Last week, I attended subspecialty talks as well as informative sessions on policies that will affect the future and practice of pathology at the 2013 ASCP Annual Meeting in Chicago. I also attended special events such as the Keynote given by Hillary Clinton, the Raible Lecture for Residents about the “Pathology of Bliss: Searching for the Happiest Place to Work,” the Training for Residents in Genomics (TRIG) workshop, multiple receptions, and the president’s black tie dinner. To top it off, I also presented during the poster session and saw old friends as well as made new ones.
But what I am struck by most about the myriad of experiences and conversations that I had last week is that as 21st Century physicians, we need to be forward thinking to contribute at a systems or global level. Sometimes, as Americans, we can be insulated and shortsighted, and as physicians we are not exempt. In the midst of talk of multiple technologies, often expensive and not available routinely at many institutions, focus on resident boards review sessions, and subspecialty relevant talks, it is easy to forget that we can transform the delivery of healthcare in this country and throughout the world not just by what we learn but also by what we do, especially in resource limited settings.
Currently, over 70% of diagnostic and treatment decisions are made based on the results of laboratory tests in this country. Much needed health reform will increase coverage for all but will also place an emphasis on outcomes based compensation. Therefore, we need to build interdisciplinary interactions between lab staff, pathologists, and other healthcare providers to work on common goals, and work together to perform the “right test, for the right person, at the right time”. We just have to work smarter, not harder. Our challenge as residents is to not bury our heads in our books or go through the motions, but to see the “bigger picture.”
In the developing world, equipment procurement can be a huge challenge. Funding is usually the initial major road block. In countries where many people live on $2.00 per day, Ministries of Health and local hospitals do not have large budgets to buy necessary laboratory equipment. In such situations, well-meaning donors from developed countries may be inspired to donate their gently used equipment to labs in developing countries.
While this donation is certainly well intentioned, it does not solve the problem. Equipment donations often do not come with assisted installation, a maintenance package or end-user training. While it may be possible to receive technical support from various international companies in some of the larger cities throughout Africa, outside of a major city technical support is difficult to obtain. Therefore, without a clear maintenance package as part of an equipment purchase or donation, the machine may languish uninstalled. The analyzer could also be used for a period of time before an inevitable breakdown renders it inoperative.
Equipment donations often do not come with assisted installation, a maintenance package or end-user training.
The issue of voltage differences between the U.S. and many African countries creates another challenge when it comes to equipment procurement. Equipment that is manufactured for use in the U.S. will not have the correct voltage for use in many African countries. This is certainly a problem when it comes to donations from U.S. labs. When acquiring new items it is crucial that those involved in the procurement process know the voltage needs at the laboratory site.
Once the equipment challenges have been met, the next hurdle is reagent procurement. With both donor-provided machines and those purchased by the local government, MOH, or hospital, funding must remain available for reagents in order for the lab to continue using the machine. I have seen labs with beautiful, well-maintained machines sitting unused because there was no money to purchase new reagents. Without long-term funding for reagents and other supplies, the analyzer itself is ineffectual. No matter if it is the local government, hospital or lab staff, or a donor involved in the procurement of equipment, it is vital that equipment maintenance and reagent supplies be accounted for at all times. A brand new machine can do no good if there is not money to ensure that it keeps working.
Overcoming these challenges is certainly possible, but all players involved in equipment procurement must be conscious of every aspect of the process.
While I was out of the office last week, Maryn McKenna wrote up a few informative blog posts about the CDC’s threat report.
The first summarizes the lengthy report (114 pages) by highlighting the top three “urgent” threats–CRE, N. gonorrhoeae, and C. difficle. She also mentions that CDC’s director Dr. Tom Frieden states “If we are not careful, we will soon be in a post-antibiotic era. And for some patients and for some microbes, we are already there.”
Another post discusses the connection between agricultural antibiotic use and bacterial resistance in humans.
As an aside, if you’re as much of an emerging disease junkie as I am, check out McKenna’s blog on a regular basis. She’s also written a book on MRSA that should be required reading for all clinical microbiologists. It’s one part history, one part science lesson, and one part cautionary tale about this bacterium.
I recently attended the ASCP Annual Meeting in Chicago and was once again energized professionally. As an ASCP Global Outreach Volunteer it was exciting for me to find so much focus on the international work being done. It was a common thread in all the general sessions, including keynote speaker Hillary Clinton, who highlighted the work of the Clinton Foundation and its partnerships in global health. There were presentations on “Pathologists Without Borders,” “Laboratorians Without Borders,” even “Diseases Without Borders.” Well, the diseases were always without borders—but now they have unprecedented transport advantages! The meeting also hosted guests from far-away places such as Lesoto and Viet Nam, who have been working hand in hand with ASCP consultants to build their educational programs and strengthen their lab workforce for a sustainable future.
During the conference my thoughts collided with themselvesas I remember trips to African and East Asian nations, and the experiences of working with colleagues around the globe—truly a bit of “Thoughts Without Borders” for me. The relationships we build are the backbone and platform for global health improvements around the world, and so much can be accomplished with on-site work. Our technology to both perform laboratory analyses and to communicate and store data is so advanced it’s mind-boggling. Yet even with our achievements in this age of “digital everything,” there is still no substitute for a handshake, eye contact, working together face to face, enjoying cultures and language lessons over coffee, and breaking bread while sharing recipes and family stories. THAT is what makes volunteering as a consultant in international health so engaging. I, for one, hope that global health and international outreach will always include professional exchange opportunities for working together in both host countries and in ours!
Next time I’ll get back on track with some travel adventures, as promised. In the meantime, if you happen to be wandering through Chicago, go by the ASCP office and say “Howdy” to the Global Outreach Team whose work and dedication make it possible for me to do what I love and give back to this crazy profession we have chosen. And be sure to get yourself some Chicago style pizza and enjoy a bit of blues while you’re there—two things that are definitely part of our American Culture! If you need a recommendation, send me a note at email@example.com.
If you didn’t make it to ASCP’s Annual Meeting this year in Chicago, here are just a few opportunities you missed:
-Over two hundred hours of continuing education
-An inspirational keynote address by former Secretary of State Hillary Clinton
-A chance to talk with exhibitors
-Networking with fellow laboratory professionals.
Perhaps the biggest benefit can’t be quantified or advertised. Attendance at the Annual Meeting brings with it a renewed sense of purpose. After chatting with fellow professionals, attending seminars, and learning new aspects of Laboratory Medicine, I remember why I entered this profession in the first place. When every day is filled with the uncertain realities of today’s healthcare, it’s easy to focus on the negatives. However, at the Annual Meeting, every seminar, analyzer demonstration, and luncheon is a reminder that the driving force of the profession is excellent patient care through the study and diagnosis of disease. It reaffirms the notion that each of us makes a positive difference in a patient’s life. That alone is worth the price of admission.
During PGY-1, my effort was mostly focused on navigating and finding where I fit into the system that is known as residency. Having not been the most clinically oriented medical student and unfamiliar with gathering patient info from electronic medical records (we had paper charts during medical school), I initially found the task of working up a patient difficult. I was often so focused on not missing an important detail that I missed the forest and only saw the trees. But in clinical medicine, it’s most important to discern what the most relevant facts are and integrate them quickly to uncover the big picture.
Being a resident is not like being a student and we eventually have to outgrow these growing pains or get left behind. It’s no longer a situation where the consequence of not doing well only impacts oneself. The stakes are higher because patient safety is involved. I know friends who were let go from their programs, not because they were not hard working, but because they could not adapt, multi-task, and keep up the required pace.
As pathology residents, we do not often see patients and it is easy to become disconnected from them.
What really refined my outlook was when I began to interact more with the lab technicians during my hematopathology rotation. They identified patients with concerning peripheral blood smears and often asked follow-up questions to find out what happened to that particular patient. Even though they could not access medical records, they still wanted to know how that particular patient fared, even though they scanned many other patients’ smears that day. I find the same with the technicians on my current molecular pathology rotation and I look forward to these interactions each day.
As pathology residents, we do not often see patients and it is easy to become disconnected from them. The many hours grossing, putting together tumor boards and morbidity and mortality presentations, and following up on critical values and inappropriately ordered tests can leave us jaded. I find that I follow up on patients more now even after the case is signed out. I credit working more closely with our technicians for my rejuvenated interest in patients as more than a case number. So, my advice to residents out there is to interact with and learn as much as you can from your technical staff because they really do have much to offer if asked.
I’ll be at the ASCP Annual Meeting this week to present a poster and receive a resident leadership award, so next blog post, I’ll let you know how it turned out!
Today I attended a great session on transfusion case studies by Carolyn D. Burns, MD, FASCP, and Phillip J. DeChristopher, MD, PhD, FASCP. The speakers were dynamic, personable, and made learning fun. They presented cases on hematology/oncology, transplant recipients, and HLA antibodies, among others. I won’t go over each case—honestly, there was so much great information I’m afraid I won’t do it justice—but I’d like to share tidbits I found interesting.
-A fact that I had forgotten from my blood banking class oh-so-long-ago: the platelets your body makes live for eight to ten days, an autologous platelet transfusion last four days, and a non-autologous transfusion would last three. If a patient has an immune response to a platelet reaction, those platelet might only live a day.
-Fellows and residents in transfusion medicine don’t actually know how to transfuse a unit of blood product. They aren’t aware of what happens in a blood bank or a transfusion center. Laboratory professionals need to be cognizant of this and be open with information. Use teaching moments when they present themselves.
-Eliminate unnecessary transfusions through dialogue with doctor and pathology. Hence the title of this post: “why do two when one will do?” It’s a mantra for the blood banker to live by.
-Don’t be afraid to question orders. Medical technologists might be the first line of defense, so to speak, and are essential when bringing questionable orders to the attention of pathologists. Don’t be afraid to speak up when your instincts are telling you something is off. Hone your critical thinking skills.
-Blood transfusion is like marriage. It should not be entered upon lightly, wantonly or more often than is absolutely necessary.
-This couldn’t be stressed enough: keep the lines of communication open. Ask the doctor and/or nurse questions about the patient; have a open relationship with your medical director; don’t be afraid to ask questions.