Musings on transfusion medicine: Educating Rita: How we exclude qualified workers

INTRODUCTION
This blog entry begins by juxtaposing a global blood supply with a global work force for purposes of comparison. It then focuses on my view of how roadblocks keep even the most qualified medical laboratory technologists out of Canada. Perhaps this situation exists in your country too?

Canada actively recruits physicians, nurses, pharmacists and other health professionals. See

Shoppers Drug Mart or Poachers Drug Mart? (CMAJ editorial, Jan. 29, 2008)
Related Letters to the Editor
Canada increasingly reliant on foreign-trained health professionals (CMAJ News, Jan. 29, 2008)

Recently, there has been a flurry of news about ISBT128 due to AABB requiring ISBT 128 implementation by May 1, 2008, an event that has been more than 10 years on the planning.

There are many benefits to ISBT128 labels and globalization of the blood supply is one:

Blood suppliers routinely sell products in the global market;
During disasters, blood products may be shared around the world.

The globalization angle caught my eye because I have long been involved in helping medical laboratory technologists and their equivalents (biomedical scientists, medical laboratory scientists, etc.) find work internationally. North America currently has a shortage of laboratory technologists and other health care workers that is projected to worsen due to an aging work force.

ROADBLOCKS
In Canada we need foreign professionals to alleviate staff shortages, at least temporarily, while we educate and train sufficient numbers of home-grown workers. But under the umbrella of protecting public safety we make it difficult for foreign-trained, well qualified medical laboratory technologists to work in Canada.

1. General Certification
The main made-in-Canada roadblock is lack of subject certification in transfusion science and other disciplines. Canada requires general certification provided by the CSMLS, which ceased offering subject certification (except for cytogenetics and clinical genetics) years ago because of cost.

For an example of a program of study, see MLS courses at the University of Alberta. (MLS also has a pre-professional year - MLS website) Note: In Canada MLS at UA is the only integrated MLS program leading to both CSMLS certification and a BSc degree. It has courses such as research projects and molecular genetics that are not included in other Canadian generalist programs.

Other Canadian programs are 2 or 3 years and lead to certification. Although not required, today many students who enter such programs already have university degrees. A few years ago there was a movement to get the integrated BSc as the entry level qualification to the profession, but it failed due to lack of support from government and employers.

The reason this is noteworthy is that lab technologists from the UK and Down Under, aka biomedical scientists, have qualifications that in many respects are more than what is required in Canada yet face significant roadblocks to being able to work here.

Use it or lose it
The effect of general certification is that experienced technologists who have worked in transfusion medicine labs for years, even if eligible to write CSMLS exams, will find it difficult to write an exam that includes questions involving clinical chemistry, microbiology, hematology, and histotechnology. After 5, 10, or 15 years of working in a transfusion service, no one can recall the nitty gritty of other disciplines. Even if they could, the knowledge turnover would make most of their prior learning obsolete.

Practical implication: Experienced blood bankers from countries such as England, Scotland, the USA, Australia and NZ must get upgrading in other lab disciplines in order to have a hope of passing the certification exam. Upgrading may involve taking a series of refresher courses (many of which do not include the exam competencies) or an entire training program of 2-3 years

Note: The CSMLS general certification exam is based on a competency profile that focuses on outcomes, not content. The competencies do not mention the traditional laboratory disciplines and are not organized around them. However, the exam questions do require knowledge, skills, and judgement in specific content areas.

2. Educational Diversity
A second roadblock is that education and training of medical laboratory technologists varies greatly around the globe. A few examples:

(i) Despite its emphasis on non-discipline specific competencies, Canadian training currently involves clinical rotations in 5 areas: clinical chemistry, hematology, histotechnology, microbiology, and transfusion science. American generalist education does not include histotechnology.

Practical implication: Americans with generalist certification cannot challenge the Canadian certification exam without taking a course in histotechnology theory and practice.

(ii) While Canadian education and training is generalist, other countries focus on specialization. For example, UK certification has multiple routes but often involves specialization right from the start of clinical training. Graduates with an honours degree in biomedical science from a UK educational institution accredited by the IBMS cover multiple disciplines but then get employed by the NHS as a trainee biomedical scientist for 2 years, during which they are required to complete a portfolio that shows their competencies. This training could be all in a transfusion service.

Similarly, NZ and Australian programs also allow candidates to specialize during their clinical training, usually in 2 disciplines.

Practical implication: UK, Australian and NZ trained biomedical scientists cannot obtain Canadian certification without obtaining practical experience in labs outside the ones that they chose to specialize in. Clinical laboratories are already struggling to train Canadian students.

(iii) The USA allows subject specialization.

Practical implication: Experienced blood bankers with ASCP or NCA subject certification cannot work in Canada because of the lack of subject certification in Canada.

CASE STUDY - EDUCATING RITA
This is the case of a real person (Rita) whose name and specific details have been changed.

Rita is a UK-trained biomedical scientist who has worked as a biomedical scientist in a transfusion service in England for ~14 years, the last few as a transfusion safety officer (TSO). She has a BSc honours degree in Physiology and Microbiology and worked at the NHS as a trainee biomedical scientist in hematology and blood bank. She now wants to come to Canada with her family and find work in a Canadian transfusion service.

Rita's experience as a TSO is excellent. She has worked with nurses and physicians in an educative role, developed policies and SOPs, conducted audits of transfusion practice, helped implement Better Blood Transfusion, participated in SHOT, developed e-learning packages, presented reports to hospital administration, liaised with regional colleagues, spoken at conferences, and managed projects such as implementation of blood salvage devices and blood tracing software.

There is no doubt that Rita is well qualified to work in a Canadian transfusion service as a TSO, where she would bring a wealth of experience and a refreshing broader perspective. However, Rita is not eligible to write the Canadian general certification exam. She has no practical internship in histology, clinical chemistry, and clinical microbiology. Even if she had practical experience in all required areas, Rita's education and training occurred more than 10 years ago. Recall is difficult and practices have changed.

Bottom line - Rita could contribute much to a Canadian transfusion service but she may not get the chance. One option, assuming her family could afford and support it, is to go back to school for 2-4 years and take a Canadian med lab tech program. Does this sound likely? Is it reasonable? Is it an efficient use of education resources?

What is the wrong with this picture? Why cannot a country that needs qualified transfusion workers put processes in place that are not one-size-fits-all solutions that exclude many of the most qualified candidates and contribute marginally or not at all to patient safety?