Stand by me (Musings on ongoing bullying in healthcare)

Stayed tuned for updates, which are sure to occur.

INTRODUCTION
The idea for the blog was stimulated by news of a celebrated, experienced UK nurse who faced being stuck off after in 2017 she saved a woman's life who was hemorrhaging after losing her baby with a blood transfusion in an ambulance. (Further Reading) But, through no fault if hers, the required prescription for a blood transfusion had not been taken onto the ambulance with the patient. The nurse claims she has been the victim of bullying by senior NHS managers after she saved the life of the woman. She was unable to return to work at the trust's insistence for ten months, and resigned after she lost a disciplinary hearing. She had to find work outside the trust and is now practising elsewhere.

She was a finalist for 2020 Florence Nightingale Nurse of the Year after raising £100,000 to buy iPads for Covid patients isolated from loved ones. Four years later the Nursing and Midwifery Council concluded the nurse undoubtedly acted in the best interests of the patient and has 'no case to answer'. In some ways this case reminds me of the Bawa-Garba case in UK where a pediatric trainee was convicted of gross negligence manslaughter. (Further Reading)

In addition to this case, harassment and bullying of medical students has been in the news in several nations for a few years. And in my province of Alberta, Canada, in 2016 a noose was hung outside a Black Dr's operating room in Grande Prairie. It was reported almost immediately to hospital administrators by startled bystanders. Yet, according to multiple doctors who wrote complaints, nothing was done to discipline the perpetrator, a white surgeon whom colleagues say still held leadership positions after the incident. (Further Reading)

The blog's title derives from a 1961 song by Ben E. King featured in the 1986 move of the same name.

PERSONAL ANECDOTES
The University of Alberta where I once taught has explicit, well defined Employment Equity and Human Rights Definitions and policies on bullying and discrimination. Yet I'm certain both still exist. The guidelines are followed by all faculties, including the Faculty of Medicine & Dentistry. (Further Reading) It covers pretty much every kind of discrimination, whether direct or indirect: any act or omission based on race, religious beliefs, colour, gender, physical disability, mental disability, marital status, age, ancestry, place of origin, family status, source of income, sexual orientation or political belief, when that act or omission results in loss of or limit on opportunities to work or to fully participate in campus life or offends the dignity of the person.

As a patient I've seen bullying by a Dr. against a trainee and at scientific conventions. As a patient the male Dr. presumably wanted the female trainee (intern or resident) to suffer abuse as a rite of passage that would toughen her up. Few likely report it as the Dr. is all powerful and they fear being judged as troublemakers that could affect their career progression.

At Canadian transfusion medicine conferences I've also witnessed bullying, again by a male Dr. (a 'biggie') against a female Dr. who had presented and was taking comments from the audience. She held her own but his comments were dismissive and abusive and it likely cost her much stress. I wondered why at the time and since and, frankly, suspect he'd not have done that to a male colleague in the same way.

As always, comments are most welcome. Would appreciate hearing about discrimination or bullying you've experienced or witnessed, You can do so by name or anonymously.

FOR FUN
Chose this song because we all need to stand by colleagues in any field when they experience bullying, discrimination, harassment of any kind. Sad to report as items in Further Reading report, the incidence of bullying in medicine remains quite high.

• Stand By Me (Ben E. King with stars and clips from the film)

FURTHER READING
Nurse who faced being struck off after she saved a woman's life with a blood transfusion has been cleared by an official inquiry (20 Apr. 2021) | Related:

Employment Tribunal of Leona Harris (18 Oct. 2019) | The complaint of unfair dismissal is not well-founded and is dismissed.

University of Alberta: Employment Equity and Human Rights Definitions

Taylor-Robinson SD, De Sousa Lopes PA, Zdravkov J, Harrison R. A. Personal perspective: is bullying still a problem in medicine? Adv Med Educ Pract. 2021 Feb 10;12:141-5. (Free full text)

Bullying in the workplace (1 Sept. 2020, CMA)  | What bullying in health care looks like, why it persists and how to eliminate it from the culture of medicine.

Medicine's bigotry and bullying problem (Oped in Canada's Macleans magazine, 8 July 2020)

Colenbrander L, Causer L, Haire B. 'If you can't make it, you're not tough enough to do medicine': a qualitative study of Sydney-based medical students' experiences of bullying and harassment in clinical settings. BMC Med Educ. 2020 Mar 24;20(1):86. (Free full text)

Australia: Culture of bullying, harassment and discrimination in medicine still widespread, survey suggests (9 Feb. 2020)

The Bawa-Garba case should usher in a fairer culture in healthcare (9 May 2019)

I heard it through the grapevine-2 (Musings on the value of Twitter)

In 2019 I wrote a blog promoting Twitter for TM professionals and for July's blog, I'll do a second one.
The blog's title derives from 1966 ditty recorded by Marvin Gaye and later Creedence Clearwater Revival.  

INTRODUCTION
To me far too few transfusion professionals are on Twitter, including medical laboratory technologists, nurses, and physicians. Many reasons, including Facebook preceded Twitter and Twitter tends to have a poor reputation in general. Today Facebook has an even worse reputation but if you're on it, you may value how it keeps you in touch with pals and family. 

In my experience TM folks on Twitter are a different breed. They want to share resources and expertise and, if you want to engage in continuing professionals education, Twitter is a wonderful free resource. Questions can be asked and answered by experts. Also Twitter is international. Based on my Twitter account (Further Reading), experts from Australia, Canada, UK, USA, and professionals from many nations in Africa and Asia participate. Glad to report that some Canadian medical laboratory technologists are on Twitter.

UNDERSTANDING TWITTER (from earlier blog)
First, Signing up on Twitter is easy 
Tidbits (Twitter 101):

• Language: Twitter is the software platform. You are a tweep. When you post a message, it's called a tweet. 
• If not on Twitter when accessing a tweet and asked to join, just click on another part of the screen and you can see direct tweets. 
• Be aware you don't need to tweet. Just as on mailing lists, you can lurk.  
• By being on Twitter you can see the replies given by tweeps to other tweeps. If not, you can see only their direct tweets (not replies). 
• Twitter gives you quicker access to important professional events and issues, allows you to share resources with colleagues.  
• As a citizen Twitter is the place to be because you get news about anything well before it appears on mainstream media, e.g., disasters, latest weather, political events. All media and reporters are on Twitter.
• Twitter hashtags are key (Further Reading) For example, they can be used to identify who to follow. And you can also see who others follow for more suggestions.

Learning Point: If you are a transfusion professional in any capacity, please consider joining Twitter. You won't be disappointed. Look at my account to see who I follow, many transfusion experts from all over the world, well known experts.

As always, comments are most welcome.

FOR FUN
Chose this ditty because Twitter is a good grapevine to keep up with the latest transfusion medicine news.

• I Heard it Through The Grapevine (CCR)
• I Heard it through the Grapevine (Marvin Gaye, live at Montreux) 

FURTHER READING

• Gardner JM, McKee PH. Social media use for pathologists of all ages. Arch Pathol Lab Med. 2019 Mar;143(3):282-6.
• Twitter hashtags (one pertinent to this blog is #transfusion)
• My current transfusion-related Twitter account: @oldbloodbanker 

You never give me your money (Musings on paying to develop COVID-19 vaccine)

Updated: 1 July 2020

What to blog about when COVID-19 dominates the news, whether it's research funding, impact on blood supplies, paid plasma proponents, testing, treatments, vaccines? Plus, of course, government guidelines and measures to prevent the spread of coronavirus while opening up the economy.

Finally decided that June's blog should discuss the question of who pays to develop COVID-19 vaccine and who gets priority once it exists, including which countries worldwide and, within countries like the USA without universal healthcare, will all be able to afford it.

The blog's title derives from a 1969 ditty by the Beatles.

INTRODUCTION
Governments worldwide have invested billions into developing a coronavirus vaccine, some given to university researchers, some to Big Pharma. There are reports that if a vaccine is developed inside a nation, that country will have priority access to the vaccine.

If COVID-19 has taught us anything it's that supply chains for crucial medical equipment like food, PPE and drugs must be secured and the best way is to produce them in the country, if possible. There are even reports of France and Germany accusing USA of diverting medical supplies like masks and that president Trump asked mask maker 3M not to supply masks and more to Canada and Latin America. Trump also bought up almost all stocks of Remdesivir, a drug used to treat coronavirus. (Further Reading)

Plus the world is experiencing infighting and global politics at its worst:
At G20 meeting of health ministers the intent was to strengthen WHO's mandate to coordinate fight against COVID-19 with a major focus on the process of crafting international agreements on any drugs or vaccines that successfully treat COVID-19. U.S. was the only country opposed to a statement that offered a framework for a united approach to fighting the pandemic and stopped funding WHO. (Further Reading)

HISTORY
The past has shown that poor developing nations don't have access to drugs that we in the industrialized world take for granted. Examples:

For the vast majority of the 325 million people living with hepatitis B or C, accessing testing and treatment remains beyond reach (Further Reading).

Without charitable donations by Big Pharma, for ages more than 75% of folks in developing world with hemophilia had little or no access to diagnosis and treatment. Those with severe hemophilia often did not survive to adulthood or, if they did, faced a life of severe disability and chronic pain (Further Reading).

Learning Points: If history repeats itself, COVID-19 will follow similar path. Folks in poor nations will be last to get the vaccine and treatments. And nations like USA whose POTUS puts America first, will try to gobble up most, leading to worldwide inequality in life-saving treatments. All at a time when the world needs to come together to fight a pandemic. 

As always, comments are most welcome and there are some.

FOR FUN
First song I chose for the blog:

• You never give me your money (1969 song by the Beatles)

Back-up song you may enjoy is 'Money' from 1972's Cabaret film.

• Money (by Lisa Minneli & Joel Grey)

FURTHER READING
Listed by date of news report

Trump buys up almost all stocks of Remdesivir, a drug used to treat coronavirus (1 July 2020)

Big pharma is taking big money from U.S. taxpayers to find a coronavirus vaccine  and charge whatever they want for it (24 June 2020)

Will coronavirus pandemic change Big Pharma's long-term focus? (15 June 2020)

Sanofi and Sobi donate up to 500 million additional IUs of clotting factor to WFH Humanitarian Aid Program (14 June 2020)

U.S. must stop blocking global effort to fight COVID-19 (23 Apr. 2020)

Big Pharma wants billions more for COVID-19 funding pot (21 Apr. 2020)

German, French officials accuse U.S. of diverting supplies (4 Apr. 2020)

WHO urges countries to invest in eliminating hepatitis (26 July 2019)

For the times they are a-changing (Musings on COVID-19 global news)

Stay tuned: Revisions are sure to come

What to write about during COVID-19? It initially stumped me. Possibilities I considered include how coronavirus has impacted the blood supply worldwide and increased pressure from paid plasma advocates to promote paying for all plasma and other body tissues. 

Finally settled on a mini-survey of coronavirus news featured in May's TraQ's newsletter to see what, if anything, that might reveal..

The blog's title is based on a 1965 ditty by Bob Dylan, and yes, it can be read many ways given the news.

INTRODUCTION
The mini-survey is based on news items I selectively collated for TraQ's newsletter during March, April, and May 2020. As past blogs will show, the blogs are mine alone and reflect my personal biases. 

For May's blog I arbitrarily organized COVID-19 news items into four topics, which have some overlap:

• General (Information, industry news, search for treatments and vaccines)
• Blood supply (Risk of shortages)
• Convalescent plasma
• Journal articles

SUMMARY 
Results of TraQ's March to May survey:

TOPIC	MAR.	APR.	APR.	TOTAL
General	0	13	8	21
Blood supply	6	3	4	13
Convalescent plasma	6	14	7	27
Journal articles	0	23	15	38

Limitations
I could have calculated results incorrectly. My search alerts may not have identified all possible news items in each category. Also, in May the number of convalescent plasma news items soared and I decided not to include  many in the newsletter, as they often involved only a few people and were repetitive of earlier news. It's possible I haven't yet been alerted to the existence of more COVID-19 research articles published in May. 

LEARNING POINTS
So, as I recall from the 1966 film Alfie, it's time to ask, 'What's it all about Alfie?' Or as I once told my Med Lab Sci students, you should try to identify the 'so what' message of research papers. So too should blogs have a point. My biased musings on the results:

• So much money is being poured into research for a vaccine and improved COVID-19 testing. It's a race to get there first among nations, including to have the vaccine manufactured in a country, as presumably that would give priority access to its citizens. 
• Seems a rush to strike gold first. Potential for industrialized nation to get priority access and developing nations to be left out as often is the case. Think of recombinant FVIII being unavailable for ages in developing nations. Also countries like India where blood banks still use ELISA to test for HIV, Hepatitis B and C, rather than NAT.
• Convalescent plasma is the flavour of the year of COVID-19. Results look promising but final results not in yet. More troubling is the notion that having antibodies allows you to return to work as you are protected. But scientists don't know yet whether people who've been exposed will be immune for life, as for measles, or if COVID-19 can return again and again, like the common cold. 
• Big Pharma wants mega-money up front to fund COVID-19 research (Further Reading). Quote from article:
• Particular concern over poorer countries’ access to medical supplies was highlighted by G20 health ministers’ failure at the weekend to issue a declaration of solidarity after this was blocked by the US. 

FOR FUN
I chose this Bob Dylan song as it reflects what's called the 'new normal' during COVID-19 and also reflects the current protests happening in the USA over the killing of a black man by a police officer. Somehow I suspect, with zero evidence, that the protests may be stronger and more widespread because of the coronavirus lockdown. Or perhaps because murder of black people by police has become all too common in America?

Chose Joan Baez to sing it for several reasons, the most important being she has a much better voice than Dylan. Also this version has the song's lyrics. Tidbit: Joan and Bob were once an item (Further Reading).

• For the times they are a-changing (Joan Baez)

As always comments are most welcome.

FURTHER READING
TraQ's newsletters

• March
• April
• May

Big Pharma calls for ‘billions’ in upfront coronavirus funding (20 Apr. 2020)

Joan Baez finally gets her public apology from Dylan (21 Sept. 2009)

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

Stay tuned: Revisions are sure to occur

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

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

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

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

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

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

Patients who need blood transfusions

• Mothers who incur significant bleeding during delivery, including those with placenta previa

• Gastrointestinal bleeding (if massive can be life threatening) with many causes such as hemorrhoids, peptic ulcers, tears or inflammation in the esophagus, diverticulosis and diverticulitis, ulcerative colitis and Crohn's disease, colonic polyps, or cancer in the colon, stomach or esophagus  

• Kidney disease, sometimes secondary to type 1 diabetes, that requires dialysis

• Any surgery that involves significant blood loss

• Trauma patients including those in car accidents who experience blood loss and victims of knife attacks or gun shot wounds

• Blood disorders, including
• Thalassemia major patients need regular red blood cell transfusions to raise their hemoglobin level and deliver oxygen to body tissues
• Sickle cell disease patients need regular red blood cell transfusions to provide normal red blood cells, lessen anemia and reduce the blood's viscosity, allowing it to flow more freely and ease disease symptoms and prevent complications
• Leukemia patients who develop thrombocytopenia need platelet transfusions to control bleeding 

The need is real and ongoing. Please encourage colleagues, family, friends, and neighbours to donate blood and save a life. It's one thing folks can do during the pandemic. Further Reading includes questions about donating in Canada and blood systems in all nations have similar information. 

FOR FUN Naturally, I chose We Are The World, originally written for 'USA for Africa' in 1985 by Michael Jackson and Lionel Richie, produced by Quincy Jones and Michael Omartian, and sung by many fabulous American  artists.  

• We Are The World 

We are the world
We are the children
We are the ones who make a brighter day
So let's start giving...

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

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

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

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

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

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

Transfusing Wisely Canada

Stand by me (Musings on transfusion medicine errors)

Updated: 1 Feb. 2020 (Learning pt. 5, Further Reading)

To begin the new decade, I'll muse on a TraQ case study from decades ago that discusses a topic not often discussed by educators in class or included in online cases* but is still relevant and merits airing. 

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

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

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

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

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

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

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

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

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

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

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

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

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

Patient B died the day following transfusion.

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

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

The Chief Medical Examiner was notified and investigated the death.

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

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

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

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

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

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

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

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

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

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

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

• Stand by me (Ben. E. King) 

FURTHER READING

• Case A8: Severe Hemolytic Transfusion Reaction Involving a Student
• Latent errors
• UK SHOT
• Farinre B. Mistakes happen. Alleviating the emotional impact of medical errors on healthcare staff. (oped) The Pathologist, 18 Dec. 2019.
• Students have a key role in a culture of safety:a multi-incident analysis of student-associated medication incidents. ISMP Canada Safety Bulletin 2018 Feb 28; 18(2):1-3. 
• Beck JB, McGrath C, Toncray K, Rooholamini SN. Failure is an option: using errors as teaching opportunities. Pediatrics. 2018 Mar;141(3). pii: e20174222. Epub 2018 Feb 13.
• Disch J, Barnsteiner J, Connor S, Brogren F. Exploring how nursing schools handle student errors and near misses. Am J Nurs. 2017 Oct;117(10):24-31.
• Barnsteiner J, Disch J. Creating a fair and just culture in schools of nursing. Am J Nurs. 2017 Nov;117(11):42-8. 
• Elmqvist KO, Rigaudy MT, Vink JP. Creating a no-blame culture through medical education: a UK perspective. J Multidiscip Healthc. 2016 Aug 8;9:345-6. eCollection 2016.
• Hernandez JS. Responding to laboratory errors. How not to lose your cool. Clin Lab News, 1 OCT. 2012
• Error-prone conditions that lead to student nurse-related errors. (ISMP, 18 Oct. 2007)

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

Updated: 20 Feb. 2020 (Fixed typos)

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

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

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

Factors that contribute to work burnout are nicely summarized in Rothenberger's  paper (Table 2) and include

• Work overload 
• Lack of control 
• Insufficient reward 
• Lack of fairness 
• Breakdown of community 
• Conflicting values between job requirements and personal values 

Please consider which, if any, play a role in your workplace.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

FOR FUN
Wavered between 2 songs, but in the end chose a very old ditty, many will think is dated:

• Bridge Over Troubled Water (Simon and Garfunkel, concert in Central Park 1981) 

When you're weary, feeling small,
When tears are in your eyes, I will dry them all.
I'm on your side. When times get rough
And friends just can't be found,
Like a bridge over troubled water
I will lay me down.

As always, comments are most appreciated. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

• "Change is the only constant in life." 

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

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

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

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

To me, a more apt cliché is one prevalent in the 1990s in Alberta, Canada when government health care cuts and restructuring decimated the laboratory and broader health system. They hired consultants to do the dirty work, then leave. Many in the lab community called them 'suits.' (See Further Reading)

• "I'm a consultant and I'm here to help."

TRADITIONAL MANAGERIAL ROLES
Managerial roles pre-AI often include the manager performing the following functions:

• Assume leadership, which includes motivating staff to achieve a common goal and being a role model for key qualities like dedication and integrity;
• Communicate to lab staff and beyond the lab;
• Delegate responsibilities to staff;
• Manage projects and budgets;
• Organise and chair meetings;
• Comply with mandatory laboratory regulations;
• Maintain current best practices;
• Manage conflicts in the workplace;
• Manage conflicting priorities;
• Manage workplace diversity (inter-generational, ethnic,cultural);
• Problem solve issues from technical to human resources;
• Develop staff skills, including CE/CPD opportunities;
• Recruit and retain talent;
• Maintain a safe workplace. 

BOTTOM LINE
So can I assume that the six 'Post-AI Laboratory Roles' are just add-ons, more or less minor tweaks, to what today's managers already do versus a revolutionary change? Is artificial intelligence and machine learning that big a deal? Will it consume a manager's time as the be all and end all? Or is it just one of many changes that laboratory professionals have adapted to over the decades. Are AI roles more critical than traditional managerial roles? You tell me.

As always comments are most welcome. See below.

Addendum
My reply to Anonymous's comment below, who writes, "A huge concern I have centres around the data chosen for algorithms used for AI decisions" and mentions two books:

• Weapons of Math Destruction: How Big Data Increases Inequality and Threatens Democracy by Cathy O’Neil (2016). I've linked it to a book review. The reviewer writes:
• "The core theme of the book is to dispel a widely held misconception of mathematical models and their results being fair, objective and unbiased." 
• "She believes that these models are here to stay but they need to used with caution; appropriate regulation is required to ensure that humans are not treated simply as collateral damage for the sake of efficiency."
• Talk by O'Neil on Weapons of Math Destruction and algorithms (12:15 min. video) | I started it part way through.

The second book that Anonymous mentions is Machines Like Me by Ian McEwan (2019). The link is a review. The book gets a mixed review. A few quotes:

• "The book touches on many themes:...artificial intelligence AI, ...but its real subject is moral choice. 
• "The epigraph quotes Rudyard Kipling’s poem “The Secret of the Machines”, which presciently expresses the uncompromising quality of the machine mind. “We are not built to comprehend a lie,” the poem goes. 
• "In Adam’s digital brain [he's a robot], there may be fuzzy logic, but there’s no fuzzy morality. This clarity gives him an inhuman iciness." 

Thanks, Anonymous, for much food for thought. Suspect algorithms come down to GIGO. Oh and they're highly susceptible to historical bias and... [Fill in the blank as you wish]. 

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

• I can see clearly now (Johnny Nash)

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

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

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

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

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

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

Updated: 2 Nov. 2019

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

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

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

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

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

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

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

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

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

FEMALE TRANSFUSION MEDICINE PHYSICIANS
Transfusion medicine is blessed with many exemplary female physicians in top positions. Some examples of ones I've known personally and met F2F (alphabetical order):

• Dr. Gwen Clarke (via Med Lab Sci, Alberta Health Services, CBS)
• Francine Décary (at conferences when CEO of Héma-Québec) 
• Dr. Judith Hannon (via CBS)
• Dr. Heather Hume (when at CBS she directed me & Kathy Chambers to create CBS's first educational site, now defunct)
• Dr. Debra Lane (as resident at Alberta Health Services, at conferences when CBS medical director in Winnipeg)
• Dr. Susan Nahirniak (via Med Lab Sci, Alberta Health Services)
• Dr. Lucinda Whitman (via CBS, National Advisory Committee on Blood and Blood Products [NAC])

Interesting that so many of these Canadian female transfusion medicine docs have held major positions (as above) and won awards. To name a few: 

• CSTM Ortho award recipients:
• 2002, Francine Décary (CEO of H-Q, ISBT President 2004-6)
• 2007, Heather Hume (Executive medical director, CBS)
• 2010, Susan Nahirniak (Chair of NAC)
• 2013, Debra Lane, Medical  Director of CBS's only joint transfusion service/ blood supplier in Canada)
• 2014, Lucinda Whitman (Chair of NAC)

Of course, Canada has many outstanding female transfusion medicine Drs. I've never met F2F but know via social media like Twitter or via e-mail. Ex:

• Dr. Jeannie Callum (who kindly contributed to CSTM blog on Ana Lima )
• Dr. Yulia Lin: CSTM Ortho award recipient, 2016; 2019 AABB President's Award, 'In recognition of her role as a master educator in the field of transfusion medicine, particularly through her contributions to the education of junior doctors through the Transfusion Camp program.'
• Dr. Elianna Saidenberg who died far too young on Oct. 20, 2019 (Further Reading) 

Special note on Elianna Saidenberg, Never met her except via her tweets, and she kindly liked many of mine.Thought she was a wonderful human being as I suspect did all who knew her up close or from afar. Clearly, Dr. Saidenberg made a difference in her all too short time on planet earth. Twitter remembers Elianna. 

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

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

I will remember you 
will remember you, will you remember me? 
Don't let your life pass you by 
Weep not for the memories.

• I will remember you (Sara McLachlan)

As always, comments are most welcome and there are several below you may enjoy. 

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

• ‘Acts of kindness to repair the world’: CBS remembers Dr. Elianna Saidenberg (22 Oct. 2019)

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

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

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