Clinical Fellow, Division of Hematology, Department of Medicine University of Toronto
Instructor, Texas Children’s Cancer Center, Baylor College of Medicine
Transfusion medicine (TM) is an important part of the broad field of hematology, and members of the TM research and practice communities participate actively in ASH programs and leadership. In response to the general lack of knowledge among trainees about TM as a career pathway in hematology, manifest recently as low attendance at the TM career-development event at the 2010 ASH meeting, the ASH Trainee Council conducted a series of interviews with leaders in the TM field to learn more about this potential career path.
The field of TM has transformed in the last 20 years from one led by hematologists to an independent subspecialty in pathology, medicine, and pediatrics. Available career options for TM specialists are in government, academics or private institutions and can involve a combination of administrative, public health, laboratory, clinical practice, and research responsibilities. TM specialists are drawn into the field by the exciting cutting-edge complexity of immunohematology (the study of humoral and cellmediated immune reactions in the pathogenesis and clinical\ manifestations of blood disorders), the ability to combine laboratory and clinical practice, the relationship to public health, the close bedside-to-bench connection, and the feasibility of combining practice with research. As Dr. Christine Cserti-Gazdewich from Toronto General Hospital described, “[TM] is a complex and dynamic field of medicine, which simply gives the illusion of stability by virtue of its culture of (necessary) procedural regimentation and quality assurance/quality control.” In other words, TM is a field dominated by process and procedures.
TM is often incorrectly thought of as a laboratory-based subspecialty, isolated from all other branches of clinical medicine. In fact, TM specialists interact with patients and medical staff on a daily basis and work with clinicians by managing transfusion reactions, hemovigilance (examination of the safety of blood supply covering the entire transfusion chain), hemostasis, blood product utilization, and apheresis. As a result of these interactions, TM specialists are well connected to their colleagues. Dr. Jacob Pendergrast, also from Toronto General Hospital, described the blood bank as “the circulatory system of a hospital. [TM specialists] respond, and circulate out their goods, to the sickest and most complex patients ... In this sense, they have their fingers on the pulse of … the hospital.”
Most TM practitioners are initially exposed to TM during hematology fellowship or pathology residency, after which they enter a one-year (U.S.) or two-year (Canada) specialized TM training program. Canada also accepts trainees from anesthesia or critical care medicine. Training typically consists of rotations in cellular therapeutics, apheresis, immunohematology, product utilization, coagulation, donor clinics, and hemovigilance.
Because of the intimate connections between TM and blood bank operations, TM training program and practice administration has largely migrated from hematology to pathology/laboratory medicine. As a result, most hematology trainees do not receive much exposure to the field. In the United States, remuneration in non-malignant hematology and TM are significantly lower than malignant hematology and medical oncology, possibly contributing to the diminished interest among hematology trainees in TM. Creative strategies are needed to overcome this “pipeline” problem and to recruit more hematology trainees into this unique and exciting field of medicine. Addressing remuneration, improving mentoring, exposing trainees to TM early in their careers, and developing novel, mixed training pathways combining TM with nonmalignant hematology practice and research are all on the ASH radar screen. The goal is to assist TM-trained hematologists to influence a large number of trainees by virtue of their dual connection with the laboratory and clinical aspects of training.
