Tuesday, December 31, 2019

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) .

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)

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. 

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.

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

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.

Saturday, November 30, 2019

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.

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."
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. 
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.

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:
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]. 

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).

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)

Wednesday, October 30, 2019

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.

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?

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):
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-QISBT 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?

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

In Memoriam: Dr Elianna Saidenberg (21 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.

Tuesday, October 01, 2019

Both sides now (Musings on humans vs technology in transfusion medicine)

Stay tuned: Revisions are sure to occur

There's much transfusion news these days on artificial intelligence (AI), big data, drones, innovations, new technology, precision medicine. In a way this blog is a follow-up to the prior one, 'Get back' (Musings on transfusion medicine's future).

September's blog (albeit published Oct. 1) was stimulated by a weekly feature ('Workplace column') on a local radio program I heard this morning (Further Reading). Also, because as an oldster I want a record of events I've experienced in the hope they will resonate with some and influence others to do similar. Otherwise when we oldsters croak, they're gone forever.

The blog's title derives from a song by Canada's Joni Mitchell.

As you read the blog, regardless of your health profession, please consider the challenges you faced if you have held a management position and, if not, think about the strengths and weaknesses of managers you have had. Also, consider the impact you as a manager have had on colleagues and the influence your managers have had on you and your career. 

Specifically, the radio column was on moving into management, generally viewed as a promotion with a higher salary. The columnist (@sandbaryeg) gave tips on becoming a manager for the first time. Her tips made me recall when I took a giant leap from a long career as a transfusion educator of medical laboratory technologists/biomedical scientists to become a lab manager at CBS ('assman' as the centre's QA department addressed my mail). True, I'd been lab supervisor in my 13-yr job before teaching, but with none of the responsibility the 'assman' position entailed.

Indeed, as I only learned later, although I managed the patient services lab at the blood centre, the position had been downgraded to 'assistant manager' in order for the centre (and perhaps head office?) to retain more control, especially over salaries. Also, I hadn't realized (bit stunned of me) that the person who had been an assistant to the prior manager and perhaps (just a guess) had applied for the job I was recruited for, and was the acting manager when I came. She was a prior student of mine, in fact in the first Med Lab Sci class that I taught all the way through, who I was and still am exceedingly fond and proud of.

My take on the consultant's 5 tips for new managers. How to
1. Run meetings, something many dread;
2. Give effective feedback;
3. Foster a team environment;
4. Attract & recruit the staff you need vs filling an existing job;
5. Manage your own time effectively.

Promotion: First, I'll note that in my experience (historical, I know, dating from 1960s-2000) often the folks who get promoted in the lab are ace technologists. If all factors are considered more or less equal, seniority may play a role. To me, that's not an effective process, but it's likely the easiest.

How often do fabulous footie players (soccer in NA) or hockey players become great managers? Not many. Why? Because the skills needed are quite different.

Needed skills? More recently, not only med lab techs/scientists but also physicians (perhaps nurses?) tend to get Masters of Business Administration (MBAs) as lab medicine and transfusion have become more and more a business. Presumably these degrees help in a new career as a 'suit' whose prime concern is the bottom line, though patient safety is always touted, given first place in communications.

I'll discuss the 5 tips in various ways based on my experience.

Decades ago as an educator I'd experienced many ineffective meetings, including those run by MDs at the departmental (Lab Med & Path) & Faculty of Medicine levels. Some dept. meetings were info-only unneeded sessions. Few required active participation. And often the minutes were totally useless to anyone not attending.
  • My experiences motivated me to write a resource for TraQ in 2009 on running meetings (Meetings as Time Wasters, Further Reading).
On running meetings in my brief career as 'assman' I was fortunate and smart to designate my prior student to run many meetings. She was experienced in the task and did it much better than I ever could. Only time I ran meetings was when it came to getting staff on board with changing almost all pretransfusion testing methods in the lab. That came easy as it was right up my alley as an educator.

In a similar vein, I was glad I'd insisted on a whiteboard for my 'assman' office as it was well used when meeting with supervisors in the various sections of the patient services lab.

As an educator I had to give feedback over decades and some was difficult. For example, telling foreign students (English as a second language), whose parents had struggled and worked hard to send them to Canada that they were not going to pass their clinical rotation. For such students it was a total disaster, an incredible loss of face and shame. Frankly, it broke my heart and I know that whatever I said to lesson the blow (e.g., they could have great success in another career) wasn't heard and didn't lesson their reality in any way.

In giving more routine feedback, as a med lab technologist with an MEd, I knew the characteristics of effective feedback. On a personal level I believe that often what shapes us for good and bad in life are 15-60 second interactions with others. For example, I'll never forget the powerful effect of my Dad saying, 'Pat, don't be afraid to be different.'

As a teacher of med lab students I always kept that in mind when giving feedback. Meant I treated struggling students the same as high achievers. And in retrospect I see that many of those who struggled have gone on to be high achievers, leaders in their field. Why? Suspect it's because success depends on many factors, not necessarily getting the highest grades.

A good pal is a standardized patient at the University of Alberta and they have a particular take on feedback, called CORBS (Further Reading):

CLEAR – Give information clearly and concisely
OWNED – Offer feedback as your perception, not the ultimate truth. Talk about how something made you feel. Use terms such as “I find” or “I felt” and not “You are”
REGULAR – Feedback is offered immediately, or as soon as possible after the event
BALANCED – Offer a reasonable balance of negative and positive feedback. DO NOT overload with negative feedback.
SPECIFIC – Feedback should be based on observable behavior and behaviors that can be modified.

Not much to say. Health care teams are similar to politicians kissing babies. Everybody does it as it's the reigning orthodoxy, the cliché of how we love to see ourselves. Again, University of Alberta has a course on it. INT D410 - Interprofessional Health Team Development.

Like to think I've been a member of many teams in health care (my transfusion families over the years) but must admit that many who promote it most publicly do not walk the talk.

Will only speak to my recruitment to be 'assman' 21 years ago. Fact was the job was not quite as advertised. In retrospect I thought they portrayed part of the job almost as if it was what became hospital liaison specialists. I totally dug the part about the centre being the pilot site for a new information system and found it a worthwhile challenge.Our talented team of med lab professionals did a wonderful job in implementing the new IS.

Similarly, I loved the opportunity to change outdated lab methods, though don't think they hired me for that. It was just my 'value added' to the job I held for all of 9 months. When I tendered resignation I explained why in exit interview. They understood more money wouldn't make a difference and admitted they could not change what I thought needed changing most (head office, though it's more complicated than that).

So did CBS recruit the right person for the job? Yes and no. Yes, because I led the talented patient services lab team successfully through a difficult time of incredible change. No, because after years in academia at a university where dissent and free speech are cherished, I didn't fit in a national organization where adhering to head office directives was paramount. That's what made you a valued team member.

The radio consultant pointed out that managers need to prioritize their tasks and serve as role models for staff as they cannot work to 10 pm over the long term. I don't have much to say except that you obviously cannot help others if you're exhausted. See it as a Buddhist concept that you need to love yourself, be okay with who you are, in order to love and help others. Over my entire career I was often the first in and last out daily but that's another story.

Are AI, big data,new technology, precision medicine all important to health care and more crucial than the qualities of people in leadership positions? Perhaps. But not to me. As a human being on plant earth, I'll always value the human condition over technology. See excerpt from 2001, a Space Odyssey (Further Reading).😁

Chose this song because I've lived long enough to see transfusion medicine evolve from being people-focused to technology-focused. As  early adopter of technology (not a Luddite), I doubt we're on the right track (Further Reading). Also, admit that I love the songs of Canada's Joni Mitchell.

Saturday, August 31, 2019

Get back (Musings on transfusion medicine's future)

Updated: 1 Sept. 2019 (Learning pt 4, Further Reading)
August's blog was inspired by a blog I saw on the UK's BBTS website:
  • Transfusion 2024: What did we learn and where will we be? (Further Reading)
To me Dr. Nicholas Watkins' blog had 3 related themes:
  • How to replace retiring staff (and their experience) with new staff, including retaining them.
    • Innovation and technology can help 
    • As can big data (electronic donor and patient records)
The blog's title comes from a 1969 Beatles ditty.


Be aware I've worked in transfusion for decades. My views are biased by long experience as are the opinions of everyone.

In the 1990s I saw how regionalization and centralization of hospital transfusion service laboratories affected staffing, along with semi-automatic instruments. In Alberta, Canada (perhaps everywhere?) that meant many transfusion labs required fewer knowledgeable specialists and could get by with mostly medical technologists who were generalists,  plus lab assistants. Another factor was an AB conservative government that removed 40% of the province's lab budget to decrease a budgetary deficit.

Similar changes across Canada resulted in all medical lab educational programs closing in Western Canada except for the two in Edmonton, NAIT and the University of Alberta's MLS. I taught in MLS but as the University of Alberta Hospital's transfusion service clinical instructor I also taught  NAIT med lab students.

Automation came much earlier to blood supplier donor testing labs. In effect donor testing labs could be mostly staffed by technologists experienced in highly automated clinical chemistry labs.

Learning point #1:
To me, these events meant a huge loss of laboratory transfusion expertise in immunohematology. In Edmonton, Alberta, for example, experienced technologists had to compete for the few remaining jobs based on seniority and many left the field. Those with a BSc in Med Lab Science (who wrote ASCP exams) were able to move to USA (and overseas to countries such as NZ) and work for years.

I don't see 'innovation and technology' as truly helping the loss of expertise except in the sense it means:
  • Med lab profession can be 'dumbed down.' With increasing technology no one needs much expertise to perform routine tasks. And I don't mean generalists and lab assistants are 'dumb', I respect them for their skills, just that their lack of transfusion expertise is the new normal in many labs. 
  • We can only hope so long as serology survives, there's a safety net in all workplaces where the few knowledgeable staff catch any errors.
Learning point #2:
Today the biggie is molecular testing, which means immunohematology expertise will eventually become passé. Presumably, if biotech manufacturers succeed with marketing campaigns that promote matching blood donors and transfusion recipients for antigens with known genes, not just in multi-transfused patients but as the gold standard for ALL transfusion recipients, serologists will no longer be needed.

Transfusion recipients will no longer develop alloantibodies from transfusion, except for ones the DNA PhD gurus haven't identified. But let's hype the hell out of precision medicine to increase profits of commercial interests.

Sounds like a perfect world, no? Local med lab staff numbers shrink to a precious few. Their pesky staff benefits are greatly reduced as an employer cost. Instead of supporting a local economy, money is funneled to foreign biotech companies, who thrive by pleasing their shareholders who grow richer and richer.

Big Data
Yep, big data can provide insights and feed into artificial intelligence (AI) to further remove error-prone humans from healthcare decisions. The downsides include patient privacy and the reality that machines make mistakes. GIGO rules and AI is only as good as human input.

Learning point #3: Privacy is big data's greatest challenge and if it fails (as is likely), big data will become just another failed trend. As to AI, I suspect it's decades away from filling the skilled worker shortage in the transfusion world. But it's already got niche roles in medicine (Further Reading).

Learning point #4: Presumably one day in the distant future AI, automation, and robotics will make human work passé. It's already started and not just on car manufacturing assembly lines. Have you seen the Android robots from Japan or those providing robotic nursing care? With an aging population and worker shortage, robots can fill the bill. (Further Reading)

My vision for the future includes humans who cannot communicate with other humans by talking and have developed enormous thumbs for texting and perhaps sexting. 😉

Choose this Beatles ditty for blog's title song
  • Get back (Paul McCartney, Live in Lisbon 2004)
It's my attempt at a joke as we can never get back to the days where oldsters like me once belonged. 😄

As always, comments are most welcome. And there are some - see below.


Wednesday, July 31, 2019

Look what they've done to my song Ma (Musings on invisible health professionals)

July's blog, another short one, was stimulated by an editorial in the Archives of Pathology; Laboratory Medicine, August 2019: Emerging From the Basement: The Visible Pathologist. (Further Reading)

The editorial reminded me that a hematopathologist I once worked with told me, "Pat, just like medical laboratory technologists/scientists (biomedical scientists in UK, Australia, NZ) feel invisible, at the bottom of the health professional pecking order, so do pathologists of all specialties."

Also on the local scene in Alberta, Canada, a new provincial government just cancelled a needed planned hub lab in Edmonton, with the new government implying they wanted to concentrate on patient care (as if clinical laboratories didn't affect patients) and the centralized superlab/ hub lab was a waste of money best spent elsewhere. The new Premier Jason Kenny argued the changes (new consolidated hub lab) would do nothing to improve patient services.

The blog's title derives by a 1970 song by Melanie Safka.

My take has always been that most folk don't have a clue what medical laboratory technologists/ biomedical scientists do. Suspect they assume we are merely the vampires/blood suckers who draw their blood samples for lab tests. Generally, folks do not realize we are highly educated and trained professionals who play an critical role in assisting physicians to diagnose and treat patients.


Fact is med lab science and clinical labs need to be more visible to the public. In this section I'm going to include tweets of colleagues and former students (my beloved 'kids') who are using Twitter to promote med lab science and make the case for why clinical labs merit respect as playing an as important in patient care.

Tweets and News

Folks you can see tweets without being on Twitter. If you are asked to join, just ignore the dialogue box asking you to join and click on the tweet off the dialogue box. All tweets are short, please read them.

1. Thanks to all who came out to the CSMLS open forum last night

2. AHS Newborn Metabolic Screening program

3. Cancelling superlab undermines foundation of patient care

4. Finally - someone took a look at what's going on

5.  Short-sighted decision to halt ongoing construction of the Edmonton Clinical Lab Hub

6. Yet another example of the importance of lab medicine

7. Pictured here are very passionate medical lab professionals seeking to educate Albertans of the critical role med lab plays in quality patient care 

8. Clinical labs save lives. We have no space & aging equipment. Cancellation of Northern AB Hub Lab leaves us wondering how will this crisis be addressed?

9. Thank you for helping champion the voice of the medical lab profession and its critical role in effective quality patient care.

I chose this song because I'm disappointed that medical lab technologists (biomedical scientists) still have to fight to be visible to the public, including some politicians, after all these years. I came to the med lab science field by a non-traditional route 55years ago and still we face the same challenges.
Look what they've done to my song, Ma
Look what they've done to my song
Well, it's the only thing I could do half right
And it's turning out all wrong, Ma
Look what they've done to my song

Harrold IM, Bean SM, Williams NC. Emerging from the basement: the visible pathologist. Arch Pathol Lab Med. 2019 Aug;143(8):917-8.

Health Quality Council of Alberta: Provincial Plan for Laboratory Services in Alberta (February 2017)

Leaning into the challenge of medical science (4 June 2019)

The UCP government scrapped Edmonton's 'superlab'. Medical experts say Alberta needs an alternative and fast (24 July 2019)

Medical lab group pushing Alberta government to address gaps after cancelling superlab (24 July 2019)

Alberta government keeps promise to cancel construction of medical superlab (20 June 2019)

Lab Tests Online: For anyone interested in what medical lab professionals do and information on your lab tests results

Sunday, June 30, 2019

I will remember you (Musings on Marion Lewis, an extraordinary Canadian)

On June 27 Julie Payette, Governor General of Canada, announced new appointments to the Order of Canada. Included in the honours was Marion Lewis of Winnipeg, who at age 93 was named an Officer of the Order of Canada (Further Reading).

As my early career was in Winnipeg I was well familiar with Marion Lewis and Dr. Bruce Chown. In 1944, she and Dr. Bruce Chown opened the Rh Laboratory to study and eradicate Rh hemolytic disease of the fetus and newborn (HDFN).

The blog's title is based on a 1995 ditty by Sarah McLachlan.

In 1943 Marion Lewis graduated from high school and trained as a 'medical technician' at Winnipeg General Hospital (now Health Science Centre). In those days there were no post-secondary institutions training what today we call medical laboratory technologists/scientists ('biomedical scientists' in UK and Down Under). As noted, only a year later she was at Winnipeg's Rh Laboratory with Dr. Bruce Chown.

With a Bachelor of Arts degree she became a Full Professor in the Dept of Pediatrics and 2 years later a Professor in  Dept. of Human Genetics. Normally that's reserved for those with MD or PhD degrees. In 1971 Marion shared AABB's Karl Landsteiner Memorial Award with Dr. Bruce Chown in 1971. To me, it's AABB's most prestigious award. And it's not the only AABB award she received.
  • Karl Landsteiner Award
  • Past recipients (Check these TM giants out: Levine, Wiener, Race, Sanger, Morgan, Watkins, Mollison, Dausset, Blumberg, Crookston, Bowman, Issitt, Gallo, Montagnier, et al.)
It's fascinating that in 1950-51 Marion Lewis needed a break and spent four months at an Italian university studying Italy's language and culture. Then she spent another three months studying in London with Dr. Robert Race and Dr. Ruth Sanger of 'Blood Groups in Man' fame. In 1951 Marion returned to Winnipeg and the Rh Lab. And the rest is history (See her University of Manitoba biography in Further Reading).

Please read Further Reading for Marion's unique career.

Of course, I knew Dr. Jack Bowman of Winnipeg's Rh Lab well as he was the Medical Director of Winnipeg's Can. Red Cross BTS while I still worked there. Wrote a blog when he died in 2005 (Further Reading).

Chose this Sarah McLachlan song because I will always remember transfusion medicine giants and especially folks like Marion Lewis who rose from humble beginnings to great accomplishments on the strength of intellect, skills, and hard work.
As always, comments are most welcome.


Saturday, June 01, 2019

We can work it out (Musings on transfusion association annual meetings)

Last revised: 2 June 2019  (See ADDENDUM below)

As the CSTM annual conjoint meeting with CBS and Héma-Québec is now on May 29 to June 2, I thought I'd muse on annual meetings in general. As readers of this blog will know, I've had a long career in transfusion starting at the bottom without qualifications but being incredibly fortunate in my employers.

I'm an outlier of sorts with atypical views and being an oldster gives me the freedom to say things that colleagues likely would not. Perhaps many may disagree with me on this blog's points. That's okay too as I'd be concerned if all, even most, agreed with me. Included are tidbits I think contribute to quality presentations at meetings.

Professional associations exist to serve and represent the interests of their members, which applies to the three associations I belonged to during my long career as a medical lab technologist turned educator: AABB, CSMLS (includes IFBLS membership), CSTM. The latter two are Canadian organizations, the first American but AABB has branched out to become international, though its headquarters remains in the USA as does its primary focus.

The blog's title is based on a 1965 Beatles ditty, We Can Work It Out.

Over the years I've attended many meetings, aka conventions and congresses. With a few exceptions most of all those attended were held in Canada by CSMLS or CSTM. One memorable one (IFBLS) was held in Oslo in 1996. Why memorable? Most of all it was because I met a Norwegian med lab technologist who worked in transfusion and we've been good pals ever since.

To me, that's Lesson #1 of what's important at annual meetings. It's not so much the scientific presentations you hear and what, if anything, you learn from them (commit to long-term memory). Face it, if you read professional journals you're pretty up-to-date on the latest and greatest. During my career the AABB journal Transfusion and similar were kept in the bathroom as a welcome distraction or read while basking outside in Canada's all too short spring, summer, fall.

Of course, I suspect not many transfusion technologists and nurses in the trenches regularly read journals. Take a peak at the index of Transfusion 2019;59(5). How many articles would you read let alone understand?

Today, keeping current also applies to those on social media platforms like Twitter where journals and associations alert folks to the latest developments. But how many of you use Twitter?

LESSON #1: The most valuable benefits of meetings are the interactions with peers, sharing experiences and knowledge that's not in journals or textbooks, including the friendships made. Often such interchanges are shared during a night-out over a meal or glass of wine/beer. Typically, chitchat involves practical and tacit knowledge only gained from experience.
Pretty certain that Lesson #2 will be familiar to medical lab technologists/scientists world-wide, at least those lucky enough to attend meetings:
  • So many of the presentations at transfusion association meetings are by physicians and researchers, though it's slowly changing. 
What this means is the information and research presented, though significant, is often not particularly meaningful nor of immediate use to those in the trenches, whether transfusion med lab techs, nurses, physicians without university appointments. And being able to use new meaningful learning right away is important to busy adult learners. In continuing education and professional development courses it's critical because 'adults vote with their feet' as the cliché goes.

Indeed, I wonder in the age of the smart phone how many meeting attendees during presentations  spend most of the time checking e-mail, texting and browsing. Suspect it's far too many. Best take is they're live tweeting but no, that's not it.

Reality is that much transfusion research is esoteric, of interest mainly to those involved in similar, narrow research.  Kudos to CSTM for its full day of workshops relevant to front-line professionals.

LESSON #2: Many presentations at scientific meeting are of minimal value to attendees, especially those who work in the trenches on the front-lines of transfusion, those in the lab and those on the wards. If you're a PhD or MD/PhD researcher and the topic coincides with your interests, the talks are no doubt fascinating.
Lesson #3 relates to a sad fact of life for many in the trenches. Years ago funding for CE/CPD was scaled back significantly. The result is fewer and fewer attend national meetings (unless local), let alone international ones. Today the cost of airfare and hotels is increasingly exorbitant.

Who can afford it? My guess includes
  • Physicians and researchers who get funding support or earn large salaries, along with those in senior positions. 
    • Bench technologists and front-line transfusion nurses not so much. 
  • Educators and those in health profession unions who get discretionary funds to use for CE/CPD but the funding wouldn't come close covering travel and hotel costs to attend meetings outside their locale. 
  • Some associations fund invited presenters, but not all.
  • An association's board of directors, whose members are volunteers and put in much dedicated time and a tiny perk is funding to attend meetings.
Many transfusion associations/organizations now offer local CE/CPD events across the country or provincially, including CSTM's Education Days. And thanks to the Internet, technology makes webcasts and podcasts possible.

LESSON #3: To what extent have annual meetings become a place for the 'elites' to meet and interact?  By elites, I mean those professionals fortunate to have funding or be wealthy enough to attend if the meeting is not in their locale and schmooze with other elites? It's a question to which I do not have an evidence-based answer, yet suspect it may be true.
Lesson #4 has been a pet peeve of mine for ages and relates to the quality of presentations at meetings by the biggies, the so-called 'thought leaders' of a profession. My experience is presentation quality is often awful, bordering on pathetic.

It's one reason I'm so glad that Medical Laboratory Science at the University of Alberta has a communications course that includes how to give presentations and gives students opportunities to practice the skills, including presenting their research projects.

Wish all MSc/PhD graduate and medical education programs included such a course. About physicians, my experience is, if a communication course or any professional development program, is not given by a physician, they devalue it. Apparently only physicians can teach physicians.😞

To me the biggest, common presentation failures include NOT doing the following, relevant to physicians, especially. BTW, the points are basic, equivalent to Presentation 101 courses.
  • Begin with a personal anecdote to grab audience attention immediately and get them to appreciate your authenticity, that you've 'been there, done that,' and dig their professional realities.
  • Explain up-front why the talk is relevant to the audience.
    • For gawd sake, don't keep it a secret.
  • Briefly outline what the talk is about, perhaps even say, if that's not what you expected, feel free to exit now. 
    • Shows you  respect the needs of audience.
  • Mention there will be time at the end for questions, if the person who introduced you did not.
  • Distribute handouts at the end and say that up front. 
    • Include your speaker notes in handouts so the audience has something substantive to take away.
    • In the early days of Powerpoint I don't know how many handouts I brought home from meetings, including making notes on each slide myself, that were all but useless and eventually tossed in a trash can.
    • Fact: If you distribute handouts at the start of a talk, the audience will concentrate on them, not what you are saying.
  • Use mostly graphics in the presentation vs bullet points. It's a way to get folks to listen to what you say.
    • If you use a few slides with bullets, do NOT use complete sentences and, regardless, NEVER read the points word for word unless you want to put the audience to sleep.
  • Forget about using any busy slides you have where the writing is minuscule and unreadable.
    • Just don't, no matter what.
    • Saves you the trouble of cynically apologizing for it being busy.
    • Because obviously you included the slide anyway, thus disrespecting your audience's intelligence. 
  • Throughout the talk refer to the experiences of colleagues and audience members you recognize, and sprinkle the presentation with their work.
    • It's not all about you, it's about those who helped you succeed.
    • Self-deprecating humour, if sincere, is appreciated by listeners.
  • Focus on key points only.
    • Though tempting, do not succumb to presenting all your data and conclusions.
    • Few viewers are as obsessed with the topic as you are.
    • The fewer key learning points, the more they will be remembered because of info overload.
  • At talk's end, briefly tell the audience what you told them and reinforce why it's significant and relevant to them. 
  • Thank the audience for their attention and thank conference organizers for inviting you.
  • With questions at the talk's end, even if you get snarky questions (yep, there are always all-about-me colleagues), try to be gracious, realizing that to most in the audience, the asker is showing themselves in a bad light and you are better than them.
    • Taking the high road always wins.
LESSON #4: Physicians and researchers, at least try to learn how to present well. I realize you could care less as you've gotten away with pathetic presentations forever and have zero motivation to change. But please try to be better because it has many rewards, adds to your reputation.
First a disclosure. Folks, for most of my career I was one of the fortunate 'elites' I referenced earlier, mainly by virtue of volunteer positions for professional associations, being an invited speaker at conferences where organizers funded travel and hotel costs, or as a perk of being an educator at a university. 

One thing I noticed in those days of yore versus today's national meetings is that now there seem to be fewer young attendees. Perhaps it's my imagination or just that all professions are aging and those in senior positions are older than before. Or maybe not.

While I hesitate to mention this, one reason could be that younger med lab technologists/scientists may not be as keen as we were in what I call the 'golden age of immunohematology.' Perhaps when considering annual fees, younger folks and many older ones too, wonder if it's worth it, questioning the benefits of membership. That is, they first ask 
  • What will the association and being a member do for me? vs
    • What can I do for my association?
    • How can I give back to my profession?
Or it could be that membership for some has become a financial burden. For example, in Canada registration with provincial regulatory colleges is compulsory for med lab techs,e.g. CMLTO annual fees. In contrast, membership in professional associations is voluntary and annual fees are a bargain in my opinion, e.g., CSTM $120 and CSMLS $167. But if you worked in Ontario and belonged to all three, the total would be $671.20. To me, that's just a tiny percentage of annual salaries and the benefits are many. 

Which brings me Julie Hendry's presentation. Julie is this year's recipient of the CSTM's  Buchanan Award, who included this slide at the end of her talk (click to enlarge - Julie's slide was tweeted by Geraldine Walsh and Clare O'Reilly on Twitter): 

Julie's challenge is a great one for CSTM members and members of all professions. We in the health professions are so lucky. 

I chose this Beatles song because its lyrics fit the blog's content.
As always, comment are most welcome (and there are some below).