2001, a Space Odyssey (Further Reading).😁

Chose this song because I've lived long enough to see transfusion medicine evolve from being people-focused to technology-focused. As  early adopter of technology (not a Luddite), I doubt we're on the right track (Further Reading). Also, admit that I love the songs of Canada's Joni Mitchell.