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