Today, Dr. Aaron Shmookler joins us who has an interestingly different type of specialty. He is a pathologist trained Blood Banking & Transfusion Medicine specialist. A year and a half out of training now, he serves in an academic setting in West Virginia.
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[01:48] Interest in Blood Banking and Transfusion Medicine
Aaron took a transitional year and started his residency in Neurology. But he realized something was missing – the lab. He went into pathology really enjoying the field.
Then he finished his Pathology residency and quickly realized he also missed taking care of patients on the bedside. So he subspecialized in Transfusion Medicine and Blood Banking that has the bedside aspect of care. Then he also gets to do the laboratory side where he works behind the scenes.
[04:14] Traits that Lead to Being a Good Blood Banking & Transfusion Medicine Specialist
In this specialty, you have to be detail-oriented, very specific, and concise. This is generally true in the field of pathology as well.'You can't miss anything. When you catch a lab result that is odd or unexpected, you better catch it and question it to make sure it's truly the right result.'Click To Tweet
What got him initially interested in Neurology was when he began caring for patients with Alzheimer’s disease. Specifically, he was interested in localizing lesions.
[06:35] Types of Patients
At the bedside, they perform a procedure called apheresis. He describes it as an “oil change” to patients. So if you have a patient with sickle cell disease, they can be chronically dependent on blood transfusions.
One of the ways they can be treated is by exchanging their abnormal red cells and transfusing them with normal red cells. The procedure can take a couple of hours.
When the problem is with the patient’s plasma, they’d also take out the plasma and given them back new plasma.
Nevertheless, there’s a whole slew of guidelines put out by the American Society for Apheresis. This would give you an idea of the kinds of conditions they would be treating and see what kinds of patients they encounter.
Aaron is also in charge of all the blood products dispensed in their hospital. This refers to whoever who needs blood such as emergency patients who come in with trauma or surgical patients in the OR. They also give blood to obstetric patients, basically, anyone who needs a blood product.
[08:55] The Role of a Physician in a Blood Bank
As someone in charge of the blood bank, a physician makes sure that all blood products that come out are going to be compatible with the patient who is going to receive the blood product.
One of the ways to do this is to make sure patients haven’t developed any antibodies to some of the antigens in red cells. If they have, he makes sure he’s able to find units of blood that would be negative for those antibodies.'My responsibility is to make sure that all blood products that come out are going to be compatible with the patient who is going to receive the blood product.'Click To Tweet
Sometimes, they might not be able to work up with the patient’s antigen status. As a result, they may need to release blood emergently. In this case, they caution physicians who require that blood that they haven’t really completed all the testing they need to do to find the best-matched blood for that.
An example of this would be cases of patients bleeding significantly and they can’t wait for any testing and they’d have to transfuse something. They’re able to provide special blood for this, but they can’t guarantee this wouldn’t cause an adverse effect. So they have to be mindful of these particular conditions.
They also manage factors. Factor VIII, for instance, is used to treat patients with hemophilia. They also make sure the doses are appropriate.
[11:35] Typical Day, Procedures, & Taking Calls
For Aaron, a typical day would be coming to work and following up on any patients that may have come in at night that required a significant amount of blood.'We have to retrospectively review a number of products that we give out.'Click To Tweet
Aaron also takes some time to teach residents and conduct research. Part of his training includes clinical pathology.
In terms of procedures, Aaron does apheresis. This involves the help of a nurse to run an apheresis machine and he oversees all of it as it’s happening.
They also have standard operating procedures such as making sure that when they issue blood, the nurses are able to transfuse it in the right way. They also have to oversee procedures that their blood bank technologists are doing.
So while not directly hands-on, they’re definitely overseeing a lot of the procedures that other people are doing.
Aaron takes about 6-8 weeks of call. A lot of the calls come from the blood bank. They can ask him about whatever questions they may have. They’re mostly blood bank-related questions although it can be specimen-related questions.
[15:50] The Training Path
After medical school, you can do whatever you want for residency. Specifically, there are residencies that may tend themselves toward wanting to become a transfusion medicine physician such as pathology.
In fact, the board certification exam for Blood Banking and Transfusion Medicine is offered by the American Board of Pathology.
Physicians who are also training in Anesthesiology may be interested in Transfusion Medicine as well as Hematology Oncology and Emergency Medicine.
In terms of competitiveness, Transfusion Medicine is not as competitive. Looking at the 2019 residency match data, there were 924 applicants for 601 pathology positions. About 95% of them were filled. This is nearly 3 physicians for U.S. senior. So 93% of U.S. seniors who apply were matched.
[18:05] Subspecialty Opportunities
You can subspecialize in just about everything. You may like to subspecialize in another subspecialty that’s a little bit closer to clinical pathology such as Microbiology or Clinical Chemistry.'The Transfusion Medicine side of things is clinical pathology heavy.'Click To Tweet
[19:10] Working with DOs, Primary Care, and Other Specialties
Aaron explains that there’s an increase of DOs that have been reported to going into Pathology. That said, he doesn’t think there is any bias against DOs.'We interact with primary care physicians a lot.'Click To Tweet
Other specialties they interact with include primary care physicians and general surgeons. They help select the most appropriate tests. They make sure that the resources are utilized in a cost-effective manner without harming the patient.
They want to make sure they’re giving patients what they need. They also see to it that blood is being used appropriately. Often, they give blood unnecessarily.
There has been a lot of data to show that a restrictive transfusion strategy can be beneficial compared to a more liberal transfusion strategy. The less you can give somebody, the better it can actually be in certain clinical situations.
Studies have shown that a transfusion of blood is independently associated with increased mortality. Hence, this has to be utilized in the right setting. Aaron’s job, therefore, is to make sure that the blood being distributed is used appropriately.'Less blood is more.'Click To Tweet
[22:30] Special Opportunities Outside of Clinical Medicine
Blood Banking and Transfusion Medicine Specialists can function as medical directors and other doctors of other blood donor centers. Teaching is another route they can take.'Whenever someone wants to go and donate blood, there's usually a transfusion specialist somewhere behind the scenes.'Click To Tweet
[24:15] What He Wished He Knew Going into this Specialty
Aaron actually took this subspecialty relatively late in the process so he wished he had known about this earlier. He also wished he knew about pathology earlier.
What he likes most about his specialty is both the patient side and the laboratory side of things.
On the flip side, what he likes the least is they’re often undervalued or unnoticed by the administrators and even patients. That said, they lack the support, resources, and the basic facilities they need compared to more money-making surgical specialties,
Additionally, as a pathologist, the workload can get busy resulting in slower than expected turnaround times which can delay care. Otherwise, haste makes waste and that could result in a significant error that can seriously harm the patient.'The job of the pathologist is to efficiently make the right diagnosis the first time around.'Click To Tweet
[27:00] Community vs. Academic Setting
Being part of a donor center would mean being very much out in the community. As a pathology trained transfusion specialist, you would be a pathologist practicing in the community.
With additional training in blood banking, you’d be able to address a lot of calls. As a result, you could be put in charge of the community blood bank.
[28:08] Major Changes in the Future
Specifically, in blood banking and transfusion medicine, they’re bringing back whole blood. They used to give whole blood in the military. They still do.
But since World War II, they’ve developed the ability to provide more component therapy. This means they’re able to give only red cells if they only need red cells. Or give only plasma if they only need plasma, and so on.
This has a lot of benefits. But they also realized that in the trauma setting, whole blood actually has been very beneficial.'We're bringing whole blood into the civilian world.'Click To Tweet
In the pathology side of things, they have a lot of emerging hot topics such as artificial intelligence, digital pathology, liquid biopsies, and next-generation sequencing. These are fancy technologies that supplement the microscope. The microscope has been used since the late 16th century and it will continue to be used for the foreseeable future.
On the negative side, there is a shortage of physicians in the U.S. and pathology is no exception.
In fact, Aaron read a 2013 article offering a predictive model examining some of the factors influencing pathology workforce supply in the U.S.
In the coming two decades, it’s projected that there will be a decrease from 5.7 to 3.7 full-time equivalent pathologist for 100,000 population. They’re actually looking at a deficit of more than 5,700 full-time equivalent pathologists.'Retiring pathologists are anticipated to peak in 2021...we need pathologists more than ever'Click To Tweet
Aaron believes that artificial intelligence would be an adjunct and it would never replace the pathologists. He doesn’t anything could come close to replicating the human eye. But when AI can help in the digital pathology perspective, this could be very useful for them.
[33:05] Final Words of Wisdom
Aaron says that if he had to do it all over again, he would still have chosen the same specialty.
He encourages students to look into pathology. Out of all the medical disciplines, he thinks that pathology offers the most subspecialties. There’s the clinical side of things and more!'There are a lot of ways you can function as a pathologist.'Click To Tweet
Finally, he encourages medical students and physicians to take care of themselves. Think of medicine as this journey on the expressway. So enjoy the scenery and reflect on the vehicle you’re riding.
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