Friday, June 14, 2013

In my life (Musings on the challenges of transfusion medicine education)

Updated: 16 June 2013 (see Resources & Literature)

This month's blog is a sampling of impressions from the CSTM conference in Edmonton, June 7-9, 2013. These days I don't often attend conferences, but the CSTM made me an offer I couldn't refuse. 

The blog's title comes from a favorite Beatle song.


Why should you continue to read if you're not Canadian? Mostly because the blog's content relates to transfusion medicine professionals everywhere. I hope that impressions and musings will resonate with your experiences and provide food for thought.

Any errors or misinterpretations are strictly mine. I did not take notes and musings are based on highlights recalled one week later. For reference, I attended only one scientific session but came away with many insights and reflections. Suspect if I'd attended the entire conference, my brain would explode.

Most delegates I saw were 'mature', meaning more than 40 yrs old. The demographics fit with my hypothesis that today mostly senior staff receive whatever sparse support exists to attend conferences. And young staff, who may not feel particularly appreciated these days, are unlikely to take funds away from family obligations for CE.

Or did I simply notice more older attendees because they're the ones I know, similar to noticing VW beetles everywhere once you own one?

The sole session I attended (not quite true, but almost) was a 4-person panel on 'Strategies for Health Care Education, Training and Competency.' Musings on 
what struck me most...

1. Two presenters (Shelley Feenstra RN, a transfusion safety nurse educator in Vancouver, BC and Rodrigo Onell MD, FRCPC, program director of the Hematological Pathology training program at the University of Alberta, Edmonton) confirmed what is well known in TM circles, namely that undergraduate nurses and physicians receive very little transfusion-related education

Surveys show that basic TM instruction is often only one lecture and graduates often cannot recall much about it. Some MD programs, such as the one at the University of Alberta, include transfusion medicine lectures and small group case studies but this is not the norm.

2. Whereas student medical laboratory technologists in Canada must pass multiple competency-based objectives in a transfusion service lab to graduate, i.e., solve real problems to an acceptable level, similar requirements to demonstrate on-the-job competency in blood transfusion practice for undergraduate RNs and MDs do not exist.

This suggests that graduate medical laboratory technologists with general certification from CSMLS who work in transfusion service laboratories are much more competent in transfusion practice than clinical colleagues (RNs and attending physicians) on the wards.
3. Dr. Onell, who has the advantage of having a BSc in MLS and working in a transfusion service for several years before becoming an hematopathologist, noted that residents in 4-year hematopathology programs may be passed from one year to the next simply by supervisors asking, "How's Joe (or Jane) doing?" If the resulting discussion is more or less, "Okay", they typically progress to the next year.
In other words, historically and in many places today, residency programs have been time-based, i.e., spend 4 years and, unless you totally screw up , you've probably got your specialty. Unless, of course, you fail the Royal College of Physicians and Surgeons of Canada examination.
Dr. Onell said that on-call hematopathology residents are put on call early in their training (within a few weeks) and typically consult supervisors for months. 
He also half-jokingly said that on-call residents, if they are smart, first ask medical laboratory technologists what they would do, then follow the advice.
4. In a reply to a question from the audience, Dr. Onell allowed that, although it's unlikely, it may be possible for a hematopathology resident with questionable competency to pass the Royal College of Physicians and Surgeons of Canada examination. The oral exam may serve as a key filter, but it's not foolproof.

5. Fortunately, residency programs such as hematopathology at UAH, Edmonton offer many resources to residents to help ensure competency, inc. The Hematopathologist.

6. In reply to a question, Shelly Feenstra, RN mentioned that the long-ago move away from hospital-based nursing programs to college and university programs had an unexpected, significant impact.

Most notably, now hospitals are barraged with multiple requests for clinical placements and struggle to fill them. In contrast, when hospital-based RN programs existed, they received priority because they were in-house and the hospital felt responsible for them.
With nursing shortages and ongoing cutbacks to healthcare, I suspect that RN training conditions are far from ideal. When busy nurses can barely devote sufficient time to patient care, training student RNs from outside is low priority. As with other health professions, the competency of graduating RNs is adversely effected by changes to the education model and cost restraints.

7. Wendy Lau, MBBS, FRCP(C) presented  on competency initiatives of the Royal College of Physicians and Surgeons of Canada (RCPSC). Dr. Lau stressed the College's new initiatives on Competency-based medical education (CBME) to be phased in over several years.

Rather than competency-based objectives per se (required for med lab technologists), the RCPSC opted for 'competency milestones' grounded in real-world needs. Milestones are the abilities expected of a physician or trainee at a defined stage of development.

[My guess is that milestones are similar to general educational goals (as opposed to specific objectives) that may or may not be measurable by direct observation due to their relative vagueness. Still, it's a start and may be all that's possible given the lack of time that physician educators have to spend  - or want to spend - on trainee assessment.]
8. Shanta Rohse, BSc, MDE, a medical laboratory technologist by background, and currently an educational specialist who manages and for CBS spoke on the importance of feedback and human interaction in developing and improving educational initiatives.

Shanta mentioned Transfusion Quest, one of the winners from the 2011 Bloodtechnet competition, as a fun way to assess technical knowledge.

A question from the audience noted a disconnect between the importance of human interaction vs the isolation of computer-based Internet learning. 

Dr. Lau had also mentioned the benefits of Internet educational devices for physicians. She thought that hand-held technology offered real advantages but joked that you'd not want a resident in the ER looking up how to treat a massive hemorrhage on a cell phone.

The question led to a discussion of how one of computer learning's strength is its ability to track educational progress.

[As a long-time TM educator, I noticed that the panel did not discuss how instruction and assessment should correlate to the type of learning, e.g., it's difficult, if not impossible, to teach and learn oral, F2F interactive communication skills on a computer. For some things you need living, breathing humans.]

1. Medical laboratory technologists, i.e., clinical lab scientists, medical lab scientists Down Under (NZ and Oz) and in UK and USA, are definitely ahead of nurses and physicians in the TM competency game.

And it isn't just because some clinical skills are more complex than medical laboratory technology/science skills and therefore harder to assess, which they often are.

For example, physicians deal with bleeding patients in the ER, where split-second decisions are life and death, and the doc needs to rapidly assess history, signs, symptoms, laboratory and diagnostic imaging information and decide how to treat before the patient exsanguinates.

However, competency of complex clinical scenarios can be assessed, if there's a will to do so. Unfortunately, a will to educate and assess competency requires resources.

2. That few educational resources exist, that education is NOT a priority, speaks to the hypocrisy especially rampant in government Departments of Health and Faculties of Medicine. Today it's all about research and bringing in mega-bucks from industry to pay for research and professor salaries, given that government support dwindles.

Sadly, one result is that what research is done follows industry's agenda, not what's best for the public.

3. Competency is essential for all members of the TM team. A cliche, but true: We're only as strong as our weakest link.

The 2011 UK SHOT Report emphasizes 'back to basics'.

Key competency-related recommendations:

EDUCATION AND COMPETENCY in blood transfusion safety remains a key issue in patient safety.

Competency assessment must be underpinned by an adequate and assessable knowledge base for both laboratory and clinical staff at every level. 
KNOWLEDGE OF TRANSFUSION MEDICINE AND OF PRESCRIBING/AUTHORISING of blood components are essential core requirements for any practitioner (medical and nursing) who prescribes or authorises blood components.
For example, recommendations in 2007 and 2009 SHOT reports still apply: 
2007 - Education of doctors and nurses involved in transfusion must continue beyond basic competency to a level where the rationale behind protocols and practices is understood. Transfusion medicine needs to be a core part of the curriculum.
2009 - The existence, and the importance, of special transfusion requirements must be taught to junior doctors in all hospital specialities. Local mechanisms for ordering and prescribing components need to facilitate correct ordering, and remind clinical and laboratory personnel where possible.
Other back-to-basics SHOT recommendations:
CORRECT PATIENT IDENTIFICATION should be a core clinical skill. Errors of identification impact on every area of medicine. The use of a transfusion checklist across the complete transfusion process is recommended to ensure correct completion of each step.
CLINICAL AND TRANSFUSION LABORATORY HANDOVER templates should be improved to include information about diagnosis (particularly haemoglobinopathies), irregular antibodies and special requirements.

Patients are vulnerable with the increase in shared care between hospitals, within a hospital particularly between shifts, and between hospital and community. (Handover toolkit for acute care)
[In other words, TM professionals must communicate with each other to protect patient safety. Doh!]
See full SHOT Report for all the gruesome details

Attending the conference, brought to mind one of my all time favorite Beatle songs (after Hey Jude), In my Life.
The song is 23rd on Rolling Stone's "500 Greatest Songs of All Time" and 5th on their list of the Beatles' 100 Greatest Songs.

There are places I remember 
All my life, though some have changed
Some forever not for better
Some have gone and some remain 
Though I know I'll never lose affection
For people and things that went before
I know I'll often stop and think about them
In my life I love you more
RESOURCES and LITERATURE (added 16 June 2013)
Today many resources exist to train graduate health professionals, inc. nurses and physicians, in best transfusion practices. A small sampling:


Again, just a small sampling. 

Graham J, Grant-Casey J, Alston R, Baker P, Pendry K. Assessing transfusion competency in junior doctors: a retrospective cohort study. Transfusion 2013 Jun 13.  [Epub ahead of print]

International Forum. Education in transfusion medicine for medical students and doctors. Vox Sang. 2013 Feb 14. [Epub ahead of print]

Louw VJ, Nel MM, Hay JF. Factors affecting the current status of transfusion medicine education in South Africa. Transfus Apher Sci. 2013 Jun 3. [Epub ahead of print]

Pirie ES, Gray MA. Exploring the assessors' and nurses' experience of formal assessment of clinical competency in the administration of blood components. Nurse Educ Pract. 2007 Jul;7(4):215-27. Epub 2006 Oct 11.
As always, comments are most welcome.