Both sides now (Musings on transfusion medicine illusions)

Updated: 17 Nov. 2013

This month I couldn't resist a blog on abstracts from the 2013 AABB Annual Meeting in Denver, Oct. 12-15, published in Transfusion, Vol. 53, No. 2S, September 2013 Supplement.

Some people use People as bathroom reading. For ~38 years (since becoming an AABB member in 1975), mine has been Transfusion, with the meeting abstract issue offering many enjoyable hours 'on the throne'. Ok, cue the chorus of, 'Get a life!' 

What follows are random observations, covering a few of the many goodies that struck me in this year's abstract supplement. 

Because the AABB meeting is on when this blog is published, I realize that few North Americans will read it. Maybe after they return home and equilibrate? 

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

TRANSFUSION PROFESSIONALS
First, using electronic access to Transfusion as an AABB member, the following data was complied.

In the Administrative and Scientific sections, searches for references to health professionals yielded the following results, i.e., number of search 'hits':

Administrative (Scientific)

• Physician: 60 (54)
• Nurse: 37 (11)
• Technologist: 28 (8)
• Clinician: 8 (15)
• Medical director: 6 (2)
• Pharmacist 1 (0)
• Perfusionist: 2 (0)

Using the scientific section, the top four would be
* physician-clinician-nurse-technologist

What stands out is how physicians dominate both abstract sections. 

SO WHAT?
It follows that physicians dominate AABB meeting abstracts. They dominate AABB's Board of Directors and certainly dominate the ability to do research. 

AABB's 2012-13 Elected Board (n=19):

• 13 MDs (68%)
• 4 Medical technologists (21%)
• 2 PhDs (11%)

Is it an illusion that nurses and medical technologists are equal to physicians in the TM stratosphere or do they continue to be historical underlings?

AUTHOR COUNTRIES
Founded in 1947, in 2005 AABB changed its name from American Association of Blood Banks to AABB. The change reflected that AABB has members in many countries and includes all of transfusion medicine plus cellular therapies.

In the Administrative and Scientific sections, searches for references to author countries showed that the USA dominates abstract presentations at annual meetings. The AABB website gives this breakdown of meeting abstracts: 

2013 Abstracts	No. accepted	Acceptance rate
Domestic	445	90%
International	215	83%

These numbers make the meeting look very international and do not fit what a quick scan showed.

Administrative section: Most non-USA authors are Canadians with 6 abstracts. Other countries such as Italy have 2 abstracts.

Scientific section: Outside of American authors, Canadians have the most abstracts (sorry, no exact count but based on a quick review Canada is number two). This reflects that it's cheaper for Canadians to attend meetings in the USA than transfusion professionals in Europe, Asia, Africa, and Down Under. It would be interesting to know how many of the 'international' abstracts were from Canadians.

Another major factor influencing AABB attendance is that transfusion professionals from Australia, NZ, and European countries have major conferences of their own to attend:

• HSANZ, ANZSBT and ASTH Annual Scientific Meeting
• BBTS conference
• ISBT congresses in Europe and Asia

SO WHAT?
AABB is not as international as it likes to portray itself. Despite boasting of membership from ~80 nations, outside of Americans, Canadians predominate. Its 19-member Board has only three non-Americans: Canadians Graham Sher of CBS and Jeannie Callum of Sunnybrook HSC in Toronto, and Mike Murphy of the UK's NBSBT and Radcliffe Oxford University Hospital.

Annual meeting attendees are mostly Americans, followed by Canadians.

Is it an illusion that AABB is an international organization? Or is it really a NA organization dominated by Yanks, with a few token Canucks? 

AABB ABSTRACTS
Now to the three abstracts selected for this blog. 

1. AP123 Transfusion Audits: Looking Beyond the Obvious

Authors: R M Bhavnagri, S M Armstrong, K Sanford. Transfusion Medicine, Virginia Commonwealth University Medical Center, Richmond, VA, USA.

The authors noted that transfusion audits are required by regulatory bodies to assess nursing protocols. They decided to use audits to build better relationships between nursing and blood bank staff. 

They rotated audits among every technologist in the transfusion service. This allowed staff to form relationships with nursing staff on each shift. The result was that relationships between nursing and blood bank staff improved.  

Comment: I really liked this abstract because anything that fosters blood bank and nursing understanding is good.
Is this an illusion? Will nurses and laboratory technologists ever be blood brothers and sisters? Evidence grows that this is so, especially in countries where medical laboratory technologists form a significant portion of transfusion safety officers. [See abstract 3 below.]

2. AP76 Bridging the Gap: The Success of Daily Transfusion Medicine Meetings

Authors: A L Sutton, N K Case, K Sanford.Transfusion Medicine, Virginia Commonwealth University Medical Center, Richmond, VA, United States 

Pathology residents continually rotate through the TM laboratory and it's the responsibility of pathology physicians and medical lab scientists to guide residents through their rotations. A new director noted a communication gap between the lab, residents, and director and implemented daily meetings.

The 20-30 minute meetings are held in the director's office and attendance is mandatory for TM residents, the charge medical technologist, and TM supervisors. 
Meetings have a consistent agenda and include blood product inventories, antibody workups, and much more. They're also an opportunity for residents to ask questions. 

Comment: Daily meetings are a great opportunity to exchange information and keep everyone apprised of current TM activities and issues.  Daily meetings that include the medical director, pathology residents, and medical technologists help bridge communication gaps.  

Equally important, they can lessen status gaps in the health profession pecking order. Disrespecting colleagues is harder when you've spent time with them close-up and know them as people.
Is this an illusion? Do medical directors have the time, let alone the will, to spend 30 minutes in daily meetings with residents and lab staff? Only if they see it as time well spent. One of the value-added benefits would be that it promotes medical technologists becoming an integral part of the health care team. 

3. P11 2012 Transfusion Safety and Patient Blood Management Survey

Authors: C Slapak, K Gagliardi. Community Blood Center/Community Tissue Services, Dayton, OH, United States; Southwestern Ontario Regional Blood Coordinating Network, McMaster University, Hamilton, ON, Canada. 

In 2012~ 40 programs based on an informal network of transfusion safety and patient blood management professionals existed in the USA.  

An online survey was circulated to transfusion safety officers, blood management coordinators, or similar in the USA and Canada  using informal US networks and the Canadian 'Transfusion' mailing list.  

108 professionals replied: 62% from Canada, 32% from US, and 6% from other countries. Almost all Canadian programs have existed for over 5 years (95%) compared to just over half of US programs (54%). 

Professional backgrounds:  

• nursing (24% Canada, 77% US) 

• laboratory (72% Canada, 9% US) 

• 6% physicians or others

The most common words in the position titles were Transfusion Safety (50%).

Training is mainly via professional experience, networking, and attending meetings. Only 8% use a formal TSO training program. 

Comment: Canada has more experience with transfusion safety officers than the USA.The UK and Australia also have more experience than the US. Although the evidence is mostly anecdotal, as in the USA, nursing has no monopoly but tends to dominate TSO positions in the UK, Australia, and NZ. [If this is not so, I'd love to hear from colleagues there.]  For example, from 'Towards Better, Safer Blood Transfusion'. A Report For The Australian Council For Safety And Quality In Health Care (Feb. 2005):

These key individuals have various titles (Transfusion Nurse, Transfusion Nurse Specialist or Consultant, Transfusion Safety Officer, Haemovigilance Officer, Specialist Practitioner of Transfusion). They are usually recruited from nursing backgrounds. They act a vital 'bridge' between the different provider groups engaged in the transfusion 'safety chain', in particular those beyond the hospital laboratory.

In contrast, in Canada medical laboratory technologists outnumber nurses 3 to 1 as transfusion safety officers or equivalent.

Is Canada's experience an illusion? It seems not, but why the preponderance of 'transfusion safety' nurses outside Canada whereas medical technologists here hold their own? An added benefit of a good mix of nurses and technologists is that understanding the daily work realities of each profession grows, and with it, increased respect. 

FOR FUN
Lately, I've listened to many songs written by Canada's Joni Mitchell. The blog's title was selected to reflect the 'we-they' schism between nurses and transfusion service technologists, including the nursing - technologist TSO dichotomy in the rest of the world compared to Canada. 

But other potential illusions include:

• Are nurses and technologists 'equal' to physicians on the health care team? (where equal means valued and respected equally for their expertise)
• Is AABB a true international organization? Or more a NA group with delusions of grandeur and global aspirations to promote its standards and associated business line, AABB Consulting Services?
• Can nurses and technologists one day be blood brothers and sisters, treating each other with respect, even awe, for their respective skills?  
• Will medical technologists ever become an integral part of the health care team, as respected as professionals with direct patient contact?

Joni Mitchell songs:

• Both sides now (~600 'cover' versions by other artists and counting)

I've looked at life from both sides now 
From up and down and still somehow 
It's life's illusions I recall 
I really don't know life at all. 

Two other fabulous songs that Joni wrote:

• Big yellow taxi
• Woodstock

As always, comments are most welcome. And we have some...

Reply #1: Re-Dr. Gwen Clarke's comment below:

Appreciate the feedback. Nice touch to include weekly telecons for colleagues in Edmonton-area hospitals. Like you say, daily meetings help promote communication, a team approach, and opportunities to learn and teach.

I've always been struck at how communication failures play a role in so many adverse events in the UK's SHOT reports. For example (from p. 6 of the 2012 SHOT Report):  

The headlines from 2012 reporting are a continued high rate of error related to omission of essential procedural steps and communication failures. 

Suspect that communication improves outside meetings too as it's easier to phone someone you see every day and works both ways for physicians and lab technologists to consult each other more.
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Reply #2: Re-Kate Gagliardi's comment below:

First, about including your abstract (#3 above: Transfusion Safety and Patient Blood Management Survey), my apologies. It's been on my to-do list to write and tell you it was in October's blog, but....

Believe it (or not) it would have happened today. <;-)

Suspect Canada's situation, where many who are not formal 'transfusion safety officers' share bits and pieces of the role, apply universally. 

Appreciate your frank comments on UK's SHOT ('gold standard') vs Canadian and American hemovigilance programs. Reminds me of a 2011 blog:

• Only in the UK & Down Under? Pity! (Musings on hemovigilance)

Sad that it's still relevant 2 years later. I keep looking for published, current data from Canada and USA. Doesn't happen.

About AABB holding meetings on Canadian Thanksgiving, that breaks me up. Case of, "If it didn't happen in USA, it didn't happen"? Unfair to American colleagues but AABB should take note, if only to maximize meeting profits.

As to TSO 'RN vs Medical Technologist' issue, I'd love to hear your views. In the meantime, I'll pursue it on other media such as Canada's TSO "transfusion" mailing list and report back here. 

Thanks again. Your input is much appreciated.  
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

I've been everywhere, man (Musings on fast-tracking those with foreign credentials)

This blog is a revised version of a recent personal blog, 'Want to work in Canada as a medical technologist? Forget it!'

Last updated: 16 May 2012 (see Addendum below)

 As a promoter of international job mobility, it has long saddened me that foreign-trained medical laboratory technologists from English-speaking nations such as Australia, NZ, and the UK face so many obstacles when seeking work in Canada. 

Do physicians and nurses face similar obstacles? Perhaps not, because everywhere in Canada, I hear physicians with British, New Zealand, South Africa, and Aussie accents. And since 'Down Under' countries are always holding job fairs in Canada for nurses, I suspect that mobility may be reciprocated, i.e., Aussi and Kiwi RNs can work in Canada without too much difficulty. But for medical technologists, it's a different story. Working in Canada is onerous, indeed.

If you are a physician or nurse, I encourage you to read (even skim) the technologist-related details below to assess how job mobility for your profession compares.

This blog derives from a Dark Daily report: "Medical laboratory technologists with foreign credentials to get fast-track acceptance in Canada."

Its title derives from an old Hank Snow ditty, I've been everywhere, man.

I love Dark Daily, but its headline and article are misleading. If I were asked about foreign-trained medical laboratory technologists from AU, NZ, UK, and USA, where English as a second language is a non-issue, and where education and training are world class, my response would be:

• All the fast-tracking in the world won't help.

As background, Canadian employers (mainly government-funded health regions) are always moaning and groaning about the shortage (soon to become worse with impending retirement of baby boomers) of nurses and physicians, as well as other health professionals such as medical laboratory technologists and diagnostic imaging technologists. In response, governments have created various fast-track schemes that supposedly will allow faster immigration and employment of qualified needed health professionals. 

USA GRADS
First, USA grads do not qualify because their general certification does not include histotechnology. In Canada, besides clinical chemistry, hematology, clinical microbiology, and transfusion science, general certification requires education and a clinical rotation in histotechnology.

Second, obtaining subject certification for USA grads in the other 4 main disciplines is out because Canada offers subject certification only in clinical genetics and diagnostic cytology.

Reasons that CSMLS does not offer subject certification in other disciplines include

• Cost (subject exams are costly to maintain) 
• Employer preference for flexible grads who can work in all disciplines
• Fear that employers may use those with subject certification to work in lab sections for which they are untrained

Accordingly, the path to employment in a clinical laboratory for a USA-educated and trained medical technologist / clinical laboratory scientist is a torturous path:

• Step 1: Attend an educational institution (Canada or US) and take a course equivalent to an histotechnology course taught at Canadian institutions. For example, see MLS 250 at the University of Alberta.
• Step 2: Convince a potential employer to provide a clinical rotation in histotechnology. In Canada this is ~4 weeks. And it's next to impossible because employers can barely offer clinical rotations to Canadian-trained students.
• Step 3: Apply to CSMLS for a 'Prior Learning Assessment'.
• Step 4: If eligible, arrange to write the CSMLS general certification exam (based on a competency profile) covering the five disciplines specified on the CSMLS website.

AUSTRALIA, NEW ZEALAND, UK

Background

In my experience, education and training 'Down Under' and in the UK are excellent and in some ways exceed that of the typical Canadian graduate, since Canada rejected the BSc as entry-level several years ago.

This decision created barriers for Canadian medical laboratory technologists to work outside Canada. 

People who did not support the BSc were employers and bureaucrats in provincial government departments of health. Reasons for rejecting the BSc varied but included:

• They perceived the BSc as entry level for nurses  as credential inflation leading to increased salaries without sufficient return on investment and they were determined to stop this happening for medical laboratory technologists.

• Employers wanted the cheapest possible medical laboratory technologists, those who could be 'turned out' as quickly as possible and paid as little as possible. 

• In their short-sighted view, with the move to increased laboratory automation and centralized testing, who needed a technologist whose education and training took 4 years?

Exception

Canada has two programs that provide both a BSc and professional certification by CSMLS:

• MLS program at the University of Alberta (UA) is the longest existing program: its first BSc (MLS) degrees were awarded in 1961. MLS also offers a post-diploma BSc.

• University of Ontario Institute of Technology (UOIT), which opened in 2003, offers a Bachelor of Health Science (Hons) in MLS.

All other programs are 2- or 3-yr diploma programs at technical institutes or community colleges (equivalent of USA 'associate degrees').

For interest, UA MLS grads enjoy international job mobility. They are eligible to write the American MT(ASCP)* exams and many have. (*To change once the ASCP's Board of Registry and NCA merge to form a single USA certification agency.)

This allows UA MLS grads to work in the USA and many did during the mid-90s when laboratory jobs greatly decreased in Canada and many educational programs closed.

As well MLS is the only Canadian program whose grads are eligible to work in NZ without writing certification exams. 

What about job mobility for technologists trained in other English speaking countries besides the USA? Can university educated and trained UK, Oz, and NZ grads easily work in Canada as med lab techs?;

Unfortunately, no. The main reason is that programs in these countries, while providing education in the 5 basic disciplines, do not require clinical rotations in all 5 disciplines.

For example, NZ graduates of university programs  are ineligible to work in Canada because they may do a year's rotation in only 2 disciplines, e.g., 6 mth clinical rotations in their 4th year in each of 2 disciplines (e.g., hematology and transfusion science or clinical chemistry and hematology, etc.), as in the Massey University program.

In contrast, a typical Canadian grad may spend 3 mths in a hematology lab and one month in a transfusion service lab, only one-third of the total time spent by NZ grads in these labs, and in the case of transfusion science, one-sixth as much. But NZ MLS grads are not eligible to write the CSMLS general certification exam without obtaining equivalent clinical rotations in all 5 disciplines.

Is this not nuts, given that NZ MLS grads clearly have more basic education than most Canadian grads, as well as more practical experience in at least 2 clinical laboratories?

OZ and UK grads are similarly stymied if they want to work in Canada because graduates of Australia and UK's university programs can specialize. Examples:

• Australia: BSc in Laboratory Medicine from Curtin University's School of Biomedical Sciences 
• UK: Bradford University's BSc (Hons) in Biomedical Science (also see Details & Modules tabs)

Why do these medical laboratory technologists face significant barriers to working in Canada? Is it all about protecting public safety by ensuring medical laboratory professionals meet Canadian standards of education and training? Or is it about protecting Canadian jobs for Canadians?

And why do graduates of Oz, NZ, UK, and US programs who are certified by their county's professional body and have worked for years in one or more areas of a clinical laboratory, need to write the CSMLS general certification examination covering all 5 disciplines to work in Canada? Beats me.

CSMLS CERTIFICATION

If the educational programs of foreign-trained technologists are deemed equivalent to Canadian programs (or better), foreign-trained candidates must still write the CSMLS general certification exam to work in almost all Canadian medical laboratories.

Most Canadian provinces have regulatory bodies that de facto require that medical laboratory technologists be certified by the CSMLS as a condition of employment in a clinical lab that performs diagnostic tests on patients.

For lab professionals with experience (e.g., those who trained 10-15 yrs ago), and who have likely worked in one discipline (perhaps two) for years, writing an exam covering knowledge and competencies in 5 disciplines is not easy. And getting clinical rotations in Canadian labs is pretty much impossible.

MUSINGS
I personally know NZ-, UK-, and USA-trained lab professionals who are better educated and trained than many Canadian grads, have ample current experience, and would make valuable contributions to Canadian labs and be exemplary employees. But they cannot work here, despite the fast-track 'BS' of our governments.

True fast-tracking would allow

• Different routes that don't require candidates to re-learn  specific disciplines (e.g., histotechnology), which they will never work in;
• Restricted licenses to practice and work only in the area or areas for which they are well qualified.

The situation is different for those for whom English is a second language:

Besides becoming fluent in English, these technologists often need to upgrade their education and training to Canadian equivalency. As but one example, in transfusion science, the association of the Rh blood group system with severe hemolytic disease of the fetus and newborn would not have been taught in Asian countries where almost everyone is Rh positive.

Upgrading programs are rare but exist. If candidates pass English language competency tests, successfully complete whatever minimal upgrading is deemed necessary, write and pass the CSMLS general certification exam, they still may not be hired if their English remains weak. That's the reality of today's clinical laboratories where staff are stressed to the max, mainly due to under-staffing.  

If asked, I often advise foreign-trained grads to enroll in a Canadian medical laboratory technology program. It's a tough sell because they have to support themselves and their families. But in the end, this route can prevent much grief and frustration.

Not a pretty picture....

Talk of fast-tracking foreign-trained medical laboratory technologists / medical lab scientists / biomedical scientists is largely smoke and mirrors.

Your thoughts and experiences are valued. Please offer feedback anonymously (or provide your name in the body of your response) by commenting below.

 Whether medical technologist, nurse, or physician:

• Is there an impending shortage in your country that would benefit from greater international job mobility?
• Does international job mobility of needed health professionals work well in your country? 
• Do foreign-trained workers face significant barriers? 
• Is fast-tracking a reality? 

Similarly, have you tried to work in another country and what obstacles, if any, did you face?

For fun
'Golden oldies' by Canada's inimitable Hank Snow: 

• I've been everywhere, man 
• I'm moving on (Intro by Johnny Cash)

And just because I love it:

• Across the universe (Beatles)

 As always, the views are mine alone.

ADDENDUM (16 May 2012)

Thanks to 'Anonymous,' who left a comment but perhaps withdrew it:

Well, it seems that both nurses and doctors have to sit exams in Canada in order to work here.... I wonder if it is possible to flood the ears of those desperately in need of lab staff with credentials of American or Australian or New Zealand educated professionals, so that the potential employer is motivated to seek change in the requirements.

The comment motivated me to suss out the following info on foreign-trained physicians and nurses wanting to work in Canada.

PHYSICIANS
Source: Global Medics

The basic core requirements for medical registration in Canada: 

A medical degree from any country that is listed in the International Medical Education Directory (IMED)

GP or specialty training that has been completed in Australia, Canada, Ireland, New Zealand, UK or USA
Authentication of medical certification by the Physicians Credentials Registry of Canada (PCRC). 

Some provinces require full verification before they will issue your license. Others will allow you to complete PCRC verification after starting work in Canada. Most provinces also require completion of the Medical Council of Canada Evaluating Exam (MCCEE).

Before taking the MCCEE, internationally-trained physicians must apply to the Physician Credentials Registry of Canada (PCRC) and send a certified copy of your final medical diploma. The MCCEE is a computer-based examination available at 500 test centers in 72 countries. 

Also see Info for foreign-trained medical doctors

NURSES

See Info for foreign-trained nurses

Process is similar to that for medical technologists (assessment, national exam). Exam info:
Canadian Registered Nurse Examination

More....

• Foreign-trained nurses in Canada wasted during shortage
• Govt. help for internationally trained nurses
• Centre for Internationally Educated Nurses