Monday, July 13, 2015

Mommas, don't let your babies grow up to be hempaths (Musings on evolving TM careers)

Updated: 14 July 2015
July's blog was stimulated by a paper in ASH's journal, Blood (see Further Reading):
  • Wallace PJ, Connell NT, Abkowitz JL. The role of hematologists in a changing United States health care system. Blood. 2015 Apr 16;125(16):2467-70. Epub 2015 Mar 6. 
The blog's title derives from a 1970s ditty associated with Willie Nelson.

What follows is my brief take on ASH's initiative for hematologists, including possible parallels it has, or doesn't have, for transfusion-related nurses and medical laboratory technologists / clinical laboratory scientists worldwide. At core, it's a tale of how to promote your profession and earn a living when the universe does not unfold as you thought it would.


Keep in mind I'm not a physician, let alone a hematologist / hematopathologist, so my take is born of ignorance. But I've never let facts spoil a good story, so here goes.  First the paper's overview:
ABSTRACT

Major and ongoing changes in health care financing and delivery in the United States have altered opportunities and incentives for new physicians to specialize in nonmalignant hematology. At the same time, effective clinical tools and strategies continue to rapidly emerge. Consequently, there is an imperative to foster workforce innovation to ensure sustainable professional roles for hematologists, reliable patient access to optimal hematology expertise, and optimal patient outcomes.
The American Society of Hematology is building a collection of case studies to guide the creation of institutionally supported systems-based clinical hematologist positions that predominantly focus on nonmalignant hematology. These roles offer a mix of guidance regarding patient management and the appropriate use and stewardship of clinical resources, as well as development of new testing procedures and protocols.
MUSINGS #1  - Systems-based hematologists
The authors imply that nonmalignant hematology is a career path that's opened up for hematologists to earn a buck and sustain their careers. In the full paper they note that traditional roles (malignant hematology) are sucking up the jobs, leaving few for others, especially non-specialists.
Excerpt:

Although this forum focuses on the United States health care system, similar issues exist elsewhere, including outside of Canada and Europe.

For example, Dr. Andrew Roberts commented that in Australia, where hematologists have traditionally been trained dually as internists and hematopathologists,

'Clinicians with high-level expertise in care of acute and chronic nonmalignant hematology have been squeezed out of appointments in both diagnostic laboratories and hospital departments dominated by subspecialized malignant hematology' (Andrew Roberts, Royal Melbourne Hospital, personal communication, January 27, 2015).
Hence, the authors propose what they call 'systems-based hematologists', ill-defined because associated expertise permutations are many. Using 'systems-based' is fascinating. I'm tempted to say it borders on bafflegab. 

What does it mean? In plain language please. Cut the weasel words. Does systems-based relate to
  • Systems thinking involving a holistic approach to all the parts of any health system? Even including, as stated in the paper,  non-medical areas such as information technology specialist, hospital quality control officer, and safety officer? In which case, perhaps systems-based is a jack-of-all-trades approach. One that encroaches on roles often fulfilled by other health professions, and even far-removed from medicine such as information technology?
Nice thought but uh-uh! Too ambitious for most hempaths. Best stick to nonmalignant hematology, where validated expertise exists.

MUSINGS #2  - Hematologists, pathologists, and weirdos

Interestingly, in Canada (and the USA), hematology is a sub-specialty of internal medicine:

Whereas hematological pathology education and training takes place in Departments of Laboratory Medicine and Pathology, at least at the University of Alberta where it is a 4-year post-graduate specialty. Likely many variations of education exists worldwide. 

For example, in the US, hematopathology is a board certified sub-specialty practiced by physicians who have completed a general pathology residency (anatomic, clinical, or combined) and an additional year of fellowship training in hematology. 

Pathologists identify diseases and conditions by studying abnormal cells and tissues.  A joke to illustrate:
In the grand scheme of medicine, historically pathologists have gotten a bad rap as Weirdos.

Perhaps it's performing autopsies on the dead that falsely defines them in the public's eye as docs who deal only with dead people, often in dingy basement labs. 


As opposed to the reality of physicians who diagnose disease and offer treatment options to front-line docs. And many treat patients personally, as front-line docs, in the case of hematologists as opposed to the more lab-focused hematopathologists.

Even today in the realm of 'sexy' forensic pathology TV shows such as NCIS, the pathologist is eccentric:

As an aside, I taught in a windowless basement lab for more than 20 years. Every spring it would flood as the snow melted. Trapping mice was ongoing entertainment. But so far as I know students were not brain dead from having so much information and problem solving thrown at them.
Personal anecdotes
1. Long ago a beloved and respected pathologist who headed a university department I worked in looked nothing like what he was. I once pointed him out to my spouse in a grocery store and asked him to guess what he did. Reply: Maybe down-on-his-luck, soon-to-be homeless dude?

He wore old baggy suits, bicycled to work, shyly looked the other way if you met him in the hallway. Superficially he was a odd-bod eccentric. In reality he was a brilliant pathologist and one of the kindest guys you could ever meet.

2. Once mentioned to university department head, a hematopathologist, that lab technologists/scientists were at bottom of the healthcare totem pole because we had little interaction with patients except as blood collectors (think Dracula), now not even that, as specialized phlebotomists are the norm. 


His response: 'Pat, it's similar for pathologists, we're at the bottom of the physician totem pole.'

3. Briefly worked with a hospital transfusion service medical director who's background was as a hematologist from the UK. He had a hard time in his job because he lacked the in-depth laboratory skills and transfusion medicine expertise of Canadian-trained hematopathologists. He thought it stupid and odd that NA MD training split the two:

4. When I think of all the physicians I know, the ones who stand out as exemplary are hematopathologists. Maybe it's because I taught them in a prior life or know them as colleagues and people. But equally likely it's because they are exemplary on many levels. Most are the antithesis of the weirdo stereotype, people-persons fully engaged with the world and their colleagues, making a difference.

MUSINGS #3 - OTHER PROFESSIONS
Are there parallels in nursing or med lab technology/science with ASH's call to develop systems-based hematologists?

1. Nursing
Nurses, including transfusion specialists, are in demand and have done well by their venture into transfusion medicine. But funding of transfusion positions is always a challenge as in Australia's example below.

Source: Abstracts of ISBT Regional Congress and conjoint BBTS Annual Conference, London, UK, June 27-July 1, 2015 (See Further Reading)

2D-S08-01: My role as a transfusion practitioner in a UK NHS  teaching hospital (
Excerpt)
2010 survey in England and North Wales: Transfusion Practitioners (TPs) made a significant contributions to improve transfusion practice at local, regional and national levels by promoting safe transfusion practice, appropriate use of blood, reducing wastage, and increasing patient and public involvement ensuring that Better Blood Transfusion has become an integral part of NHS care. 
Anecdotal evidence shows that the role and responsibility of the TP varies widely and has changed for most since it was introduced over 10 years ago, with significant variation in how TPs spend their time.
2D-S08-03: The role of the transfusion practitioner in Australia (Excerpt)
Currently there are 113 dedicated TP positions and many more staff involved as blood/transfusion champions. There are also 12 TP positions within the Australian Red Cross Blood Service (ARCBS). 
Education available in Australia to support the TP role and others working in the area including the Graduate Certificate in Transfusion Practice, BloodSafe eLearning Australia, and an extensive range of learning experiences offered by the ARCBS. In this tight economic environment there is constant pressure in all states regarding the funding of these positions.
Similar to American hematologists, perhaps transfusion-specialist nurses would benefit by highlighting more general ways they add value to the health care system?

2. Medical laboratory technology / clinical laboratory science
Several years ago there was a movement in Canada, perhaps elsewhere, to get med lab techs on healthcare teams that went on patient rounds. 


The discipline chosen for the experiment was clinical microbiology and the tentative name for the new category was clinical technologist, meaning health professionals who observe and treat patients rather than theoretical or laboratory studies.

Nothing much came of it. So far as I know, it failed. As an example, what's missing from this TOC?


Why did it fail? Maybe because clinical microbiologists exist higher up the totem pole, either with MD or PhD degrees.

From a broader perspective, lab professionals have a huge career liability, namely technology.  Anything that eliminates humans from the process (and concomitant human error), is valued above all. As is technology-associated automation that eliminates staff and their ongoing financial liabilities like benefits and pensions.

BOTTOM LINES
In a time of cost restraint, all health professions are wise to seek unique niches showcasing and promoting special skills that enhance patient well being and safety, as well as their own careers. Then we rely on health policy analysts who advise government to be objective / evidence-based and for politicians to put public good above partisan political dogma. 


At which point, I admit to ROTFL.

Perhaps one day physicians, like medical lab technologists, will be told the equivalent of

  • We've got a device that frees you up from many mundane tasks so you can concentrate on using your core skills to the max 
Actually, that's already happened. They're called nurses, occupational and physical therapists, pharmacists, etc. And, physicians often fight them tooth-and-nail to protect their turf and scope of practice, all under the umbrella of patient safety.

An exception is Alberta's Primary Care Networks, so maybe the times they are a changin'.


Update (14 July 2015): A recent news item on TraQ relates to changing times:
Iggbo is a US company similar to Uber, except the mobile app connects physicians with freelance phlebotomists in the locale who collect blood for the ordered tests. The idea for the business was stimulated by a government crackdown on the practice of paying process-and-handling fees to doctors that could be considered kickbacks. (See Further Reading for background)
The Iggbo app fits with an earlier tongue-in-cheek blog: 
Perhaps workforce innovation to ensursustainable professional roles for hematologists will one day include freelancesystem-based clinical hematologists. 
Hempaths who meld mobility, flexible lifestyle, and entrepreneurial spirit with tech-based logistics (apps) to support reliable patient access to hematology expertise.
FOR FUN
Some songs apply to many professions, including health professions. This Nelson ditty epitomizes the issue, as does Dylan's. 
And you must admit that both icons overcame their nasal singing voices with content that resonates.
Or for a real trip down memory lane
As always comments are most welcome.
FURTHER READING
1. Wallace PJ, Connell NT, Abkowitz JL. The role of hematologists in a changing United States health care system. Blood. 2015 Apr 16;125(16):2467-70. Epub 2015 Mar 6. (Full free text)


2. How docs pick their residency (Scroll to Pathology)


3. Abstracts of ISBT Regional Congress and conjoint BBTS Annual Conference, London, UK, June 27-July 1, 2015 (See p. 8 for the transfusion practitioner abstracts)

4. As background for Iggbo: WSJ exposé puts HDL on the defensive

Saturday, June 13, 2015

I heard it though the grapevine (Musings on AABB promoting academia-industry partnerships)

Updated: 15 June 2015

June's blog is stimulated by May's issue of 'AABB News' featuring 'Advancing Cellular Therapies Together'. 

The blog's title derives from a Marvin Gaye classic covered by Creedence Clearwater Rival in 1970.

Frankly, the rah-rah! uncritical tone of the AABB articles surprised me. They mentioned logistical challenges to academia - industry partnerships but not one, repeat, NOT ONE, of the well known pitfalls when industry funds medical research. Didn't even allude to such problems existing.

Why no mention of pitfalls? Is it because of AABB's self-interest in promoting a business line?

In her editorial, 'Advocating for Cellular Therapies', AABB president Lynne Uhl writes:
'AABB will continue to advocate for clear regulatory pathways that avoid overly burdensome requirements for existing cellular products and promote rapid translation of novel findings from CT and regenerative medicine research to treatments for diseases.'
Sounds logical that AABB would advocate for easier access of medical discoveries to the marketplace where they can help patients. But the stance aligns with industry's usual complaint that governments set up needless roadblocks and should just get out of the way because industry will ensure patient safety. Really? LOL!

Let's take a brief closer look at AABB News' cellular therapy features.

AABB NEWS ARTICLES
A few selected highlights from 3 articles:
1. Evolving partnerships between academia and industry (p.4)

'As state and federal government funding...has declined... industry support has allowed many academics to continue their research, and academic institutions ... justify such collaboration as a pathway for the commercialization of important discoveries for the common good.'
2. Academia and industry collaborate in cellular therapy partnerships (pp. 8-10)
This article is an interview with Yongping Wang, MD, PhD, scientific director of the stem cell laboratory at the Children's Hospital of Philadelphia (CHOP) and Deborah Sesok-Pizzini, MD, MBA, chief of the blood bank and transfusion medicine division at the CHOP.

'The partnership gives both parties a new outlook on their work. It also brings together the different strengths of the two enterprises, which hopefully results in synergy.'
'The ultimate goal of these partnerships is to develop a mutually beneficial relationship that will result in scientific advancements.'
3. Advancing cellular therapies through partnerships (pp. 12-17)
'Many institutions and companies form partnerships drawing on each other's strengths to ease and speed the journey to market.' 
California Institute for Regenerative Medicine (CIRM): 'We are working to remove the barriers that slow research, without compromising safety.'
WHY RESEARCHERS AND UNIVERSITIES LOVE INDUSTRY FUNDING
  1. Government research grants are getting harder to obtain.
  2. Researchers may lose positions without outside research money because public universities increasingly suffer from decreased government funding and expect staff to be self-funded, especially in medical faculties.
  3. Industry funding combats the long-standing bias that universities are 'ivory towers' divorced from the real world.
WHY BIG PHARMA LOVES UNIVERSITY COLLABORATION
  1. Outsourcing cheaper, as those in blood industry know
  2. Adds credibility, especially if researchers are seen as 'thought leaders' 
  3. Access to research facilities cheaper than building them
  4. Well educated staff who work for free, inc. PhD students
  5. Way to recruit scientists and see future staff in action
  6. Form of advertisement, if researchers are in same field 
  7. Free advertising as universities tout industry partnerships to combat 'ivory tower' stereotype
WHAT COULD GO WRONG?
The short answer is just about everything. Of course, just because Big Pharma funds a study does not invalidate it. Most studies with commercial applications are funded by industry. But the scientific community needs to assess every aspect of such studies carefully using the hallmarks of critical analysis of scientific literature.

I'll highlight two threats that industry funding poses to medical research:

1. Easier Research
Industry tends to fund technology- and drug-based research because they are its business lines and such research happens to be easier. Big Pharma and the biotechnology industry doesn't fund difficult qualitative research on soft skills such as communicating, conflict management, human relations, negotiating, team building
, etc.  Why would it? 

Yet soft skills deficiencies account for serious errors in patient care. For example:

Communication
Communication deficiencies are common causes of adverse transfusion events. Patients with special transfusion needs such as those requiring irradiated or CMV-negative blood components are particularly at risk when communication fails.The spectrum of communication deficiencies includes the following failures:

  • Physicians not communicating with nurses, technologists, pharmacists, etc., and vice versa
  • Attending physicians not communicating with residents and interns
  • Staff from one unit not communicating with another unit
  • Staff on one shift not communicating with the next shift
  • Documentation not accompanying patients from facility to facility
Which research would industry be more likely to fund?
  • Educational research to improve health professional communication
  • Technology-based mistake-proofing tools like Blood Loc, a combination-lock-secured disposable bag that ensures positive identification occurs before blood can be unlocked and transfused
No brainer, right? Funding techno-solutions involves easier research. No messy human traits to deal with. 

Research priorities
Of course, to make the point, I've given an apples-and-oranges example of competing research needs. But make no mistake, within transfusion medicine many pressing research needs compete for limited funds


For example, on 25-26 March 2015, the U.S. National Heart, Lung, and Blood Institute (NHLBI) hosted a conference on 'State of the Science in Transfusion Medicine', for which AABB provided highlights. Priorities identified included
  • Need to integrate basic science within clinical trials design
  • Research to determine how to make better products, whether synthetic, bioengineered or 'pharmed' 
  • Several other themes: 
    • Hemostasis
    • Donor health and safety
    • Transfusion requirements of different patient populations, particularly pediatric and neonatal patients
I cannot help but wonder where all the research on molecular blood typing fits in the priorities identified at the NIH conference. Immucor and others claim it will 'revolutionize blood bank operations' and they work hard to make that goal a reality. But is it the best use of scarce research funding? See my take:
Having industry control which research 
gets done is not good.

2. Funding Effect
Financial interests can influence research outcomes in many undesirable ways. (See Resnick below) Besides outright fraud, well intentioned researchers may produce biased results unconsciously. 


For example, suppose I'm a university researcher who's increased my prestige and job stability because I've obtained a $1 million contract from Big Pharma to collaborate on investigating a new cellular therapy in what industry calls the 'niche area of oncology'. (Who knew cancer was a niche business line?)

A negative research result or one that shows only a marginal benefit will not further my career. But I'm ethical and have no intention of deliberately skewing results. Resnick below explains the nitty-gritty of what can go wrong from start to finish:

  • Problem selection 
  • Research design 
  • Data collection 
  • Data analysis 
  • Data interpretation 
  • Publication and data sharing 
A funding effect on medical research is real. I repeat, funding does not negate research, but we need to be aware of its insidious influence.

BOTTOM LINE
Collaboration and partnerships between academia and Big Pharma (and other health-related industries) are facts of life. Such collaboration has many benefits and many pitfalls.

Can the transfusion medicine community, particularly NA leading organizations such as AABB, please take its self-interest blinkers off and give members some credit for having a brain?

Vacuous, Rah! Rah! articles undermine AABB's credibility. I expect better from an organization I've respected and been a member of for 40 years.

Sidebar: Does 40 year membership mean I'm eligible for 'emeritus / life membership' in AABB?
AABB proposed bylaw change:
"Emeritus Membership to be renamed Life Membership with the eligibility requirement to be changed from 10 consecutive years of Individual Membership in AABB to 30 consecutive years."
As always, comments are most welcome.

FOR FUN
The version of the blog's title song that I I prefer is CCR's.

Don't you know I heard it through the grapevine
Not much longer would you be mine
I heard it through the grapevine
I'm just about to love my mind

What did I hear via the grapevine of AABB News? That respected organizations like AABB now mindlessly promote academia-industry collaboration as if it was the greatest invention since sliced bread. And not a whisper, not a hint of the real possibility of down-sides. Clearly they're industry's poodles.

FURTHER READING

Monday, May 18, 2015

Heart of Gold (Musings on sucking $ from body tissues)

Updated: 27 May 2015
May's blog was motivated by three items in TraQ's May newsletterUse of 'liquid gold' in two news items and an EU-funded report that showed 'a clear tension between the plasma derivative (PD) and the blood/blood components sectors'. Links to articles are provided below:
  • Unregulated USA stem cell industry is 'wild west', in which liposuction fat was described as 'liquid gold' because patients pay big bucks for fat-based stem cells
  • Canberra Red Cross calling on donors to consider donating 'liquid gold' plasma
  • EU-funded report calls for changes to plasma regulation
The blog's title derives from a 1972 ditty by Canadian Neil Young.

1. USA'S QUACK FAT-BASED STEM CELL INDUSTRY

A brief excerpt (revised for brevity and clarity): 
The liquid is a dark red 'soup', a mixture of fat and blood, that is pumped out of the patient's backside (fat ass?), treated with a chemical, run through a processor, and injected into knees, elbows, faces, penises, you name it. 
The 'soup'  is rich in stem cells, magic bullets that, according to some doctors, can be used to treat just about anything from anti-aging to face-lifts to multiple sclerosis to ALS.
It's quackery, critics say. But it's a mushrooming business,almost wholly unregulated. 
Those profiting call it "patient-funded research". Others say charging patients to participate in medical research is  unethical, unauthorized, for-profit human experimentation. 
The number of stem-cell clinics across the U.S. has surged from a few in 2010 to more than 170 today. Many clinics are linked to large, for-profit chains such as Cell Surgical Network.
Of course, it's quackery. Another example of medical professionals with vested interests promoting unproven treatments for gain.

2. AUSTRALIAN RED CROSS'S 'LIQUID GOLD'

The Australian Red Cross Blood Service (ARCBS) in Canberra promotes plasma donation via plasmapheresis because of a growing need.

A spokesperson said that plasma is used for 18 different treatments including burns victims, trauma patients and cancer patients, plus being used successfully as an immunity booster.

"We call it liquid gold because it can save so many lives."

Hard to decipher this news item. The spokesperson is likely referring to blood components (e.g., fresh frozen plasma, cryoprecipitate, etc.) and plasma derivatives. Most donated plasma in Australia is processed by the plasma fractionator, CSL Behring, to make many products that ARCBS buys back, I assume, and distributes to hospitals. If incorrect, please let me know.

And Australian donors are not paid, in the same way that Canadian plasmaphereis donors are not paid for plasma, although I assume some is sent for processing to manufacturers and sold back to CBS. From CBS's 2013-14 Annual Report (p. 40):

'Given that self-sufficiency is not operationally or economically feasible in a volunteer, unpaid model, Canadian, Blood Services strives to maintain a sufficiency of 30 per cent for immunoglobulin (Ig). 
The demand for Ig, continues to rise in Canada and internationally, and, to meet our needs, Canadian Blood Services purchases, surplus recovered plasma (from voluntary donations) from the United States for fractionation.' 
Seems that Canada supplies 30% of its own plasma for immunoglobulins, a plasma derivative / plasma protein product. But buys the rest --'recovered plasma' donated by unpaid, volunteer American blood donors  --  from non-profit US blood organizations. Really?

The worldwide PD market was estimated at $11.8b USD in 2009. Plasma truly is liquid gold, especially for manufacturing companies like Grifols with a global market share of about 20%. In 2013 Grifols net profit rose by a whopping 34.6% to 345.6 million.

3. EU REPORT CALLS FOR CHANGES TO PLASMA REGULATION

An EU-funded report looked at the plasma industry and produced several recommendations based on what industry wanted.

Some of the highlights:
  • The International Plasma Fractionation Association railed against the trend for ever-larger clinical trials for new or modified plasma products, most pronounced for coagulation factor products, making it harder and more expensive to run clinical trials.
  • Call for harmonization of regulations covering the selection of donors and plasma in the USA and Europe because, for example, mutual recognition of inspection reports could cut costs.
  • IPFA expressed concerns and suggestions related to regulations on donation, e.g., legal status of eligibility criteria, mandatory presence of medical staff, recall/exclusion for (v)CJD. 
    • For example, they said a permanent presence of a physician in a plasmaphaeresis centre adds significant costs without adding any substantial benefit. Qualified health professionals (nurses or who knows who) can do the job. 
  • The Report also notes a clear tension between private, for-profit companies supplying plasma derivatives to a steadily growing market, including unproven clinical uses, and the public sector, supplying a relatively stable demand for blood and blood components.
In other words, for-profit plasma manufacturers want to minimize costs in any way to maximize already fabulous profits for their shareholders.

BOTTOM LINE
Stem cells, plasma, and even molecular blood typing as in April's blog, While my guitar gently weeps -- It's all about the money, folks. 


Are the quack fat-derived stem cell entrepreneurs all that different from the paid plasma industry shilling IVIg as the latest and greatest for who knows what? 

Or that different from molecular genotyping companies and their advisory TM experts implying that any blood transfusion without genetically matched donors is 'bad blood' or not 'best practice' or so 20thC? 

Those trying to influence decision makers are powerful lobbyists with vested interests in the $ billions. 

And sometimes with support and collusion from transfusion medicine's 'thought leaders'.

FOR FUN
Rather than promote body tissues as 'liquid gold' I'd rather promote a 'heart of gold'. Silly me? A losing battle but one worth fighting.

As always comments are most welcome. 

FURTHER READING

Sunday, April 12, 2015

While my guitar gently weeps (Musings on the seduction of technology)

Updated: 13 April 2015
April's blog focuses on news items from TraQ's latest newsletter that have a commonality. 
  • The main item deals with a molecular assay to identify 35 red cell antigens from 11 blood groups. 
  • The other, included to illustrate the blog's theme but mainly here for fun, focuses on the clinical uses of platelet-rich plasma (PRP). 
I'll leave it to readers to ascertain what the stories have in common. The blog's title derives from a 1968 George Harrison ditty in the Beatles 'White Album'. 

 NEWS ITEMS
MUSINGS on MOLECULAR BLOOD TYPING 
Typing of blood group antigens at the molecular level has been in the works for years. Now it's moving beyond its original special uses because of technological advances, decreasing costs, and lobbying by vested interests. 

However, its cost-effectiveness is still unproven. Immucor's PreciseTypeTM HEA test costs ~$350 USD but that likely varies significantly depending on individual contracts. And any cost study I've read in journals like AABB's Transfusion is so dependent on assumptions as to be almost meaningless and needs to be read carefully and critically.

Also, molecular blood typing is not the be-all, end-all for the 100s of blood group antigens that exist, since not all are DNA-defined. But the list of antigens covered is impressive and includes nearly all clinically important blood group systems (see Further Reading). 

Of course, other companies besides Immucor compete in the molecular blood typing business, including BloodChip® by Progenika Biopharma.(Source: Greg Denomme's paper in Further Reading)

Regardless, molecular blood typing has no end of proponents, mild and strong. For example:
I wrote a blog on this topic years ago: 
  • Snip, snip the party's over (Dec. 2010) 
    • Suggest you read it later, if the mood strikes. My predictions have come true but they were no-brainers. 
Me Medicine
Now molecular blood typing is being marketed as personalised medicine, ie., the tailoring of medical treatment to individual characteristics of each patient. The idea derives from the 13-year, $3 billion Human Genome Project. For example, Immucor advertises PreciseType this way:
Makes it seem that anything less is substandard. Get with the program, health care providers, because it's all about me.

But many experts like Donna Dickenson, emeritus professor of medical ethics and humanities at the University of London and research associate at the HeLEX Centre, University of Oxford caution that
MUSINGS: PLATELET-RICH PLASMA (PRP) 
I'd read several news items over the years about PRP's use in orthopedics, particularly for athletes:
And recently the owner of a local restaurant I frequent mentioned that she had her own plasma injected into her knee but had to pay for it as it wasn't covered by Canada's universal health care system, at least for her. She said her knee caused a lot of pain (she's a 50-something server in the restaurant) but apparently it wasn't bad enough to be operated on yet. 

With that as background, recent news items on PRP's expanding clinical uses caught my attention. Medical tourism grows daily, at least for the rich. Seems Dubai now has more plastic surgeons per capita than any other city in the world and hopes to attract half a million medical tourists by 2020. 

The penis and vagina PRP nonsense was included just for fun. But really, Academy Award nominees got a coupon for a Priapus Shot? You cannot make this stuff up. 

BOTTOM LINE 
Okay, I lied because I'm sure you've gotten the blog's theme by now:
  • Where there's a buck to be made or an agenda to be advanced, clinical uses of diagnostic tests and products will inevitably expand well beyond what's evidence-based. 
TM poster-child for phenomenon? Intravenous immunoglobulin (IVIg). 

But what's surprising, at least to me, is how few voices, especially in the TM community, question the *expanded use* of innovations like molecular typing of red blood cell antigens under the guise of me-medicine. Particularly since our so-called 'thought leaders' are so into evidence-based these days. 

I understand why advances that help solve real TM problems are celebrated. But why the uncritical approach? Is it because blood typing at the molecular level is 
  • A marvelous innovation and all want to be seen as 'with-it' hipsters on DNA's bandwagon? Versus being old-fogeys who resist change? 
  • Way to develop a business line and maximize earnings in a shrinking field like TM in age of 'blood conservation 'über alles', e.g., AABB? 
  • Outright self-interest for those who specialized in molecular technology and need to maximize their career's life-span?  
  • Seen as eliminating humans from the equation, such as interpreting serological test results, thus must be good? 
  • High-throughput automated innovation, another way to decrease costs by eliminating those pesky creatures, aka staff, with their costly salaries, benefits, and pensions? 
    • Better to give money to international companies than keep staff, aka tax payers and community builders, employed at home?
    • Plus many staff are probably contemplating retirement anyway and eliminating their jobs will help make that decision easier? 
  • Viewed as best thing since sliced bread, not just a significant innovation with specific uses, motivating proponents to abandon whatever critical thinking skills they ever had?  
BOTTOM LINE 
Personally, I wholeheartedly agree that molecular blood typing is a useful, indeed marvelous, advancement that will make blood transfusion safer for many. Celebrate its potential but please don't promote it beyond clear clinical uses so that anything else seems sub-standard, as in this over-the-top headline: 
  • 'Boston Children’s Hospital ends BAD BLOOD between donors, patients' (Emphasis is mine)
FOR FUN 
'While My Guitar Gently Weeps':
  • #136 on Rolling Stone's "The 500 Greatest Songs of All Time"
  • #7 on its list of 100 Greatest Guitar Songs of All Time
  • #10 on its list of The Beatles 100 Greatest Songs. 
While my guitar gently weeps (Paul McCartney and Eric Clampton tribute to George Harrison, Queen's Golden Jubilee, London 2002) 
I don't know why nobody told you 
How to unfold your love 
I don't know how someone controlled you 
They bought and sold you. 

I look at the world and I notice it's turning 
While my guitar gently weeps 
With every mistake we must surely be learning 
Still my guitar gently weeps 

As always the views are mine alone and comment are most welcome.

FURTHER READING 
References for those who want to delve further into the blog's topics. 
Molecular blood typing
Nice overview: Denomme GA. Prospects for the provision of genotyped blood for transfusion. Brit J Haem 2013 Oct;163(1):3-9.

For molecular blood typing in detail, see these papers from 2009. Info overload but fascinating insight into predicting the future (All papers free full text): 

Molecular blood group diagnostics.Transfus Med Hemother. 2009 Jun; 36(3): 154–155.(editorial) 

Five expert opinions on the question ‘Will genotyping replace serology routine blood grouping in the future?’ 
Interpretations are mine. (Author origins refer to where they worked then, not necessarily nationality.) 
  • Opinion 1: Only partly. Unlikely unless... (Germany) 
  • Opinion 2: Probably (Switzerland) 
  • Opinion 3: For some applications (Austria) 
  • Opinion 4: Personalized versus Universal Blood Transfusions – Combining the Efforts: Probably but in combination with enzymatic conversion (ECO) to remove A and B antigens (Sweden) 
  • Opinion 5: Yes (Netherlands) 
Platelet-rich Plasma 

Monday, March 16, 2015

I will remember you (Musing on retiring TM professionals & their patients)

As always, stay tuned for revisions 
This month's blog was triggered by ongoing retirements of longtime colleagues, medical laboratory technologists (clinical lab scientists) who work in transfusion services, blood centres, and Canada's provincial blood coordinating offices. The retirements come to my attention because I manage a mailing list ('transfusion'), whose subscribers are mainly Canadian and include laboratorians and nurses.

Because I've blogged about similar themes before, I decided to keep it short and add a few related news items from TraQ.

The blog's title derives from a memorable song by Canadian Sarah McLachlan, one that I've used before and love.

RETIREMENTS
We have known for ages that all health professions have an ageing workforce and that many would retire shortly, presumably leading to significant staff shortages.

Another long-standing concern is an impending brain drain. The loss would be especially acute in the laboratory 
due to automation, regionalization, and centralization, once the few remaining transfusion specialists retire with insufficient knowledge transfer to the next generation. Succession planning has not been a priority in health systems where staff barely have enough time to perform routine tasks needed for safe patient care.

As noted, over the past couple of years, many transfusion colleagues whom I've known for decades have retired, or are about to. They worked from coast to coast to coast in Canada and made incredible contributions to our transfusion medicine system. They seldom, if ever, get the national credit they deserve upon retiring.

Just a thought. Perhaps the CSTM would consider celebrating some of these wonderful transfusion professionals on its website as an ongoing feature?

NEWS ITEMS
1. Israel: Health system faces severe shortage of medical laboratory workers . Key points:
  • Close to half of Israel's lab workers are 55 or older
  • Lab worker with a doctorate and eight years' seniority gets 34 shekels ($8.80) an hour, similar to a hospital orderly
  • As expected, graduates prefer to work in other sectors
That low wage is pretty incredible.

2. Canada: CBS Regina component production lab to close in 4-5 years, as production moves to Calgary 


CBS's long-term plan is to regionalize blood component production to a few centres the way it regionalized blood donor testing earlier. Employees who find themselves without a job transfer to other positions (if available), move to other locations (impossible for many), or leave the organization.

The strategy is to innovate, mobilize knowledge, be on the leading edge of best practice, rightsize, leverage business lines, and be a leaner organization. 
Translation: Put safety first in all communications because it makes us look good but get rid of as many staff as possible, hire cheaper ones, save money. 

3. Scotland: Infected with hepatitis C via transfusion, woman charts her journey back to life

Interesting report of a Scottish woman who contacted transfusion-associated HCV ~27 years ago when she gave birth to a child and received 4 blood transfusions.

The UK experience with compensating people infected with HCV via transfusion is messy.

We need patients to remind us that, when the blood system gets it wrong, as it so tragically did with HIV/AIDS and HCV, people may die. And if they survive, they suffer for a long time and in many ways.

MUSINGS

  • Let's not forget our retired transfusion colleagues who dedicated their careers to helping others. We owe them a lot, not the least of which is friendship, mentoring, support, and many a shared laugh at meetings. For a chuckle see this conference cartoon via @academicssay on Twitter
  • To refresh the profession, we need to pay people a competitive salary, i.e., competitive to what health professionals with similar education and training earn. 
  • Leveraging and other management jargon, ubiquitous in our transfusion leaders' communication these days, fools no one. It's about the cost savings, stupid. 
  • Our transfusion 'thought leaders' (how's that for jargon?) continue to brag that the system is the safest it's ever been. And it is. That cocksure confidence was what led to the HIV/HCV tragedies. I'd prefer a little less braggadocio, a little more humbleness.
  • Let's never forget the patients in our care whose lives were harmed because our transfusion medicine leaders - caring and dedicated and extremely bright - nonetheless screwed up.
FOR FUN
Only one song fits this blog's theme:

And I 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.

Saturday, February 07, 2015

Islands in the stream (Fun musings on TM's crusade to cut costs - there's an app for that!)

Updated: 14 Feb. 2015

This blog derives from an article in the Jan. 3, 2015 issue of The Economist:
The blog is a follow-up, a sidebar in newspaper parlance, to a blog I wrote for TraQ's January newsletter:
The earlier blog discusses the rancor and over-the-top claims that can occur during contract negotiations, especially when employers such as national blood suppliers consistently opt to cut costs by hiring cheaper, less educated staff.

The current blog muses on HR 'what ifs' related to saving money by using outsiders and training remaining staff 'on the cheap' using apps. The tone is irreverent, the content tongue-in-cheek. If you're offended, don't be.

The blog's title derives from a 1983 Bee Gees song. The Bee Gees were the brothers Gibb, born on Isle of Man, who sold more than 220 million records worldwide.

#1. What if...
CBS, Canada's national blood supplier, expanded its Donor Care Associate initiative ('multi-skilled clinic employees' perform all clinic functions, from venipuncture to donor screening, tasks previously done by RNs) beyond nursing to transportation?

In northern climates I envisage 'Transport Care Associates' working for blood suppliers such as BFDC ('Blood Fluids Dot Ca').

In tropical climates, perhaps turtles, slow but steady and reliable?

#2. What if...
An equivalent to Amazon's 'Mechanical Turk' existed for transfusion services?  Why not a global blood bank work force where transfusion medicine specialists 

  • Work from home
  • Choose own work hours
  • And no one needs to pay for their benefits except them
  • National blood suppliers would crow to government paymasters, 'Look how we've decreased costs.'
  • Not mentioning on whose backs savings were realized and probably increasing the CEO's salary for his great work
Let's call it 'BB-a-Go-Go' with these business lines:
  • BBaGG-IH: Want expert help with an unexpected crossmatch incompatibility, complex antibody identification, blood grouping conundrum, any immunohematology challenge? 
    • Get these IH folks fast as they're a dying breed.
  • BBaGG-Scribe: Need experienced SOP writers or help creating a blood contingency plan to deal with severe blood shortages from pandemics and other disasters? 
    • They'll create e-text files. Bonus: Older Scribe staff will produce notes in readable cursive writing in the margins of existing documents. Yes, really!
  • BBaGG-Consultants: Looking for 'suits' to down-size the organization or decimate it by out-sourcing tasks to for-profit firms, then flee the ugly aftermath? 
    • Our 'suits' don't clean up the detritus of the 'past civilization' but we can supply grief counsellors for a fee.
  • BBaGG-RN: Seeking advice for how to tame and educate pit-bull nurses refusing to re-draw mislabelled specimens? Typically, the RN's dialogue proceeds as follows:  
    • 'I know I took blood from the right patient.'
    • 'Don't you know you're risking the patient's life with your stupid lab rules?'
    • 'The poor patient has been "stuck" 4 times today already!'
For an extra fee, we offer the online RN-tailored course, 'Quality Control, what's it all about, Alfie?'
  • BBaGG-Dominatrix: Desperate to neuter abusive docs who insist on blood now, who don't care about your 'bloody positive antibody screen nonsense', just want group O RBC NOW, because they were told in med school group O was the universal donor, safe for all?
    • With Dominatrix Plus, the physician gets a safe word or phrase to indicate they cannot take it any more. We suggest 'Lab uber alles' or 'I'm lab's poodle'.
Other 'BB-a-Go-Go' business lines are possible. Feel free to suggest some in Comments.

#3. What if
A smartwatch app existed that included all the pre-administration checks that a nurse must do before administering a transfusion? Let's call it 'Last Chance':

  • The watch has a camera that monitors the checks, and beeps if one were missed, identifying the missed detail. 
  • A nursing manager  - for fun, the spitting image of Nurse Jackie - pops up on the watch's screen and gives a video message about what to do next and why you better do it NOW. 
  • The bedside nurse can reply and ask questions with a video message in return. 
The app could also include built-in alerts to check the patient during and after the transfusion.

With bulk purchases, buyers get the add-on, 'Doomsday Clock', which shows how close to midnight it is, indicating how close the nurse came to an OMG! patient disaster.

#4. What-if
An app existed that allowed instant access to transfusion medicine experts, 24-7? 


Say you're a hematopathology/hematology resident on-call and the biomedical scientist / lab technologist calls with an issue you've never heard of. Chances are she or he knows more than you but you can never admit it.

You could call the transfusion service medical director, yet again, further digging your own grave, or you could use this 'killer app',  PMA ('Protect My Ass') for medical residents. Currently, versions exist only for Blackberry and iOS phones, plus iOS tablets.

Wait, there's more! PMA includes a simulation of how residents can learn to be obsequious to RNs on the wards, bowing to their superior knowledge and experience, and learning from it.
SUMMARY
The Economist's piece expertly analyses the pros and cons and obstacles to the ongoing trend of on-demand freelancers who work without job security, without benefits, without pensions.

That's where national blood suppliers like Canadian Blood Services are heading. It's a trend everywhere.

My view is the trend is inevitable but not progress, not admirable. And, as The Economist points out, a freelance work force doesn't contribute to happy staff who consistently give their all for employers they love and respect, and whose success is tied to theirs.

BUT the trend exists because .... [you fill in the blank] 


Wish List: I'd like to see an app that translates management's weasel words into what they're really saying. One example: 
  • 'We're pleased to report a "cost saving" of ...' probably means,
    • We've eliminated expert frontline staff;
    • Replaced them with less educated, cheaper staff; 
    • Perhaps replaced them with automated equipment, likely sending money to a foreign international company rather than hiring local staff and keeping wages in the community;
    • And given execs a bonus and pay raise for their brilliance in decreasing costs.
FOR FUN
This duet of the Bee Gees song is perhaps the best country duet of all time. One of my favorites, the song fits what I see the transfusion medicine community should be but isn't. The lyrics also suit upcoming Valentine's Day.

Islands in the stream
That is what we are
No one in between
How can we be wrong
Sail away with me
To another world
And we rely on each other....

Not a disco fan but this Bee Gee ditty from 'Saturday Night Fever' with John Travolta is irresistible. Also relates to TM workers in era of cost restraints:
As always the views are mine alone and comments are most welcome.