Thursday, December 29, 2016

Don't worry, be happy (Musings on decreased government funding as a TM disruptive force)

Updated: 2 Jan. 2017 

Last December I got a bit mushy and wrote
  • Islands in the Stream (Musings on how love of transfusion medicine unites us) [Further Reading]
This year I'm not as sentimental and am okay with being a grinch who stole Christmas. Besides Dr. Seuss's tale has a happy ending. Not saying it applies to this blog, though it may. You decide.

Continuing the series on disruptive forces that affect, or will affect, the practice of transfusion medicine (TM) is hard. Why? Mainly because of all TM health professionals, to date the ones who have been most affected by disruptive forces are medical laboratory technologists / biomedical scientists (whatever they're called in your country). I suspect that an in-depth discussion of laboratory realities would cause many nursing and physician eyes to glaze over.

Including the three main TM professionals is part of the challenge of writing TM blogs. For the most part I try to write about big picture 'poop' that affects all so lab techs, nurses, docs can relate.

So what is December's blog about? It's about the disruptive force of DECREASED GOVERNMENT FUNDING of health care in those nations where universal health care exists, and to a lesser extent in the USA.

USA readers may think the blog is not as relevant because you don't have government-funded universal health care like the rest of the developed world (Further Reading). But from what I've read on medical laboratory and clinical laboratory educator lists, similar things happen in the US, perhaps for different reasons. For example, consolidation is rampant in the blood industry. (Further Reading)

The blog was stimulated by a seemingly odd source:

  • How physicians can keep up with the knowledge explosion in medicine (Further Reading) 
One suggested solution was to create the equivalent of 'paralegals' for medicine. Yes, my mind works in strange ways. More later.

The blog title derives from an 1988 ditty, 
which I've used before, by 10-time Grammy award winner, Bobby McFerrin . 

In an effort to keep the blog short and sweet, well at least shorter, I'll muse on Canada and leave it to you to judge if similar events apply to your country. References for many of the points will not be provided because they are available by doing simple Google searches. For example, in writing a literature review, you do not need to reference facts taken as a given and available in many resources, e.g., Donald Trump will become the 45th US President.

December's blog was also partly motivated by the economy currently tanking in my Canadian province of Alberta because prior governments made us depend on the price of oil to provide government services, including health care. Unfortunately, our economy regularly tanks. Suffering from boom and bust cycles is normal if you depend on others for prosperity, others like Saudi Arabia and the nations that make up OPEC (Further Reading).

The blog reflects on the disruptive force and effects of governments deciding to save money on the backs of health care professionals and the health system, including patients. First I outline the immediate effects in general of decreased funding, then present long term consequences for transfusion medicine.


Decreased health care funding began in a big way in Canada in the 1990s. Driven by right wing ideology, provincial governments (responsible for health care in Canada under our constitution) decided to save money in many ways, including by cutting funding to health care, particularly clinical laboratories. 

The result was a concurrent move to regionalize and centralize laboratory testing because it facilitated saving money by eliminating laboratory administrative staff and 'trench workers' alike (See Dianne Powell, Further Reading).

Management gurus tapped into the big government money available to consultants by propounding
 catch-phrases such as 'right sizing' and 'working smarter, not harder'. All in the belief that 'BS baffles brains', which it apparently does when it comes to governments to whom bafflegab is second nature.

'Working smarter, not harder' particularly rankles because it led to managers of transfusion labs trying to do more with less  - in effect, being guinea pigs to government experiments - and considered failures if they couldn't.

For example, if five labs became one lab, the first to be axed could be four lab supervisors, now that only one was needed. Similarly, the five trench workers who covered the midnight shift as the sole technologist on duty could become one worker. You get the idea. What happened in Canada due to this disruptive force was many lab technologists, mainly middle managers and trench workers, lost their jobs.

Education programs
Concurrently, med lab technology/science programs closed across Canada, since far fewer graduates were needed. 

In Canada in the 1990s only two programs survived in the 4 western provinces (constituting ~31% of Canada's population) and both were in Edmonton, Alberta, perhaps due to the programs' strength, since Alberta was the province hurt worst by funding cutbacks. I taught in one (MLS, University of Alberta) and was a clinical instructor for the other (NAIT).

Medical lab technologists/clinical lab scientists
Under NAFTA, those with university degrees were lucky to get clinical laboratory jobs in the USA, where shortages had become extreme. Others had to give up the career they loved and had worked at for up to decades when laboratory jobs disappeared.

Clinical placements
Another factor was that government cutbacks resulted in clinical labs becoming under-staffed. Staff could barely keep up with doing core work (patient testing), let alone train students. As a result no one wanted to, or even could, train students, even though it was in their best in interest for succession planning.

Semi-automated and fully automated lab instruments found great favour and prospered in the era of decreased government funding of clinical laboratories. Instrument manufacturers promised their impressive looking instruments would decrease staff numbers, a tempting advantage since staff had costly benefits such as supplementary health insurance and pensions.

Companies also tried to take the edge off axing technologists by claiming now they could concentrate on more interesting skills and let the instrument do the 'grunt work' (my phrase). Cue a kumbaya moment. Except those without a job wouldn't be singing.

But, oh how pathologists' eyes would light up at the thought of becoming less of a cost centre in the hospital hierarchy. Of course, the more bells and whistles the gizmos had, the bigger the eyes.

No one seemed to care that

  • Government money was sucked outside Canada to multinational for-profits, rather than to staff who worked in Canadian communities, paid taxes and raised their families here. 
  • Lab automation operates on a razor-blade business model
  • Despite promises of smooth integration with lab information systems, automated instruments often had a hidden cost - the need to buy middleware so they could 'talk' to the LIS. And then the fun begins.
Perhaps nurses can add to this discussion, at least I hope so. In Canada, decreased government funding of health care led to unemployed graduate nurses being recruited to the USA, Australia, NZ, pretty much everywhere outside Canada. More than 20 years later, Canadian hospitals still suffer because there are not enough nurses to staff operating rooms, emergency departments, etc.

Indeed, the nursing shortage is growing because of an aging workforce (Further Reading). Impending baby-boomer retirement affects all health professions.

In Canada, decreased government funding did not affect physicians as much as med lab techs and nurses, mainly because physician numbers are much lower. However, in Alberta in the 1990s lab physicians lost jobs and, as might be expected, were compensated much more than other health professionals.  See 'History of 1990s Laboratory Restructuring in Alberta':

In a way the long-term consequences of decreased government funding are the same for lab technologists, nurses, and physicians. Here I'll focus on transfusion medicine tidbits.

How have TM labs coped (saved money), and with what effect on medical laboratory technologists/scientists, post-government funding cuts?

Regionalization and centralized testing laboratories and increased automation all led to decreased staffing needs. But more than that, automated instruments led to a decreased need for well trained transfusion specialists.

Less educated and specialized staff
Hospital transfusion service labs are more than happy to decrease costs by hiring lab assistants (some with formal educational qualifications but also those trained on the job). Generalist technologists who work in other labs such as chemistry and hematology also play a key role, especially in labs beyond the centralized transfusion service lab and in rural areas.

The result has been fewer and fewer transfusion specialists with more and more staff relying on the few specialists to problem solve and keep transfusion service laboratories functioning safely. When TM specialists retire, who can fill their key role?

For decades, some TM educators have referred to hiring less well educated staff as the 'dumbing down' of the profession. That sounds harsh but does not mean that lab assistants or generalists are dumb because they clearly are not and deserve respect. Rather it means that with the advent of automation and 'mistake-proofing' tools, many staff no longer need to be as educated and trained as before. For example:

Mistake-proofing is designing processes and devices to help prevent errors and make them obvious at a glance. Synonyms include error-proofing, fail-safing, and the politically incorrect idiot-proofing. Mistake-proof devices are common in daily life. Ex:

  • Beeping alerts when keys are left in cars or headlights are left on
  • Computer dialogue box that asks, "Do you want to save the changes you made...."
Mistake-proofing tools are also commonly used in transfusion processes and include:
  • Checklists for specific processes;
    • Inspection checklists for receiving blood into inventory;
    • Pretransfusion nursing checklists;
  • Colour-coding of ABO antisera;
  • Cross-checking work done by others;
  • Barcodes on donor bag labels;
  • RFID for release of transfusion units from refrigerators and more (Further Reading)
Bottom line - Labs: To make a transfusion lab run safely, some staff  must be well educated transfusion specialists.  How many depends on the locale, test volume, patient mix, etc. My experience is there are too few specialists and they're aging, about to retire in large numbers.

How have hospitals and blood suppliers coped (saved money), and with what effect on nurses, post-government funding cuts?

In hospital wards across Canada there are fewer and fewer RNs, also fewer LPNs. Instead we have a new category of health worker, called by various names, including heath care aides and nursing attendants.

In Canadian hospitals, such workers usually have formal qualifications taking about a year to complete, including an internship. They often are the main care givers, especially to the elderly in long-term care.

Besides being short-staffed, the big nursing change within hospitals, discussed in the first 'disruptive force' blog, is the advent of transfusion nurse specialists/safety officers and blood conservation nurses. But they arose from the tainted blood tragedy and government regulation, not government cost-saving measures.

Blood suppliers
In Canada, as a cost saving measure, CBS decided to axe the number of expensive nurses it employs by hiring cheaper on-the-job trained 'donor care associates'.

* Health Canada approves new blood donor screening model (10 Feb. 2013)

This correlates to how USA blood donor centers operate, where  phlebotomists are trained on-the-job to draw donor blood and perform other functions. Having a Certificate of Phlebotomy helps since employers would rather get trained staff to decrease their costs.

Once I joked that CBS may do the same with its transport staff.

Bottom line - Nursing: I've no idea how well 'donor care associates' work at CBS and what effect, if any, their employment has had on nurses, other than fewer jobs available. On hospital wards, nurses suffer from short-staffing and a different mix of staffing, which is stressful.

How have TM labs 
coped (saved money), and with what effect on medical staff, post-government funding cuts? With regionalization and centralized testing labs, fewer transfusion service medical directors exist because one physician fulfills the role for an entire health region. 

And, although all staff have responsibility, transfusion service medical directors are ultimately responsible for keeping patients safe, which becomes more challenging with staff shortages and a different mix of staff.  

In the health care system in general, several strategies have been floated to decrease physician costs, and some have been tried. 

For example, in Alberta a system of primary care networks exists (Further Reading). They work well (I've accessed one myself) and consist of physicians and other health professions, including nurse practitioners, dietitians, respiratory therapists, exercise specialists, etc.

The cost saving derives from the benefits of preventative medicine and using less expensive health professionals as appropriate. Now that Canada has assisted dying legislation, the Alberta government expanded the list of medical professionals authorized to assist patients with their deaths to include nurse practitioners. (Further Reading) 

The news item that caught my eye dealing with physicians:

  • How physicians can keep up with the knowledge explosion in medicine (Further Reading)
The article proposed interesting solutions:
  • Create 'paralegals' for medicine (para-medicals)
    • Meaning let nurses and junior doctors do more
  • Build a learning medical information ecosystem
  • Wow, what a bafflegab mouthful! At first it seemed to mean teamwork between health professionals (always a great idea), but then the authors pivoted to information technology. 
Always the technological solution, eh? Makes me laugh because I know physicians who have difficulty using their office computer system to renew a prescription easily. And some of these docs are not that old.
  • Mutter, mutter...Why won't it let me select renew? Aaargh! (Then writes it in pen on the computer print-out)
And how many physicians resist Twitter as a huge waste of time and don't see it as a valuable tool? Yet they attend medical rounds for the sandwiches (and to be seen) and chitchat or snooze or check e-mails throughout? Or perhaps, just to show how clever they are, ask the presenter an obscure question?  Perhaps I'm being too cynical but that's how it seems sometimes.

Bottom line - Physicians: On a personal level, transfusion physicians have been more successful than lab technologists and nurses in fighting job loss caused by government cutbacks. Or maybe it just seems that way because their numbers are fewer. Of course, medical directors of transfusion service labs feel the full staffing effects of having fewer specialist lab technologists/scientists.

I cannot but smile imagining physicians being told they must concede a significant percentage of what they always considered their health care role to others. But don't worry about it, docs, it's to your advantage. Others will now do the boring 'grunt work'. And you'll be able to concentrate on the interesting, complex stuff you were educated for. Don't worry, be happy.


With cost cutbacks, low morale affects all health professions to varying degrees. My experience is morale falls mainly due to uncertainty, lack of control, and feeling devalued

When government cutbacks occur, health systems are stressed to the max and are forced to change. You might think of it as tough love. The change includes finding innovative ways to keep functioning safely. What often results is a series of experiments, experiments in which both staff and patients are the guinea pigs. 

Often outside consultants are brought in to push and implement what is often the hobbyhorse that's become their cash cow. Sorry, couldn't resist the mixed metaphor. They implemented 'the solution' elsewhere and now they're the experts, commanding big money. It's led to the joke
  • 'We're consultants and we're here to help you.' [Sure you are.]
➽In this system-wide experimental laboratory where cost saving rules, the biggest impact on staff is uncertainty and loss of morale. Change is always hard but even 'keeners' can soon become unhappy when they learn that they have no control over events, including job loss. Competent, skilled staff are let go because their positions are eliminated. In a unionized environment sometimes the 'best and brightest' lose jobs due to lack of seniority.

Moreover, staff who survive the cuts often feel guilty. The 'Why me, not them' syndrome. Suddenly folks you've worked with for years are gone, perhaps needing to change careers they love, and you're left for no apparent good reason. Some may even need a job to care for their families away more than you do but....

In such an environment staff invariably begin to feel devalued. Unfortunately, this is one of the most long-lasting invidious effects of cost restraint in which it matters not how capable someone is, how dedicated or how loyal. Staff begin to feel like checkers being moved around a board, where any checker will do. 

Effects such as low morale take a long time and much effort to reverse. It seems that some feelings are branded into people's souls, and not in a good way. 

The other long-lasting invidious effects are mistrust and cynicism about the intentions of governments, that with a limited money pot, make choices that cripple a health system and leave it with a lasting hangover. This happened in Alberta, Canada in the 1990s.

Similarly, where massive funding cutbacks lead to significant job loss, internal disruption and re-organization, distrust and cynicism invariably extend to the administrators who lead the health system, whether those at hospitals or the blood supplier. 

The health care system becomes similar to a dysfunctional family with some of its characteristics
'One or both parents exert a strong authoritarian control over the children. Often these families rigidly adhere to a particular belief (religious, political, financial, personal). Compliance with role expectations and with rules is expected without any flexibility.'
In the case of health care, the de rigueur belief system includes cliches such as 'do more with less', 'work smarter, not harder', the lean business model and its many variants rule. Oh, and by the way, no dissent allowed

One final tidbit: The long-term effect of decreased government funding leading to less educated and trained staff is disconcerting because 
  • A little knowledge is a dangerous thing. 
The most dangerous folks in any profession are those who do not know what they don't know. And that plays out daily on hospital wards and in transfusion services labs, where we can only hope there are enough well educated specialists to catch errors leading to patient harm. 

In this blog I muse about the short- and long-term effects of the disruptive force of decreased government funding for health care and transfusion medicine in particular.It's happening everywhere.Will governments have a

It's doubtful. Today governments still do not consult frontline workers enough, or at all, about coming cutbacks and give them an opportunity to participate fully in a transparent change process.

Changing government policy is difficult and analogous to Newton's First Law of Motion:
A body at rest will remain at rest unless an outside force acts on it, and a body in motion at a constant velocity will remain in motion in a straight line unless acted upon by an outside force.
A sufficient outside force hasn't acted because professionals in the health system tend to accept whatever poop falls on their heads and do everything to make it work. Don't rock the boat, yes, this worries us, but let's wait and see. Somehow we'll muddle through, even if it creates much stress to us.

That's the thing. Physicians, nurses, lab technologists/scientists in transfusion service labs make the system work, regardless of the personal cost to their health and well being. And those in charge, physician-administrators
 (see below), bureaucrats, politicians alike, seem happy to let them. 

This song has been used before because it fits some of the blogs and, face it, I obviously like it.

For interest, in 1988 McFerrin's song was used by 'Bush 41'  - a one term President - as his official campaign song without McFerrin's permission. McFerrin protested, stated he'd vote against GHW Bush, and dropped the song from his performances. Ouch!

Anyway, given recent political events in the USA, you can likely guess my take on Donald Trump. Similarly for the long-term effects of government cutbacks, I could slit my throat (figure of speech) or sing this song and I choose the latter.

Here's a little song I wrote
You might want to sing it note-for-note
Don't worry, be happy
In every life we have some trouble
But when you worry, you make it double
Don't worry, be happy Don't worry, be happy now

As always comments are most welcome.


CSTM blog: I will remember you: Dianne Powell on lab restructuring

Dec. 2015 blog: Islands in the Stream (Musings on how love of transfusion medicine unites us)

How physicians can keep up with the knowledge explosion in medicine (19 Dec. 2016)

The rise of the hospital administrator [Reality is that hospital administrators railed at in the article are often physicians who've become 'suits'.]

Alberta's Primary Care Networks | Edmonton Southside PCN

Alberta government expands medical professionals authorized to assist patients with their deaths, by including nurse practitioners (12 Dec. 2016)

Truth about the nursing job market

USA blood industry consolidation

Blood industry shrinks as transfusions decline (2014)
Blood centers should position themselves to be agents (not victims) of change (2014)

U.S. health care from a global perspective

U.S. spends more on health care than other high-income nations but has lower life expectancy, worse health
Middleware revolution bridging automation gaps

UK health agency plans RFID trial to staunch transfusion errors (2006)

The case for RFID in blood banking (USA perspective, 2016)

Saudi's destructive oil freeze (March 2016)