I've been everywhere (MLS grads in the Klein era)

Updated: 3 Feb. 2019 (Major re-write)

Folks, the article below by a University of Alberta graduate in Medical Laboratory Science (MLS) was written 22 years ago. I have her permission to include it in a blog. I think it's timely because it documents -using one example- what happened to Alberta's health professionals under Ralph Klein in the 1990s, now touted as a fiscal hero by UCP's Jason Kenney.

IMPORTANT: I alone am responsible for the blog. The MLS grad agreed I could use her article in a blog, whose content was unspecified.

Although somewhat political, I decided to include it in the 'Musings on Transfusion Medicine' blog series as it relates to one of several students who got work in New Zealand's Blood Service and to education for medical laboratory technologists/scientists.

BACKGROUND
The student in question was lucky in her decision to get a university degree in MLS because it gave her international mobility. So many  of Alberta's excellent medical laboratory technologists with diplomas did not have that option.

As someone who was asked by many with diplomas what their options were when jobs in Alberta all but disappeared under Klein, it was hard to tell them the reality. Many were experienced and talented but it mattered not. Unlike MLS grads, the USA wasn't possible because of NAFTA requiring a BSc in jobs the USA needed. To work as a technologist you also needed to be certified by ASCP or similar. In contrast, most MLS grads had opted to obtain ASCP certification upon graduating so had no USA barriers to employment for what they were educated and trained to do.

Getting MLS grads accredited to work in NZ and qualified for work visas was difficult. First, I sent the entire MLS curriculum to the NZ certification body to prove the program was equivalent to NZ's, which had adopted a university entry level and called graduates medical laboratory scientists or biomedical scientists. Getting MLS's program accredited was the easy part.

Second, the job had to be on a skill shortage list, plus candidates needed a job offer from a recognized employer, in this case the NZ Blood Service. Other criteria were age, health and character requirements. Much more was required, including booking plane flights before acceptance by the NZ Canadian embassy was guaranteed. I well recall the incredible bureaucratic nightmare the MLS students endured to go Down Under.

These MLS grads, my 'kids' as I call them,were brave pioneers, undertaking a grand adventure. Thanks to PC Premier Klein, dozens of other grads uprooted them selves from their homes and families and moved to the USA where they were treasured as fabulous health professionals.

For example, out of the blue I was contacted by a maker of blood bank software (Wyndgate, now part of Haemonetics) who explained they'd done a software demo for the NZBS and were so impressed by the Canadian MLS grads, they hoped other grads would be willing to travel to California to work for them. As it turned out two MLS grads did, including this graduate, a grad of the post-diploma BSc program.

LEARNING POINTS
1. Having experienced Klein's health care cuts in Alberta, which we still are recovering from, I'm no fan of politicians like UCP Kenny who bow down to the god of decreasing a deficit. Especially when they put that above the welfare of health professionals and diss them for being pampered public service workers.

2. Seeing the fossil fuel energy sector whine about lost jobs and decreased profits, after so many good years of mega-profits, makes me chuckle at the irony. Yes, I have empathy for those who have lost their jobs. In the good years many folks, regardless of education level, earned $100K+ in the oil patch, worked hard, long hours and lived the good life.

Medical lab technologists spent much effort, time and big-$ to get an education. Oil-patch dudes, who portray themselves as pull-themselves-up-by-the-bootstraps macho-men and now whine, are portrayed as victims of the governing Alberta NDP of all things by the opposition UCP, not victims of the glut of oil and falling prices.

Meanwhile, in the 1990s public sector workers like my young MLS grads just got on with making the best of a bad situation at great personal trauma and expense. Yet the conservative UCP refers to health care professionals and others in the public sector as pampered, spoiled elites. Really?

3. To me, the most important lesson is please get the most education you can. Because it not only opens your eyes and mind, it gives you the opportunity to be the best you can, to contribute the most you can, and to be prepared when disaster strikes. As it did in Alberta in the Klein years.

REFLECTIONS ON A DEGREE-COMPLETION PROGRAM

My name is Kathy Swainston. I graduated from the Medical Laboratory Technology program at NAIT in June of 1989. Over the next three years I worked in both a small hospital setting in Jasper and in a larger centre, the Red Deer Regional Hospital. It was while I was sharing the Student Supervisors position in Histology at RDRH that I decided that I needed to return to school. I had attended university for two years before going to NAIT and I felt that I needed to complete my university degree.

At first I explored the post-diploma degree that UBC offers, before I realized that [Med Lab Sci at] the University of Alberta could offer me the same option much closer to home. I had already made the decision to leave my job, even though the future of health care in Alberta was very much up in the air at the time. In September of 1992, I was once again enrolled in university. The next two years involved a lot of hard work, but it was worth it.

The first year was tough, but not as tough as for the four year university student. Because of my training at NAIT, I was given credit for the labs that accompanied most of the courses that I took that first year. That first year got me back up to speed in all of the five disciplines of laboratory work. It also introduced me to a first year biochemistry class, which I thoroughly enjoyed and an introductory statistics class, which I endured.

As part of the degree you are required to complete a 3-or-6 credit research project. I found the experience extremely valuable. I chose to do a 6 credit pro- ject titled 'Characterization of the gene(s) that allow avirulent phase Ill Bordetella pertussus to grow on nutrient agar.' I enjoyed my time in the laboratory working on my own and learning to troubleshoot the problems that arose. I was able to experience first hand what it would be like should I decide to pursue graduate studies.

We were also required to take a course called 'Communication and Analysis of Biomedical Information.' It was set up in two stages; one part involved the research and presentation of a medical case-study to my peers. This gave me the opportunity to present my findings as a lecture to classmates and instructors. It was a great way to practice speaking in front of a group of people, which is harder than it appears.

The second part of the course involved doing a literature review of a selected topic relevant to laboratory medicine and writing a review paper in a format suitable for publishing in a scientific journal. This entailed lots of time in the library looking through journals and using on-line services such as Medline to search for articles. l chose to review 'Extraction, Amplification, and Study of Mitochondrial DNA from Ancient Remains.'

In the second year you could take advanced courses in the disciplines you most enjoyed. Some courses gave an in-depth look at instrumentation and troubleshooting, very valuable in today's laboratory. We had the opportunity to examine the management side of things, which was an eye-opener. We were exposed to the latest techniques in genetic testing and other technologies, such as flow cytometry. All in all received a very well rounded education.

l graduated in the Spring of 1994 with a BSc in Medical Laboratory Science. In the end pursuing a post- diploma degree has given me more knowledge and confidence in my work. l am more confident in conveying my ideas and knowledge to others and am a better technologist because of my experience.

Having a BSc in Medical Laboratory Science has allowed me the opportunity to explore the job market in the United States, Saudi Arabia, and other Commonwealth countries. Because of the degree and the generous help of the staff in Medical Laboratory Science at the U of A, l am now living and working in New Zealand along with five other MLS graduates.

The instructors in Medical Laboratory Science not only teach, but provide valuable help when searching for a job post-graduate. l would like to take this opportunity to praise their effort and thank them all.

For technologists looking to further their education, l would definitely recommend the post-diploma degree at the University of Alberta.

l would like to thank Pat Letendre for her help in editing this article.

Kathy Swainston, RT, BSc (MLS) Hamilton, New Zealand
Published in the ASMLT Spectrum, Jan. 1997

FOR FUN
Decided to use very old ditty by Canadian legend Hank Snow. What happens to health professionals when politicians value money above people. Tragedy is a career killer for those without international mobility. For those with mobility it's still traumatic.

• I've been everywhere (Hank Snow)

As always comments are welcome. See those below.

Both sides now (Musings on where careers take us)

Updated: 2 August 2017

July's blog originated when, after decades of hoarding 'stuff', I finally decided to clean out a file cabinet. In the Medical Laboratory Science (MLS) folder, where I'd taught for 22 years+, I came across a graduation talk I'd given in 1991. The talk got me thinking about preserving (via a blog) some of the history of med lab techs who got caught in the cost constraints of the 1990s and had to work outside Canada. Some eventually decided to transition to other careers. 

The idea for the blog further crystallized when a local radio station used as its 'talking point of the day' 

• 'How did your education (or lack thereof) play into your career? Are you doing the job you trained for and can people still learn on the job?'

I thought the question's focus was slightly off because it assumed that education for a career was mainly for a particular profession's job-specific tasks and ignored all the transferable skills students learn with a good professional education.

Executive version: What follows is an edited version of the grad talk followed by my musings on what happened to the careers of some graduates in the 1991 class. My thesis is that, if education for a career is sound, graduates come out with the self-confidence and transferable skills to transition to wherever life takes them.

Why read it? The educational issues discussed relate to med lab techs/biomedical scientists everywhere and cover a few of the transferable skills essential to any health professional. As well, the blog may resonate with nurses and physicians who find themselves forced to travel to foreign lands for job opportunities. 

Today where I reside (Edmonton, Alberta, Canada), depending on which provincial political party wins the election in 2019, health professionals could find themselves back in the 1990s when medical laboratory technologist, nursing, and laboratory physician jobs all but dried dried up due to the government's obsession with balanced budgets. 

The blog's title derives from an iconic 1967 song written by Canada's Joni Mitchell. I used it once before for a 2013 blog.

GRADUATION TALK TO MLS CLASS of 1991
What follows is an edited version of the talk. It's a run-of-the-mill talk but makes a few points I think are key to a sound education and still apply 26 years later.

Thanks very much Terry for your generous introduction. I am glad to have this opportunity because there are a few things I still need to cover with this class. First, I thought we would have a spot quiz, because students love them. Be aware that some of the answers will only make sense to the graduates. Let’s begin, starting with a test of your long-term memory.

Q #1: How many 1st-year MLS students does it take to change a light bulb?

• Five. One to change it and four to set up Kohler illumination.

Q #2: How many 2nd-year students does it take to change a light bulb?

• None. At least not in my class. You see, they were all asleep during my Powerpoint presentations and the light would only have disturbed them.

Q #3: How many 3rd-year students does it take to change a light bulb? [3rd yr is the clinical rotation yr]

• The whole class. One student to change it and the rest to complain that their friends in other faculties had all summer off to do it.

Q #4: This one is a test of your short term memory. How many 4th-year students does it take to change a light bulb?

• Again, the whole class. One to change it and the rest to complain that it should be deleted from Path 401 [a catch-all course, long since dropped].

Q #5: How many MLS instructors does it take to change a light bulb?

• Ten. One to change it and nine to evaluate whether it was done right.

Now that the spot quiz is over there are a few things that I would like to talk to you about in a more serious vein. 

A few weeks ago I went to the Ambassador Awards at the Convention Centre. It was attended by people from all walks of life who belonged to associations like the CSLT [now CSMLS] that can bring conventions to the city. The organizers gave out awards and asked all of us to act as ambassadors by promoting Edmonton as a convention site. 

The thought occurred to me that in one way or another we all act as ambassadors. For example, when we are tourists in a foreign country, or when we interact with visitors to our city. 

So I would like to talk tonight about the idea that all of you—the MLS graduates of 1991—are going to be ambassadors for MLS whether you realize it or not. No matter what the future holds for each of you, all of the people you will meet will be gaining impressions of MLS through you, your actions, and attitudes. 

Now before you say, “Good grief! I can’t handle the pressure—-MLSers for life”—I want to tell you that I have great faith in each and every one of you. As an MLS instructor I have been privileged to share a part of your life for the past few years. 

Let me explain why I think that you will be great ambassadors. In a way, I feel like the mosquito in a nudist colony. I don't know where to begin.  

First, there are all of the things you have learned while in MLS. And I’m not talking about the knowledge and technical skills you have assimilated, although these are important. You have learned so much that what you have forgotten would fill a library.No—I’m talking about transferable skills that you will find useful all your lives. 

For example, you have learned how to be good listeners. Goodness knows you have had enough practice being listeners during your time here. As you begin your careers, remember the words of a wise person who once said, “good listeners are not only popular everywhere, but after a while they know something.” I have learned much from listening to you over the years.

You have also learned how to communicate clearly, both orally and in writing. Who can ever forget their first teaching assignment? I should explain that our students give at least three oral presentations to classmates and instructors beginning with teaching assignments during 3rd year. 

I’m sure that some of you think that teaching assignments were cruel and unusual punishment—both for the student and the audience. But, boy, do they ever pay off. The progress you made was really shown when you presented your 4th-year research projects. Your instructors and supervisors were impressed. 

This ability for you to make presentations will be a real plus for you in any career. I tell you this because I have listened to many technologists, scientists, and doctors who have not had the advantage that teaching assignments provide—namely to express ideas clearly and concisely. And listening was brutal.

There are many other intellectual skills you have learned. For example:

• Your grasp of the scientific method and all that entails; 

• The ability to be skeptical about so-called established knowledge, and yet to be open-minded about complex issues;

• You know that it is okay to say, “Gee, I  don’t know, but I will find out”;

• Most important of all, you know how to learn. 

You will draw on these skills over and over again— especially because medical laboratory science is evolving so rapidly. 

I would like to shift for awhile to some of the ways you have all grown in your personal development. 

Those of you who entered MLS lacking self-confidence have seen your belief in your abilities increase. Self-confidence is essential because no one will believe in you if you don’t believe in yourself. I’m not talking about being over-confident and self-important, but rather about the quiet self-assurance of people who are competent and know it. 

Conversely, if you came with a fair degree of self-confidence—if you were like me at 18 (and trust me, I was 18 once—and thought I pretty much knew everything) —then your experiences in MLS have added to your growth by teaching you humility. 

Your entire 3rd year was an exercise in discovering your strengths and weaknesses, coming to terms with them, and accepting both praise and criticism gracefully. 

It was hard to be evaluated each and every day of your hospital rotation; it was hard to accept feedback that you may or may not have felt was justified. But you all did it, and because of this you will have a big advantage in the workplace, as well as in life.  

Having a positive approach to learning will always serve you well. You know that imperfection is only human. The important thing is that we all try to do better. And keep in mind that misery is optional. 

You have also learned what friendship means. In the years ahead, you will remember your friends very fondly . One definition of a friend is “a friend is one who dislikes the same people that you dislike.” There is a lot of truth in this, but a better way to think of friendship is to realize that the only way to have a friend is to be one. You have all done that during your university days. 

Let me remind you that universities have always stood for the dignity of each human being—for the belief that each individual is to be appreciated for what they uniquely think, do, and feel. I want you to realize that you are important and have had an impact on your friends and teachers in MLS. 

Earlier I said that, whether you realize it or not, you are going to be unofficial ambassadors for MLS. Over the years, you have seen many role models—instructors, professors, nurses, doctors, and technologists. As ambassadors-—-with personalities and styles of their own—they succeeded to varying degrees in creating good-will for their professions. Soon you too will have this responsibility. 

As you leave MLS, remember the people who have influenced you. Think of those who have treated you with dignity and patience, who smiled rather than frowned, who took the time to criticize constructively, who showed you how to solve problems as medical laboratory scientists, who loved their subject, and who challenged you to be your very best. 

These are the people you will want to emulate as you become role models for others. And now, graduates—this is your night. You have struggled and succeeded in a difficult program. We, your instructors, are very proud of you. You have chosen a rewarding and challenging career.  

In conclusion, it's a cliche but always believe in yourself. You are graduates of the most rigorous Medical Laboratory Science program in Canada and one of the best in the world.  And don't be afraid to dream of what you want in life. No matter what the future holds, you have the right stuff to succeed.

MUSINGS
Of the 22 students in the 1991 MLS graduating class, here's what I know 26 years later about their careers. Most, as would be expected, went on to have careers as medical lab technologists/scientists. But the 1990s brought severe healthcare cuts in Alberta and throughout Canada and jobs became scarce. Graduates' careers I'm aware of:

• Went to NZ to work for New Zealand Blood Service (NZBS) - 2
• Worked for CBS, Canada's national blood supplier for years - 2
• Dentist - 1 
• Lawyer - 1 (after years of working as a med lab tech in Canada and later for NZBS)
• PhD (microbiology) - 1
• Gynecologist -1 (who was in Christchurch, NZ on a fellowship learning advanced laparoscopic surgery when the earthquake struck in 2011)
• Radiologist - 1 (after many years of working as a med lab tech in USA)

To me, this validates that graduates of MLS at the University of Alberta learned many transferable skills and had the self-confidence to believe in themselves and accept challenges, as well as to dream. As one example, the MLS grads who went to NZ to work for NZBS (six in all from several graduating classes) were brave indeed and went through all the government hoops and regulations, requiring incredible stamina and belief that they could do it, no matter what. 

ANECDOTE #1
I'll share correspondence I had with one grad (John) 8 years later (when he was 30 years old) and again, 14 years post-graduation. John, like most MLS grads, had written the USA's ASCP(MT) exams when he graduated from the University of Alberta MLS program. As a result, he could go to the USA under NAFTA with a BSc (MLS) and work in a profession that was deemed needed in the United States. He worked for years as a med lab tech in Montana and also acquired EMS certification and worked part time as a firefighter. 

He wrote me and 3 others in MLS in 1999 because he had obtained his green card and could apply to U.S. medical schools and needed references from his instructors.

Bottom line was that John was accepted into an American medical school in ND, interned in Spokane, Washington, and later got a residency at the coveted Mayo Clinic in 2005, followed by specializing in radiology.He also did a fellowship in Neuroradiology at the Mayo Clinic. 

Mayo Clinic info (1999):"The Mayo residency and fellowship programs are among the most sought-after in the world. Last year, nearly 7,000 people applied for slightly more than 360 positions....Last year, the medical school accepted only 42 new students and only about 5% of those who applied for a residency or a fellowship."

Going back to MLS, in the 3rd year, students rotate through the clinical laboratories in groups of 3 or 4. I distinctly recall John's group because they were so motivated and, more importantly, so much fun to teach. Honestly, everyone should be so lucky to have such students.

John rotated with two female students (Donna and Jennifer), who both went to to work for NZBS in Hamilton, NZ for several years. Jennifer eventually became a lawyer and now works for a law firm in Edmonton where she represents hospitals/health regions and their employees, including AHS . Donna, who prior to NZ had worked for years in a Las Vegas mega-lab where technologists were more like factory workers, later worked for CBS and now works in a local hospital laboratory.

My spouse and I visited NZ for 6 weeks in 1998-99 over Christmas/New Years and touched base with two of the MLS grads, including Donna, who had the courage to go to a foreign country to practice their profession. They had made the best of a bad situation and were loving their foreign adventure.

These grads believed in themselves and were great ambassadors for MLS at the University of Alberta.

ANECDOTE #2
While the MLS grads worked for NZBS, a US software company visited to demonstrate and pitch its blood bank software. Reason I know this is that the software company (Wyndgate Technologies, now Haemonetics Software Solutions) contacted me. 

Specifically, they wanted to know if MLS had more grads like the ones working at NZBS because they were very impressed with them and would love to hire some.

Bottom line: Two MLS grads were brave enough to transition to software testing and moved to Sacramento, California to work for Wyndgate in 2000. One worked for Wyndgate/Haemonetics for 15 years, latterly in a senior management position.

FOR FUN
I chose Joni Mitchell's 1967 song for two reasons. Of note, it has been covered ~600 times by other artists and counting. 

First, I love it. By any standard, Canada's Joni Mitchell is a songwriting genius.

Second, to me it means that life isn't always what you expect it to be. We win some, lose some in the careers we choose but in the end we're left with the illusion of what we hoped it would be. And that's okay providing we acquired the skills to follow our dreams past the illusion. Perhaps too philosophical?

• Both sides now  (Joni Mitchell in concert, 1970)

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

As always, comments are most welcome.

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:

• Hematology profile (CMA)

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:

• An internist, surgeon and pathologist go duck hunting

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:

• Dr. Donald  'Ducky' Mallard

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:

• What is the difference between a hematologist and a hematopathologist?

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?

• Guide to Interdisciplinary Team Roles and Responsibilities

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 connects doctors with phlebotomists through a mobile app (~Uber cabs) 

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: 

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

Perhaps workforce innovation to ensure sustainable professional roles for hematologists will one day include freelance, system-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.

• Mommas, don't let your babies to grow up to be cowboys (Willie Nelson, Farm Aid, 1985)

Or for a real trip down memory lane

• The times they are a changin' (Bob Dylan, 1964)

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

When sweet dreams become nightmares (Musings on health officials & Big Pharma)

Updated 17 Sept. 2012

August's blog is stimulated by disappointment, even disgust, with those associated with health care who turn out to be dishonorable, i.e., liars and thieves who put their welfare above those they serve.

Would be nice to write a cheery, upbeat theme for the dog-days of summer (in northern hemisphere), but recent news items are enough to make me, and I'd guess most readers, gag.

Regardless of your location, the blog has much food for thought because the issues are global. Honest, you could not make this crappy behavior up.

The title comes from a song by Annie Lennox, a Scottish singer-songwriter and political activist.

ALBERTA, CANADA
These events happened in my backyard but I know it could happen where you live and probably has.

The gist of this sad tale is that Allaudin Merali, hired by Alberta's provincial health system (AHS) as CFO in May 2012 at a salary of $425,000, resigned in July after a CBC reporter broke the story of his exorbitant expense claims ($346,208).

The expenses occurred during his previous employment with Capital Health (before AHS was created) as its CFO (Jan. 2005 - Aug. 2008). For interest, a CFO's responsibilities.

Is Merali an outlier? I suspect not. This type of abuse had to be normal for the health system or it would have been flagged and stopped.

The health region's CEO kept signing off, and who knows for how many others pigs at the trough. You know, all the senior political cronies (oink! oink!) our provincial government appointed to make decisions for us, invariably with minimal or no input from health professionals in the trenches.

To think that my colleagues and I would never include liquor in our expenses (makes sense as it's discretionary spending and not allowed). We'd fly the cheapest airfare, as required, despite inconvenient schedules like red eye flights. Being good employees with integrity, we'd meticulously  use time-inefficient airport shuttle buses so as to keep our expenses minimal in the interest of fairness to those paying.

Not this Merali dude, though. And to top it off, after losing his job in 2008 (when Alberta's health system was reorganized), he received $1 million in severance and a $1.6 million retirement plan over 10 years ($13,303/mth).

17 Sept. 2012: AHS chair whines on cost of audit & info requests into executive expenses (Ya gotta love these guys)

Pretty sweet, eh? (Said the Canuck with a grimace, not a smile.)

GRUESOME DETAILS
News items:

• One place spending wasn't cut (Background on expense scandal)
• Merali resigns after prior expense claims revealed 
• Alberta Treasury Board knew of Ontario controversy surrounding Merali before offering job 
• Former Capital Health CEO Weatherill, who approved Merali expenses, resigns
• Health executives, including former CFO with outrageous expenses, get gold-plated pensions
• Merali's expense claims (obtained by CBC reporter) 

Fascinating stuff. Many routine charges (e.g., conference registration), but who knew the nobs also charge for booze? Fact is, Merali, earning a substantial salary, charged for everything. I bet if he bought a small packet of kleenex or gum drops at the airport he'd have charged them. 

BOTTOM LINE
It's a saga of greed and privilege rampant at the highest levels of a health care system. Leaders are supposed to model expected behavior and instill confidence in a shared vision to benefit all. Gak!

The behavior of this particular Alberta health official falls so short. But he cannot have been alone. If you or I behaved as Merali did (and who knows who else at the top did), we would not, indeed could not, get away with it. Adding to the odious conduct, the situation indicates a double standard that undermines the entire system.

At the same time as Merali was at the trough, Alberta's health professionals struggled to do more with less, as did the entire health care system (too few staff, too few beds, too few long-term care facilities, etc.)

During this time (2005-8), when lunching at a nearby hospital I'd occasionally talk to laboratory technologists who were former students. When asked how things were going, they'd invariably reply anything from not good to brutal.

My next question was, "What's the main issue?" The reply was always a variation of, "Too few staff." So few, that existing staff could not take holidays as there was no funding for part-time or casual staff, even if suitable replacements existed.

Once a PhD lab director stopped by and looked positively ashen. In conversation he noted that what was happening (Alberta's restructuring from multiple health entities to one) was even worse than the 1990s when cost cutbacks were severe and uncertainlty reigned:

• History written at the time (ignore links to news items as they're likely inactive) 

One lab technologist told me that they had a gag order not to talk to outsiders on threat of firing. If Alberta's physicians were bullied, you can bet everyone in the system was.

Charming. What a way to run a health system.

As cost restraints prevailed in the trenches, Merali (and who knows which other senior health officials) was living the high life at tax payers expense. Dining at the most expensive restaurants, getting a phone installed in his Mercedes (Who does this in the age of cell phones?), repairing his Mercedes. It must have been hard to rack up almost $350,000 in expenses over 3 1/2 years.

Is this narrative unique to Alberta, Canada? I doubt it. My take is that it's happening somewhere near you, but you may not know about it yet or ever, unless you have professional reporters who can investigate.

And we know what's happened to real reporters in print journalism in the Internet era. Sites that compile news have gutted the system and users expect news and everything else on the Net to be free.

BIG PHARMA
Big Pharma presents a similar tale of corruption, indeed a worse one. Seems reports of bribery and putting corporate benefit above vulnerable patients never stop.

• GlaxoSmithKline pleads guilty in $3B US drug fraud case

GSK admitted misbranding 2 drugs and withholding safety data for another:

GSK had total disregard for the health of vulnerable people they were supposedly helping - knowing their actions could cause harm, but doing it anyway for self-advantage.
If I did that as a health care professional, I'd be guilty of criminal negligence.

• Pfizer settles bribery charges (11 Aug. 2012) 

With USA regulators clamping down, drug firms seem to have stopped (I say seem because who knows) perks for doctors and similar bribery. But not so in developing countries.

Pfizer's conduct seems to be normal for Big Pharma. 8 of the 10 biggest firms on the planet mention costs for corruption charges as a risk.

Big Pharma's behavior is similar to tobacco firms selling cheap disease-causing cigarettes in developing countries, not caring about those who die. With a decrease in sales in industrialized nations, multi-national companies in the UK and USA decided to spread smoking to developing countries:

• Tobacco and the developing world
• Unstoppable march of the tobacco giants 

Or take the case of our Canadian government (the Harper government as they like to be called), which for a few jobs in Quebec in the asbestos industry, refuses to support a global ban on the well documented killer, asbestos:

• Health Canada's advice on asbestos ban rejected by Harper government

Shameful. Disgusting. Sickening. Criminal. Tobacco companies, Canada's Harper government, and drug companies  - all behave similarly.

MUSINGS
The spectre of senior health officials in my province and their culture of privilege is one thing. I expect it's the same whether in countries with national health care systems (most of the world) or the USA, where private health competitors do whatever it takes to survive and make profits.

What also gets me is that I know several industry reps who are decent individuals. It's hard to think that they work in an environment where bribery and lying are normal. But to think otherwise would be naive. Sadly, evidence to the contrary abounds.

When first entering the health professional many years ago, I had dreams of helping others and being one of the good guys. Definitely a profession that was a notch above used car salesmen, who had a well deserved reputation for lying and cheating customers. But I've learned that health care is also a business, and a nasty, nightmarish  one.

What to do? Focus on the positive in daily work, shine a light on the rats among us, and hold those who tarnish the field to account, a lifelong challenge. Or say nothing, do nothing, be nothing?

FOR FUN
Can there be any fun after such all too real events? Of course. First, a great song that outlines the reality described above:

• Sweet dreams (Annie Lennox) Some of them want to use you...Some of them want to abuse you...

Next, a slightly sappy 1960s ditty that expresses what we hope for all those involved:

• Who's sorry now (Connie Francis)

Lastly, to end on a positive note, and just because I love the song and its fabulous artist appears at the Edmonton Folk Festival this weekend:

• Are you ready for the thing called love (Bonnie Raitt) 

As usual, the views are mine alone. Comments are most welcome BUT, due to excessive spam,  please e-mail me personally or use the address in the newsletter notice.  Great comments below - be sure to read them.

Smile on your brother: Musings on labour woes in the blood system

The idea for this month's blog came from the latest labour relations difficulties facing North America's blood suppliers. The title derives from the lyrics of a 1960s song recorded by many, Get Together.

USA - American Red Cross [ARC]

• Staff cuts at ARC harm blood supply, coalition says
• Connecticut: Red Cross workers: Phlebotomist firings due to contract tiff (includes comments from fired worker)
• Southern California: Nurses may strike over wages, benefits, practices
• Background (labor's perspective): Labor relations at the ARC and its impact on employee and donor safety (23 page report by Philip Dine)

Canada

• Canadian Blood Services (CBS): Nurses vow to fight CBS pilot to phase out RNs from donor screening
• CBS: "Moving forward to pilot multi-skilled workforce"
• Hema-Quebec [H-Q]: H-Q deplores union's attitude and invites the public to give blood

This blog uses the above labour conflicts to offer musings on the role of trust among TM health professionals. Because the underlying issue in any management / employee negotiation relates to trust, I will not discuss the specifics of the news reports. Besides, without in-depth knowledge of what is actually happening, analysis would be folly.
Many good friends are either staunchly pro- or anti-union health professionals. I know from experience that discussing union issues, like religion and politics, is sure to lead to passionate disagreements fueled by anecdotes and emotion, not objective, evidence-based logic, and may result in hard feelings. I'm hoping not to wander into that morass as the blog's narrative unfolds.
UNIONS
As background, to my knowledge, Canada's blood system, both blood suppliers and hospital-based transfusion services, are mostly unionized. Unionized workers usually include laboratory technologists, lab assistants, and nurses, and a diverse group of other staff, e.g., clerical, IT, lab scientists, maintenance, etc.
Some employees, e.g., TS laboratory managers and blood centre management positions, may be "out of scope" (not included in union contracts).
Practical implications of being out-of-scope include the

• ability to negotiate salaries and benefits directly with employers (and to keep them private from co-workers);
• subtle promotion of a them-versus-us mentality;
• ability of employers to fire you without the hassle of a union grievance.

As well, for non-union health professionals at senior levels, including dismissal terms in personal contracts, and threats of legal action for wrongful dismissal, may result in generous, golden handshakes for staff such as TS and blood centre medical directors.
Many of the news items referenced in this blog involve contract negotiations. From my experience observing Canada's blood system, frequently workers do not trust employers / management to do the right thing for employees, patients, and the public at large. The worker view is often that management has a hidden agenda, typically to save money, even at the expense of safety.
Conversely, it's not that rare for employers / management to regard unions negatively, and by extension to view their members as overpaid and more or less lazy, with unions leading to unwarranted, costly job perks and promotion of the most senior rather than the most competent staff. Management seldom voices such opinions publicly and would deny them if asked, but these viewpoints exist nonetheless.
Indeed, these perspectives reflect public opinion, with proponents on both side of the union issue.
The unproductive, adversarial mentality in labour negotiations seems relatively common everywhere despite major progress in labour relations worldwide during the 20^th C.
The sad fact is, that with contract negotiations, a lack of mutual trust is common. When discussions reach an impasse, each side often sees the other as self-serving and sometimes in even more negative terms.
Tidbit: In 2007, the percentage of employees that were members of a trade union (Source: OECD - Union density 1960 - 2007) included:

• Australia: 10% (2006)
• Canada: 29.4%
• Norway: 53.7%
• Sweden: 70.8%
• UK: 28%
• USA: 11.6%

These statistics likely do not include the employees such as physicians and university professors who are not members of a union, per se, but do belong to professional associations that act as unions by negotiating contracts and benefits.
A ROSE BY ANY OTHER NAME
When is a union not a union? When it calls itself a professional association. When working at the University of Alberta I was in the Association of Academic Staff, which negotiated salaries and benefits for professors. The Association's activities approximate that of a trade union.
In Canada, health care is a provincial jurisdiction and provincial medical associations negotiate physician fees that are binding for insured services.

• See Paying for Physician Services in Canada (1996)

Despite their loftier broader goals and objectives, Canadian provincial medical associations perform some of the same functions as unions. Yet unions may be disdained by some professionals partly because of their origin as trade unions, with "trades" somehow being more lowly than professions.
For interest, Norwegian and Swedish physicians have no problem in identifying their medical associations as unions. Many of their physicians are state employees, as are physicians in many other European countries.

• Swedish Medical Association
• Norwegian Medical Association

To my knowledge, Canada's transfusion medicine physicians (hematologists, hematopathologists, pathologists) who work for transfusion services and blood suppliers are usually salaried employees, although they often have multiple appointments that earn additional salary. In essence, they too belong to professional associations that function partly as trade unions.
TRUST
People who work as part of any health care team must trust each other's competence, trust that each will to do the best job possible, maintain a high level of quality care, and put the patient first. There are checks and balances in the TM system, e.g., audits of blood transfusion requests, error management programs, etc., but the system would not function without trust in a colleague's motivation and competence. The first instinct of health professionals is to trust each other to maintain high practice standards, unless shown otherwise. For example:

• When talking to a nurse on the ward who reports a possible transfusion reaction or to a physician in the ER who requests unmatched RBC, do lab technologists routinely think, "That lazy bum is so self-serving"?
• When discussing follow-up treatment of patients suffering from transfusion complications with nurses, or holding a staff meeting with laboratory staff to plan implementation of an new LIS, do TS medical directors routinely think, "These nurses / techs deserve less pay and fewer benefits"?
• When management staff from national blood suppliers consult with blood centre medical directors across the country, does "head office" routinely think, "These MDs don't have patient safety at heart. Their attitude is deplorable."?

Do management staff who are not members of a health profession (whether representing health regions, hospitals, blood suppliers, or governments) often think such thoughts about members of the TM team?
I think not. The many technologists, nurses, and physicians that I have known over a lifetime in Canada's blood system are dedicated to patient safety and trust each other to provide the highest quality care possible.
How is it that trust seems to evaporate with labour negotiations?
CASE STUDY
In the mid-90s in Alberta, health care restructuring caused major job losses in the laboratory sector. One result was the creation of Calgary Laboratory Services* (CLS), a private lab that assumed 100% of clinical lab services in Calgary, one of the province's two major cities.
* CLS is now a wholly owned subsidiary of Alberta Health Services (organization responsible for providing publicly funded hospital and other health care in Alberta)
The case study below describes how a union (HSAA) and private-sector lab (CLS) cooperated under extremely traumatic circumstances. It paints a rosy picture of what's possible. I have no idea how closely it conforms to reality but there may be some lessons here.

• Beyond Collision: High Integrity Labour Relations. Calgary Laboratory Services -- HSAA Case Study1 (2004, by Darcy Shenfield and Allen Ponak)

All this lack of trust and conflict reminds me of a song from the 1960s:

• Get together (performed by the Youngbloods)

As the song's lyrics go,

C'mon people now, Smile on your brother Ev'rybody get together, Try and love one another right now

Comments are most welcome BUT, due to excessive spam, please e-mail me personally or use the address in the newsletter notice. Let me know if you think I'm off the mark.

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

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

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

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

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

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

• We can work it out

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

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

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

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

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

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

The types of studies I have in mind would compare TM-related costs, efficiencies, and clinical outcomes in various developed countries. Such costs are incredibly difficult to identify with validity. But in countries with national blood services, these figures should be determinable, albeit with many assumptions, provisos, limitations and perhaps even a glut of 'weasel words' as often appear in cost studies due to the many variables involved.
For example, Canadian Blood Services has only three testing facilities and 12 manufacturing facilities to serve all of Canada except Quebec. Canada is the 2nd largest country in the world, just behind Russia and just ahead of the USA in territorial size.
CBS's annual reports include an incredible amount of hard data:

• Report to Canadians (2008 - 2009)

Some tidbits from the report above:

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

A few possible comparisons for international studies:

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

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

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

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

• BC PBCO
• Transfusion Ontario

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

Canadian grads were amazed at the U.S. system in which an incredible amount of their time was spent on what to bill for various lab tests, something that was not required in Canada. Yet this emphasis on fees and cost did not result in more evidence-based test rationales.
Grads often reported that the U.S. labs they worked in were still routinely performing tests that had been abandoned in Canada in the 70s and 80s, tests that contributed little, if anything, to treatment or clinical outcomes.

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

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

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

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

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

As always, views are mine alone. Comments are most welcome BUT, due to excessive spam,  please e-mail me personally or use the address in the newsletter notice.