FISH! Philosophy

In Seattle, Pike Place Fish Market is nearly synonymous with the Pike Place Market. Tourists and locals stand and watch the fish mongers fill orders by throwing fish around the stand.  Everyone, including the employees, laughs and enjoys the atmosphere. This is where the FISH! Philosophy was born. FISH! is a leadership training method that focuses on four concepts to increase collaboration and excitement about work:

  • Choose your attitude
  • Be present
  • Play
  • Make someone else’s day

These concepts are not mind-blowing, and this is exactly why they’re effective. They are easy to remember and easily integrated into daily practice, whether you are a teacher,a an office worker,  or a laboratory professional. Becoming an effective and productive employee starts with choosing your own attitude. For example, when you choose the attitude of empowerment, support, and kindness, you start enacting them. In other words, you become kinder and you support and empower others more easily. As an experiment, I recently said to myself “I am energized and excited” when I was feeling the complete opposite. I started it as more of a joke, to be honest, but the interesting thing is that within twenty minutes, I actually became energized and excited. The power of our attitude is immense and we can all use it to our own and others’ benefit.

To be present is not an easy task. We are often pulled in many different directions, whether professionally or personally. Sometimes we can only think about work when we are at home, or we want to be at home when we are at work. The power of being present comes from acceptance; accepting that we are at work frees us from the resistance that is sapping our energy if we are mentally at home. We have all had conversations where someone wasn’t quite present and we can all remember how frustrating that was. On the other hand, having a conversation with someone who is present makes us feel important, appreciated, and empowered.

Work can be a serious place, especially when lives are at stake. However, there are always moments of play possible, even if it is during breaks or at lunch. If we focus on making someone else’s day, not only do we create a happier work force, we become happier ourselves. We all know how good it feels to make someone laugh, to make someone feel cared for. Perhaps it is something small, like asking if you can bring someone a coffee when you are running out to get one. Or perhaps you leave them a nice note or do a small task for them to make their day easier. I have a notepad with “Awesome Citations.” It is a simple note that I fill out and I hand to someone each week. Making someone’s day does not have to be big or extravagant. It is often the small gestures that people remember.

So go out and be present, while choosing your attitude. Play a little at work to make someone’s day. The simple acts we take every day can transform an entire department and organization. So why not throw some fish and have some fun?



-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.


My story begins many decades ago when I was working in the laboratory at Bronson Methodist Hospital in Kalamazoo, Michigan. While my favorite departments were Blood Bank and Hematology, I had the honor of working with Joie Vine and Dr. Hubbard, the supervisor and chief pathologist, respectively, of the microbiology department. Microbiology was my least favorite department, but luckily for me, Dr. Hubbard discovered early on that I loved to learn. Dr. Hubbard was small in stature, yet large in leadership skills.  He knew when to be serious and when to be light-hearted.  That attitude permeated the lab. Dr. Hubbard made it possible for me to go to the AABB conferences and U-Hospital (University of Michigan) for specialized training. As a lab professional, I was living the dream!

It was spring when Joie told me she was going on vacation and was short-staffed.  She asked me to fill in for her during the lunch hour for one week, which would allow her staff to go to lunch.  I said yes.  Everyday Dr. Hubbard would check in with me on his way to and from lunch.  By Thursday, I was really missing Blood Band so I decided to have some fun.  When Dr. Hubbard stopped by microbiology,  I opened a  feces container.  I look at him and said, “hmmm, looks like feces,” held it to my nose, “smells like feces,” and with my finger, I scooped a little and placed it in my mouth. I proclaimed, “it tastes like feces!” He was in total shock.  After a brief moment I burst into laughter and so did he!  I had placed peanut butter in the feces container!

So if you’re thinking you can’t apply the Fish Philosophy to the clinical laboratory environment, remember, we “Choose our Attitude every day.” It feels good to “Be There” when a friend needs us.  I’ll always remember when Dr. Hubbard said that “I Made His Day!” because we took a break from our serious work and played!

Catch the Energy — Lab Professionals are Fun People!



-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.  

Tissue is the Issue: Splitting Specimens, Part 1

When we think about infectious disease (ID) and specific syndromes (culture-negative endocarditis, for example), it can be difficult to know the etiology.1 This is because different microorganisms can cause similar symptoms and depending on the specimen submitted to the laboratory for testing, you may need to split your specimen. It may be that the infection is localized to a small area (valve vegetation) and all you get for processing is a small volume of tissue. Another scenario is that you get a sufficient amount of specimen, but you must split the specimen for culture, multiple send out studies, pathology, etc. Or even worse–a small volume specimen that you need to split for multiple diagnostic tests.

We recently had a case of endocarditis. The patient’s blood cultures were negative, and she was going to have her mitral valve replaced. The ID team requested that we send the tissue for broad-range bacterial and fungal sequencing. We can do that- not a problem.

The Issue

As requested, the specimen (mitral valve vegetation) was split once it was received in the laboratory. Half went into the freezer for sequencing requests which we send to a reference laboratory and the other half was processed for bacterial (including mycobacteria) and fungal cultures.

In our experience, if no organisms are observed, then no DNA is detected. Therefore, it is not beneficial to send tissue for sequencing if we do not observe an organism (or something that looks suspicious for an organism) to begin with. In parts 2 and 3 of this series we will go into greater detail of the workflow for examining tissue for infection, but for now we will focus on the processing piece.

No organisms were observed in the direct smears (Gram, fungal, and acid-fast) and all cultures were negative. Because no organisms were observed, we did not send the tissue for sequencing. However, the patient was not improving and ID insisted that we send the tissue for sequencing anyway. As a last ditch effort we decided to homogenize the frozen tissue to see if by chance organism was present.

Long story short: the Gram stain did not reveal organism, but acridine orange2 did. We cultured the tissue and recovered an organism. Moral of the story: specimen processing can be tricky. It is an inherent issue that we must be aware of. How were we to know in which part of the tissue the organisms were? By definition, this is sampling error at its finest.

The Solution

Moving forward, rather than split the specimen prior to processing we have changed our protocol to homogenize the tissue first, then split the specimen. We believe this will eliminate similar scenarios from happening again in the future.

The Conclusion

All specimens are different in their composition. Unlike body fluids, which are easy to vortex and make homogeneous; tissue is more complex. Whatever the specimen, make sure your protocol(s) reduces sampling error.


  1. Subedi SJennings ZChen SC. 2017. Laboratory Approach to the Diagnosis of Culture-Negative Infective Endocarditis. Heart Lung Circ. 26(8):763-771.
  2. Lauer BAReller LBMirrett S. 1981. Comparison of acridine orange and Gram stains for detection of microorganisms in cerebrospinal fluid and other clinical specimens. J Clin Microbiol.14(2):201-5.


Martinez Headshot-small 2017

-Raquel Martinez, PhD, D(ABMM), was named an ASCP 40 Under Forty TOP FIVE honoree for 2017. She is one of two System Directors of Clinical and Molecular Microbiology at Geisinger Health System in Danville, Pennsylvania. Her research interests focus on infectious disease diagnostics, specifically rapid molecular technologies for the detection of bloodstream and respiratory virus infections, and antimicrobial resistance, with the overall goal to improve patient outcomes.

Chemistry Case Study: Conjugated Bilirubin in Neonatal Jaundice

Case History

Patient was a 1-week-old infant in the level 2 NICU born at 37 weeks. This infant was initially born with indirect hyperbilirubinemia but now also has increasingly elevated level of direct bilirubin (see measurements in table below). Neonatologist requested conjugated and unconjugated bilirubin test due to increasing elevated level of direct bilirubin. Conjugated bilirubin test is not routinely performed in our hospital laboratory and needs to be send out.

Question: What’s the difference between conjugated bilirubin and direct bilirubin? When does conjugated bilirubin need to be assessed?

Ref Range 3/6/18 3/7/18 3/9/18 3/10/18 3/12/18
Bilirubin total, neonatal 1.0-10.5 mg/dL 9.2 8.7 10.8 10.2 8.6
Bilirubin direct, neonatal 0.0 – 0.6 mg/dL 0.5 0.7 1.8 1.8 2.1


Neonatal jaundice is commonly seen in newborns in the first few days of life, mainly due to increased bilirubin formation from break down of red blood cells and limited conjugation of bilirubin. Total bilirubin normally peaks at day 2-3 and should decline by day 4-5. Sample is collected via heelstick in green top tube and protected from light. Measurement of total bilirubin is interpreted based on the Bhutani Nomogram to assess risk of hyperbilirubinemia. Most often, unconjugated bilirubin is elevated in neonatal jaundice owing to hemolytic causes. In cases with prolonged jaundice, conjugated bilirubin needs to be determined to rule out cholestasis.

Conjugated bilirubin refers to bilirubin conjugated with one or two glucuronic acid, and this term “conjugated bilirubin” is often used interchangeably with direct bilirubin. Direct bilirubin refers to bilirubin fractions that can directly react with diazo reagent without the addition of accelerator, such as methanol or ethanol. This fraction usually includes conjugated bilirubin and delta bilirubin. Delta bilirubin is formed by covalent bonding between conjugated bilirubin and albumin, and has a similar half-life as albumin, 21 days. Therefore, direct bilirubin measurement overestimate conjugated bilirubin and in cases with persist or atypical jaundice, clear differentiation between conjugated and direct bilirubin is important. Clinician should know what the laboratory is measuring when interpreting the bilirubin fraction results.

In laboratories, conjugated bilirubin can be assessed by the VITROS BuBc dry slide, which simultaneously measures unconjugated (Bu) and conjugated (Bc) bilirubin by use of a mordant. In the presence of the mordant, the visible spectra of conjugated and unconjugated bilirubin are different, allowing measurement of both species from a single slide. Fractions of bilirubin can also be separated by HPLC, but this is not practical to use in a routine clinical laboratory. In this case, conjugated bilirubin was measured by VITROS BuBc slide test, and result came back elevated at 1.0 mg/dL (ref range: < 0.3 mg/dL).



-Megan Ketcham, MD is a 4th year anatomic and clinical pathology resident at Houston Methodist Hospital. She will be completing both hematopathology and dermatopathology fellowships. Her interests include pathology resident and medical student education and skin lymphomas.


-Xin Yi, PhD, DABCC, FACB, is a board-certified clinical chemist, currently serving as the Co-director of Clinical Chemistry at Houston Methodist Hospital in Houston, TX and an Assistant Professor of Clinical Pathology and Laboratory Medicine at Weill Cornell Medical College.

Blood Bank Case Study: Transfusion Transmitted Malaria

Case Study

A 26 year old African American female with sickle cell anemia presented to a New York emergency room with cough, chest pain, fever and shortness of breath. Laboratory results showed an increased white blood cell count, slightly decreased platelet count and a hemoglobin of 6.2 g/dl. Her reticulocyte count was 7%, considerably below her baseline of 13%. Consulting the patient’s medical records revealed history of stroke as a child and subsequent treatment with chronic blood transfusions. She was admitted to the hospital for acute chest syndrome and aplastic crisis and care was transferred to her hematologist. Two units of RBCs were ordered for transfusion.

The blood bank technologists checked the patient’s blood bank history and noted her blood type was A, Rh(D) positive, with a history of a warm autoantibody and anti-E. The current blood bank sample confirmed the patient was blood type A, RH(D) positive with a negative DAT but the antibody screen was positive. Anti-E was identified. Per request of the hematologist, phenotypically similar units were found and the patient was transfused with 2 units of A RH(negative), C/E/K negative, HgS negative, irradiated blood. The patient’s hemoglobin rose to 8g/dl and she was discharged from the hospital 3 days after transfusion.

Ten days after discharge the patient returned to the emergency room with symptoms including aching muscles, fever and chills. A delayed transfusion reaction was suspected. A type and screen was immediately sent to the blood bank. The post transfusion type and screen remained positive for anti-E, DAT was negative. No additional antibodies were identified. However, a CBC sent to the lab at the same time revealed malarial parasites on the peripheral smear. The patient was consulted for a more complete medical history and reported that she had never traveled outside of the country. A pathology review was ordered and the patient was started on treatment for Plasmodium falciparum.



Red Blood cell transfusions can be life saving for patients with sickle cells anemia. These patients are frequently transfused by either simple transfusion of red cell units or by exchange transfusion. Because of this, alloimmunization is reported to occur in 20% to 40% of sickle cell patients.1 Blood bank technologists are very diligent in adhering to strict procedures and follow a standard of practice aimed to prevent transfusion reactions. While preventing immune transfusion reactions may be the most forefront in our minds when transfusing the alloimmunized patient, it is important to consider transfusion transmitted diseases as a potential complication of blood transfusions.

Malaria is caused by a red blood cell parasite of any of the Plasmodium species. Mosquito transmitted infection is transmitted to humans through the bite of an infected mosquito. Transfusion-transmitted malaria is an accidental Plasmodium infection caused by a blood transfusion from a malaria infected donor to a recipient.

Donors, especially those from malarial endemic countries who may have partial immunity, may have very low subclinical levels of Plasmodium in their blood for years. Even these very low levels of parasites are sufficient to transmit malaria to a recipient of a blood donation. Though very rare, transfusion-transmitted malaria remains a serious concern for transfusion recipients. These transfusion-transmitted malaria cases can cause high percent parisitemia because the transfused blood releases malarial parasites directly into the recipient’s blood stream.

Blood is considered a medication in the United States, and, as such, is closely regulated by the FDA. Blood banks test a sample of blood from each donation to identify any potential infectious agents. Blood donations in the US are carefully screened for 8 infectious diseases, but malaria remains one infectious disease for which there is no FDA-approved screening test available. For this reason, screening is accomplished solely by donor questioning.2 A donor is deferred from donating if they have had possible exposure to malaria or have had a malarial infection. Deferral is 12 months after travel to an endemic region, and 3 years after living in an endemic region. In addition, a donor is deferred from donating for 3 years after recovering from malaria. It is important, therefore, for careful screening to take place by questionnaire and in person, to make sure that the potential donor understands and responds appropriately to questions concerning travel and past infection.

Malaria was eliminated from the United States in the early 1950’s. Currently, about 1700 cases of malaria are reported in the US each year, almost all of them in recent travelers to endemic areas. From 1963-2015, there have been 97 cases of accidental transfusion-transmitted malaria reported in the United States. The estimated incidence of transfusion-transmitted malaria is less than 1 case in 1 million units.4 Approximately two thirds of these cases could have been prevented if the implicated donors had been deferred according to the above established guidelines.3 While the risk of catching a virus or any other blood-borne infection from a blood transfusion is very low, a blood supply with zero risk of transmitting infectious disease may be unattainable. With that being said, the blood supply in the United Sates today is the safest it has ever been and continues to become safer as screening tests are added and improved. Careful screening of donors according to the recommended exclusion guidelines remains the best way to prevent transfusion-transmitted malaria.


  1. LabQ, Clinical laboratory 2014 No.8, Transfusion Medicine. Jeanne E. Hendrickson, MD, Christopher Tormey, MD, Department of Laboratory Medicine, Yale University School of Medicine
  2. Technical Manual, editor Mark K. Fung-18th edition, AABB. 2014. P 201-202
  3. Accessed April 2018
  4. The New England Journal of Medicine. Transfusion-Transmitted Malaria in the United States from 1963 through 1999. Mary Mungai, MD, Gary Tegtmeier, Ph.D., Mary Chamberland, M.D., M.P.H., June 28, 2001. Accessed April 2018
  5. Malaria Journal. A systematic review of transfusion-transmitted malaria in non-endemic areas. 2018; 17: 36. Published online 2018 Jan 16. doi: 1186/s12936-018-2181-0. Accessed April 2018



-Becky Socha, MS, MLS(ASCP)CM BB CM graduated from Merrimack College in N. Andover, Massachusetts with a BS in Medical Technology and completed her MS in Clinical Laboratory Sciences at the University of Massachusetts, Lowell. She has worked as a Medical Technologist for over 30 years. She’s worked in all areas of the clinical laboratory, but has a special interest in Hematology and Blood Banking. When she’s not busy being a mad scientist, she can be found outside riding her bicycle.

To Be (MDS) or Not To Be? The Conundrum of Cytoplasmic Vacuolation in Hematopoietic Precursors

Every hematopathologist and pathology trainee knows to be wary of the myriad of causes that could mimic the dysplastic changes seen in marrows involved by MDS. Many times morphology alone, without genetic or cytogenetic evidence of clonality can be tricky. The list of things that can recapitulate changes seen in MDS seems to grow longer every day – and with it the length of our ‘canned comments’ on ruling out reactive causes of dysplasia. Within the recent past, two bone marrow biopsies crossed my microscope, both sent to ‘rule out’ MDS. Both had almost identical morphologic findings, but very different diagnoses. Here are some representative images from the marrow aspirates and iron stains:

Figure 1. Representative Wright-Giemsa stained cells from Case 1 (A and B) with accompanying iron stain (C) showing numerous ring sideroblasts.  Representative Wright-Giemsa stained cells from Case 2 (D) with accompanying iron stain (E) showing some ring sideroblasts. 


Images A through C come from case 1, a 67-year-old woman with a past medical history of non-alcoholic steatohepatitis (NASH) complicated by hepatic encephalopathy and recurrent ascites who underwent bone marrow biopsy for new onset pancytopenia with transfusion-dependent anemia. The marrow was slightly hypercellular for age and showed progressive trilineage maturation. Granulocytic and erythroid progenitors did not reveal quantitatively significant dysplasia. The one dysplastic megakaryocyte identified is pictured here (panel A). Interestingly many erythroid and granulocytic precursors showed cytoplasmic vacuolation (panel B showing granulocytic vacuolation). An iron stain (panel C) revealed 44% ring sideroblasts. Case 2 is represented in images D and E and was from a 64-year-old man with no significant past medical history who presented with lethargy and anemia. This marrow was also slightly hypercellular for his age and showed borderline-significant dysplasia in megakaryocytic maturation. Granulopoiesis and erythropoiesis were unremarkable except for cytoplasmic vacuolations in many cells (panel D). An iron stain showed 8% ring sideroblasts (panel E).

Both cases were signed out descriptively, urging the clinician that we needed to rule out reactive causes of dysplasia before a definitive diagnosis of MDS could be rendered. In both cases we suggested waiting for the cytogenetics results for a more comprehensive analysis. Additionally, we recommended testing for serum copper since copper deficiency can be the cause of dysplastic morphology, cytoplasmic vacuolation, and ring sideroblasts.

Case 1 revealed markedly diminished copper and normal cytogenetics. Copper replenishment was curative. Case 2 revealed normal copper levels and a complex karyotype that contained numerous MDS-associated abnormalities confirming the clonal, and therefore malignant nature of these changes. Despite being almost identical morphologically, these case were diagnostically and prognostically poles apart.

Copper is an element that serves as a micronutrient required for hematopoiesis. It’s presence in many readily available foods including meat, fish, nuts, and seeds renders diet-related copper deficiency a rare phenomenon. Zinc-supplementation is one of the causes of copper deficiency in published reports. Copper deficiency has been well documented to mimic dysplastic changes seen in MDS; but these morphologic findings and cytopenia are reversible. Characteristically, cytoplasmic vacuolation is an important morphologic clue that there could be an underlying paucity of serum copper.  Another aspect of copper deficiency is the presence of ring sideroblasts which also can mean MDS. It is very important to consider this differential diagnosis when dealing with marrow specimens sent to rule out MDS. This Lablogatory post highlights the significant overlap between presentation and morphologic findings between MDS and copper deficiency supporting the notion that a high index of suspicion, good communication, stat copper levels, and cytogenetics or MDS FISH studies are very helpful in delineating benign from malignant.


  1. Dalal N. et al. Copper deficiency mimicking myelodysplastic syndrome. Clin Case Rep. 2015 May; 3(5): 325–327.
  2. Willis M.S. Zinc-Induced Copper Deficiency: A Report of Three Cases Initially Recognized on Bone Marrow Examination. AJCP. 2005 Jan; 123(1): 125–131
  3. D’Angelo G. Copper deficiency mimicking myelodysplastic syndrome. Blood Res. 2016 Dec; 51(4): 217–219.
  4. Karris S and Doshi V. Hematological Abnormalities in Copper Deficiency. Blood 2007 110:2677



-Kamran M. Mirza, MD PhD is an Assistant Professor of Pathology and Medical Director of Molecular Pathology at Loyola University Medical Center. He was a top 5 honoree in ASCP’s Forty Under 40 2017. Follow Dr. Mirza on twitter @kmirza.

Microbiology Case Study: A 79 Year Old Male with Rheumatic Heart Disease

Case History

The patient is a 79 y/o male with past medical history of rheumatic heart disease, permanent atrial fibrillation, mechanical aortic and mitral valves (2004), status post single chamber pace maker for bradycardia (2010), and prostate adenocarcinoma treated in 2000. He had new MRI compatible pace maker placed on Oct 19, 2017. During follow-up he was noted to have a hematoma over the incision site. He had a revision done on Nov 3, 2017. At that time, the blood from the incision site was sent for culture. 

Laboratory Identification

Gram stain showed moderate amount of polys with no bacteria seen. The isolate was a gram-negative rod that was identified on the MALDI-ToF as Burkholderia multivorans.


Image 1: Semi-mucoid, yellow-grey colonies on Chocolate agar and on Blood agar plates.


The Burkholderia genus appears as gram-negative medium-sized straight rods, with the exception being B. mallei which is a coccobacillus. The will grow on blood, chocolate, and MacConkey agar. Oxidative-fermentative-base-polymyxin B-bacitracin-lactose (OFPBL) agar can be used to isolate B. cepacia and Ashdown medium can be used to isolate B. pseudomallei. They are non-lactose fermenters on MacConkey, but B. cepacia can turn into a dark pink to red due to oxidation of lactose after 4-7 days.

B. multivorans is a species within the Burkholderia genus, which are normal to plant, soil, and water, but not normally considered common human flora. Formerly of the Pseudomonas genus, B. cepacia, B. mallei, and B. pseudomallei are the most commonly seen as infections in humans. Further, B. cepacia and B. mallei are not typically human pathogens in a healthy human host. Because of the rarity of this genus to infect humans, their pathogenicity is not well known; but, importantly, they are intrinsically resistant to many antibiotics and can thus be associated with hospital acquired infections.

Of this genus, very little literature is present on B. multivorans specifically, and of the literature that does exist, most of it is in relation to cystic fibrosis patients. Taxonomic advances has shown that B. cepacia complex is a cluster of nine closesly related genomic species or genomorvars (1).  B. multivorans represents genomorvar II. Hospital acquired clinical infections from this complex (but perhaps not specifically from this particular genomorvar) has been seen following catheterization, cystoscopy, heart surgery, and with contaminated ventriculoatrial shunt (2). B. multivorans biochemically is oxidase positive, catalase positive, lipase positive, nitrate-reducing, urease positive, resistant to colistin, and can grow at 42C (3, 4).

A recent comparative genomic study showed that B. multivorans is a highly evolutionarily preserved genome with genomic characteristics from the environment and isolated from cystic fibrosis patients to be similar, and that isolates from different continents are also similar (5). Further, a murine model for pulmonary infections showed that B. multivorans could persist in the host by establishing an intracellular presence within macrophages, which could explain the persistence of this pathogen in cystic fibrosis patients (6). Importantly though, due to the conserved and common genomic structure, there rests a possibility for potential vaccination for cystic fibrosis patients against B. multivorans.

The patient was prescribed a single dose of oral Bactrim and then advised to come into the hospital for admission for IV antibiotics. IV ceftazidime was started with pending blood cultures, which are negative at the time of this documentation.


  1. Coenye T. et al. Taxonomy and identification of the Burkholderia cepacia complex. J Clin Microbiol 2001;39:3427-3436.
  2. Pallent LJ. et al. Pseudomonas cepacia as contaminant and infective age. J Hosp Infect 1983;4:9-13.
  3. Henry DA. et al. Phenotypic methods for determining genomovar status of Burkholderia cepacia complex. J Clin Microbiol 2001;39:1073-1078.
  4. Vandamme P. et al. Occurrence of multiple genomovars of Burkholderia cepacia in patients with cystic fibrosis and proposal of Burkholderia multivorans sp. nov. Int J Syst Bacteriol 1997;47:1188-1200.
  5. Peeters C. et al. Comparative genomics of Burkholderia multivorans, a ubiquitous pathogen with a highly conserved genomic structure. PLoS One. 2017, 21; 12 (4): e0176191.
  6. Chu KK. et al. Persistence of Burkholderia multivorans with the Pulmonary Macrophage in the Murine Lung. Infect Immun 2004; 72 (10): 6142-6147.


-Jeff Covington, MD, PhD, is a 1st year anatomic and clinical pathology resident at the University of Vermont Medical Center.


-Christi Wojewoda, MD, is the Director of Clinical Microbiology at the University of Vermont Medical Center and an Associate Professor at the University of Vermont.

Faculty Insights: Teaching Medical Laboratory Science in a Blended Learning Format

Thus far, we’ve talked about the structure of our blended model of curriculum delivery and the learner experience, but what about the instructor experience teaching in this format?

I surveyed a few of our faculty members about their experience teaching in our Medical Laboratory Science (MLS) Program, and their comments about our blended model of curriculum delivery fell into a few themes:

Benefits of the “flipped classroom” model

“Having students complete the lecture content as homework and then meeting with them for the hands-on ‘face-to-face’ learning adds another layer and more reinforcement of key concepts. If learners can’t understand what they’ve read or interacted with in the online component, they’ve got another chance to hear a short review of the material and actually perform a hands-on, real-world lab activity to reinforce again what they have learned. This is what makes blended learning so effective—read, learn, see, do—it hits the learning from every angle.”

“I believe the blended learning style with the online component is very effective, and I would bet that students retain more information and retain the information longer than in traditional formats. It’s all about reinforcement.”

Role of the instructor from “Sage on Stage” to a facilitator of the student’s knowledge acquisition and enhanced student learning

“As an instructor, I am no longer required to be the “Sage on the Stage,” and the questions from our students tend to be more specific, in that they come into the classroom prepared, having some base knowledge of the content.”

“I love teaching with a blended format. Having the online component allows the student to review the learning content prior to coming to lab where we meet face to face. The online blackboard format allows for several different ways to attack the learning, which is nice for the variety of students that we have (age, gender, and background), as well as a variety of learning styles.”

“Teaching with the online component allows for embedded written lessons, recorded lectures, PowerPoint handouts, images, YouTube videos, interactive activities such as a discussion board and wikis, and online worksheets—all at which the student can work through as fast or as slow as needed. Online learning allows for multiple levels of reinforcement to help make the information stick. It also helps learners be in control of their own learning. Access to information is not just a one-time shot in a live lecture. It’s there to use and review as much as needed.”

More time for instructor-led hands-on activities

“Time is another factor. We are only given so much time with the MLS students, and if we had to present all the lecture material in the classroom, we would not have time for all the laboratory activities that we have developed.”

“I like the fact that it puts the onus on the learner to engage with the material ahead of time, which allows for more hands-on learning in the classroom. The blended format makes it extremely conducive for a laboratory-based class.”

“When teaching morphology of cells, I like to use online question ‘banks’ with images of cells, crystals, casts, etc., for the students’ practice. They can review these question banks as much or as little as needed outside of the classroom. They can practice morphology identification at home, outside of class—all without the need of a microscope. Not only do they come into the classroom/lab knowing their cells, but they can work more efficiently and progress more quickly to advanced case studies.”

“I think the flipped model we implement is a great way to enhance our students’ reading skills and comprehension, while holding them accountable for completing the required assignments.”

“The blended approach allows us to address more difficult concepts. While the students may be able to grasp the concepts from their online reading, they also need talking points to confirm that they actually understand and can apply the concepts. We have found that giving the students the task of learning the online concepts can only really be successful if we follow up with them the next day, starting with a discussion about their online homework. We also give quizzes and have designed laboratory activities that apply the online concepts.”

Varied thoughts about course maintenance

“While the time to develop online content can be extensive, once it’s built in this format, it is easier to update and maintain on an annual basis.”

“It is not so easy to maintain the details in the online course. It takes a lot of time and effort to update all of the dates for assignments and other activities for each class section. Once the core components are built, one can easily add to the content. However, if one is building a new module or lesson, it can take a lot of time. It seems that the time to maintain an online course is similar to the time it takes to keep materials up-to-date in a traditional course.”

“At first, it took some getting used to grading assignments online, but I am used to it now and actually prefer it. It’s so easy for a student to do a “copy/paste” when filling out an online worksheet, so I do question typing (copy/paste) vs. writing things out on a worksheet and how well the information is sticking. With the intensity of our program, time is of the essence. I like that as soon as students submit their online assignments, I can grade it. Some students like to work ahead, and some turn things in at the last second. With the online submissions, I can grade as they come in, instead of getting hit with 24 assignments at once, which is a big time-saver for me.”


“One of the greatest positives with [the software] Blackboard Learn is that we can use the system with multiple learners. The learner has easy access to the course once he/she is added to system. One cannot always say that with traditional classroom teaching/learning. Unless the content/didactic is recorded, there is not easy access to the materials.”

In summary, I would stress the following key points as benefits of adopting a blended approach to curriculum delivery:

  • Increased classroom time for hands-on activities that are more closely aligned with what the students will actually be doing once they graduate, get jobs, and go to work.
  • Increased instructor satisfaction.
  • Students are more prepared for the classroom activities.
  • Increased ability to engage students with higher-learning concepts.
  • Course maintenance is more efficient, and learning tools are enhanced.
  • Time and cost savings are realized, related to repurposing of curriculum across different learners.



-Susan M. Lehman, MA, MT(ASCP)SM graduated from the University of Wisconsin-Madison in 1983 with a BS in medical technology. She is program director for the Medical Laboratory Science Program and course director for Clinical Microbiology I and II; her areas of interest include distance education and education methodology.