the state of training todaythe latest books reviewed

learning by tweet: TeamHaem

Issue 1April 2013

Haem Trainee

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Page 3 -­‐The Birth of Team HaemThe use of social media inhaematology training

Page 5 -­‐Course Calendar

Page 6 -­‐Book ReviewsHemophilia and HemostasisColor Atlas of Clinical Hematology

Page 7 -­‐The FRCPath Crisis in HaemWhat should we do as trainees? -­‐ apersonal viewpoint from Australia

Haematology is a fast moving specialty withnew developments almost on a weekly basis.As a result there are a large number of journalsand outlets for scientific discourse andpublication. However, there has never beensomewhere for Trainees to share theirexperiences or knowledge -­‐ not necessarily of ascientific nature, but of simply how to get alongor gain new experiences in the subject theylove.

The HaemTrainee aims to fill that gap. Thiselectronically-­‐published magazine will bedistributed every 4 months, and will be filledwith information on new educationalresources, reviews of books and courses,guides on how to do something differentduring your training, personal viewpoints, andmuch more. In fact, this magazine is yours, andI want you to write to me to let me know whatyou want, and if possible to write it too!

I look forward to hearing from many of you andwant to hear your positive and negativecomments about this first issue by email -­‐editor@haemtrainee.com

Joel NewmanEditor, Haem TraineeHaematology ST7, London

Welcome to the firstedition

Issue 1 - April 2013Contents

Production of this magazine has been supported by anunrestricted grant from Gilead Sciences Ltd.

Reasonable care is taken to ensure that Haem Trainee articles and other informationon theweb site are up-­‐to-­‐date and accurate as possible, as of the time of publication,but no responsibility can be taken by Haem Trainee for any errors or omissionscontained herein. Furthermore, responsibility for any losses, damages or distressresulting from adherence to any information made available through this website isnot the responsibility of Haem Trainee. The opinions expressed are those of theauthors and do not necessarily reflect the views of either their institutions or HaemTrainee.

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The Birth of Team HaemSocial Media in Haematology Training

Teamhaem is a new educationalproject set up by a group of traineesin the Northern Deanery. It is a brand-­‐new, sparkling, innovative way toteach and learn…or so I thought until Iagreed to get involved. It turns outthat there has been a paradigm shiftin medical education and us ‘oldies’need to catch up. So give me fiveminutes of your time and let meintroduce you to the overlappingworlds of social media and medicaleducation.

Dipping my toes in the waterI currently work as a Haematologyregistrar and I’ve been interested inteaching for some time, slowlyworking my way through a distancelearning qualification in medicaleducation. So when a local consultantasked for volunteers for ahaematology social media project Ithought ‘why not?’

I’m not technologically minded, hadnever tweeted a thing; even myfacebook profile is woefullyunpopulated. It’s fair to say I wasn’tthe obvious person to start up a socialmedia (known as SoMe) teachingprogramme. But after signing up totwitter and watching the activities ofa few of the well-­‐established teachinggroups I was sold. I could see thevalue of a forum where people fromaround the world could debate topics,share information and work togetheron clinical scenarios at the click of abutton.

The teamhaem basicsHow does Teamhaem work? A case isdesigned and a brief introduction isposted on a blog(www.teamhaem.wordpress.com)with an accompanying question for’followers’ to consider. The blog isposted on our twitter account, soanyone who has a twitter account and

follows @teamhaem will see that theblog has been posted and a case hasbegun. We ask that people read thecase and then respond on twitter withtheir thoughts on the question posed.Further aspects of the case are postedover the following week and morecomment and debate ensues. Thecase is then summarised on the blogto act as a future educationalresource. We are not experts(although our participants might wellbe), but we have chosen a case thatwe believe is topical, relevant anduseful and tried to moderate debateto encompass multiple opinions andperspectives. It’s early days but as ourtwitter community grows, so thequality of debate and contributionevolves.

We currently have about 300followers, consisting of aninternational mix of medical students,haematologists, pharmacists, doctors,patients, scientists, medicalorganisations, universities andeducationalists. Some join inregularly, some watch from thesidelines, some retweet our work,some contact us directly regardinghaematological issues.

You might be thinking so far so good –but not something I fancy. Perhaps itseems like something for medicalstudents rather than a fully-­‐fledgeddoctor? A bit too gimmicky? Let mesee if I can persuade you to thinkagain.

As far as the teamhaem casediscussions go I can see that eachperson’s learning style will influencehow useful they might perceive this tobe. I’ve always found group revisioneasier than hitting the books alone;always preferred case studies toacademic prose; remembered apatient’s story rather than a textbook

description of pathology. The idea ofthe cases we present is that they arechallenging diagnostically, that theyare memorable, and that they arerelevant for all our working lives. Assuch I hope we are helping you tapinto that shared learning experiencethat we used to have as med students(remember those group revisionsessions powered by cake/wine?) butthat we rarely have time for now thatjobs, partners and babies make louderdemands on us. Plus it is a seminarthat you can have from home towhich you can invite an Americanexpert, an Australian peer and anIndian medical studentsimultaneously – which I think ispretty amazing.

The benefits of SoMe above andbeyond Teamhaem

I think learning and sharing via SoMesuits Haematology as a discipline. Wehave an awkward chasm to span inour job: on the one hand we areheavily involved in liaison withmultiple disciplines, on the other weare clinicians with our own, complex,patient load. We are frequently askedto advise on issues we find routine(that 4am warfarin phone call springsto mind), but in order to do thiseffectively we need a goodrelationship with, and understandingof, other specialities and disciplines.We need to be known as a usefulresource but also to keep our genericknowledge up to date and conversingwith other health care professionals isone way to do this. Fed up of theover-­‐requesting and investigation ofd-­‐dimers? Express that opinion thenext time you see colleagues chattingabout it on twitter. Not sure why yourlocal pharmacists are twitched abouta drug side effect or indication? Askone! You can do all of this from thecomfort of your sofa with one eye on

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the tv and what’s more the responseyou get might well include links todocuments or guidelines, or even achange in practice in the case ofopinions you offer.

Twitter journal clubs are springing uptoo and are great for debating papersthat are relevant to multipledisciplines, such as secondary VTEprophylaxis or blood transfusion. Apaper is made available to ‘followers’in advance and at a set time and dateeveryone ’meets’ on twitter to discussthe paper, with a moderator shapingdiscussion. The range of opinions andknowledge on offer in such debatescan be breathtaking.

As haematologists we also deal withfantastically rare diseases that manyclinicians will never hear of, much lesscome across. We need a network ofexperts that we can contact andconsult, and the ability to locateinformation and resources on thatonce-­‐in-­‐a-­‐career patient with thebreathtakingly rare disease (dittoexam cases). The rarer the case themore likely it is that there is no rightanswer and the potential of SoMedebate to really tease out the issues,concerns and beliefs of colleaguesaround the country/world is, I wouldargue, unique.

So what’s stopping more of us gettinginvolved?Persuading my colleagues to getinvolved hasn’t been an easy processhowever. I understand this on apersonal level. I hadn’t even dabbledin Twitter before this project came upand I don’t speak ‘computerese’ , somy determination to understand howit all works was based on acommitment to the project ratherthan a passion for SoMe in itself – Iwould probably have lost interest if Ihadn’t signed up to launchingteamhaem .

But at the same time I am frustrated –now that I ‘get it’ I want everyone tohave a dabble and see what it has tooffer. I have already learned so muchand will continue to do so with every

passing day as I peruse the rollingnewsfeed supplied by ASH, NEJM,BSH, Sepsis UK and so on.

I think there are five sticking pointsfor SoMe ‘virgins’, although perhapsyou can think of more.

Privacy is, I think, a big issue. Statingan opinion on twitter is like stickingyour hand up in a giant lecturetheatre with an audience of experts –that can take guts. But you can havean anonymous account on twitter soas long as you behave sensibly andprofessionally (no swearing, insults orcomments on your own job/employer/patients) it seems a shameto be put off for this reason. Similarlyit is crucial that no patients arementioned, even anonymously and inpassing – perhaps some of us worrythat a comment could slip out?

Image is an issue too. A lot of peoplethink of twitter as a frivolous toy,used to rate x-­‐factor contestants andso on. I guess that is true for some,but in the world I have created forteamhaem on twitter I see none ofthat. Those people that I follow arelargely medical educationalists, medstudents, doctors, medical charitiesand patient groups, medical societies,government organisations and otherhealthcare professionals. I am muchmore likely to see retweets of recentNEJM articles and NICE guidelinesthan comments on Lady Gaga orRhianna. So Twitter is what you wantit to be – for me it is an educationalresource only and my personal liferemains in the real world.

Technology is an issue too and I’m noexpert – but I promise it isn’t thattricky! Sometimes you follow all therules and your tweet doesn’t appearon a hashtag as you expect, or adebate is tricky to follow. All I wouldsay is stick with it – it works moreoften than it fails.

With a smartphone and constantaccess to the internet there is theconcern that SoMe can be intrusivetoo – a colleague commented to me

that she likes to keep home and workin different ‘boxes’. I can’t deny thattwitter can creep in to your personaltime, but if it ultimately makes you amore efficient learner (as I argue)perhaps it should be seen as aninvestment which will ultimately paydividends.

The final sticking point is relevance –many people just feel that there areso many educational resources outthere that they don’t need to bebombarded with yet another streamof information; why bother? To that Iwould say two things – firstly this isthe way a lot of younger doctors/students are learning and as such it islikely to dominate professionalinteraction and learning before thoseof us in our 30s retire. So ignore it allyou want now-­‐ one day it will swallowyou up despite your protests. Butmore importantly I find it is a greatway to focus my attention – I can joinin journal club debates on papers Iwould never have got around toreading, much less analysing; I can getlinks to all sorts of papers and articlesI would otherwise have missed; I cansuss out what the students strugglewith and therefore how to improvemy local teaching; I hear aboutmeetings and conferences that wouldhave passed me by. This is the futurefor doctors – we can’t fully assimilatewhat is now almost endless clinicalinformation, but we can learn tolocate and organise resources that arerelevant to us.

Go on, have a dabble…

I hope I have managed to persuadeyou of the merits of SoMe for doctors,and hopefully to participate inteamhaem cases. The best way to getan idea of what there is out there is toopen a twitter account and take alook – use that time on the way towork instead of reading the freepaper, or fill your time whilst waitingfor a friend at the cinema/pub.

Emily GravesHaematology SpRNorthern Deanery

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Course Calendar

Here are a few places to look to get you started…

Twitter@teamhaem; search for #teamhaem to see what is going on@gassclass/ #gasclass – the anaethestists show us how it should be done#ecgclass – the cardiology version of gassclass@twitfrg/ #twitfrg – medical students flexing their SoMe muscles@twitjc – journal club, meets on Sunday evenings 8pm#ukmeded – discussion group relating to medical education in the UK#FOAMed – international SoMe medical education hashtag – some of these guys are the founding fathersof medical education via SoMe and are truly passionate about what they do…@emilygravesuk – not because I tweet, but because I’m happy to help if you contact me!

Blogs about SoMewww.kevinmd.com/blog/2013/03/flipped-­‐classroom-­‐future-­‐medicine.htmlwww.mededelearning.wordpress.comwww.sotonccp.org/2013/01/students-­‐don’t-­‐study-­‐hard-­‐study-­‐smart/ -­‐ a blog aimed at students butuseful for us all in its advice on SoMe.www.sotonccp.org/2013/01/foamed/ -­‐ aimed again at med students but explains what FOAMed is andwhat it can offer you.

Friday 24th May 2013BMJ Masterclass in Haematology (BMA House, London)http://tinyurl.com/bmjhaem

Thursday 13th to Friday 16th June 2013European Haematology Association Congress (Stockholm)http://tinyurl.com/eha2013

Monday 16th September 2013One-­‐day Morphology update for Biomedical Scientists and 1st year SpRs (Hammersmith Hospital)http://tinyurl.com/morphcourse

Monday 16th September 2013One-­‐day Haemostasis and Thrombosis update for consultants and senior SpRs (Hammersmith Hospital)http://tinyurl.com/morphcourse

Tuesday 17th September 2013St.Mary's one-­‐day course in laboratory aspects of haemoglobinopathy diagnosis (Hammersmith Hospital)http://tinyurl.com/morphcourse

Wednesday 18th and Thursday 19th September 2013St.Mary's two-­‐day course in advanced haematology morphology (Hammersmith Hospital)http://tinyurl.com/morphcourse

Friday 20th September 2013St.Mary's one-­‐day course in histopathology of the bone marrowhttp://tinyurl.com/morphcourse

If you have a course you want advertising here, please let us know -­‐ editor@haemtrainee.com

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Haemophilia is afascinating subjectinvolving the care ofsome of the mostvulnerable individuals,and the continuation ofthat care for theirentire lives, throughvarious life events,operations, and more.

Clinical experience in the area can be patchy, and unless youmanage to spend time in a dedicated haemophilia centre,knowledge of care for these patients is limited to theoccasional individual presenting with a bleed, or the phonecall from the surgeons half an hour prior to operating onsomeone with a bleeding disorder.

Unlike other textbooks, this book does not take youthrough the pathophysiology of haemophilia, and otherbooks are required to cover that ground. What it does do istake you through commonly, and sometimes uncommonlyencountered issues with haemophiliacs in a case-­‐basedmanner, and present you with practical advice as to how to

manage them. As a result of this, many of the managementrecommendations are the authors’ own, and evidence tosupport them are often anecdotal. Topics covered includevalve replacement and haemophilia, compartmentsyndrome, dental procedures, joint bleeds, inhibitor removaland many others including coverage of the other non-­‐A/Bhaemophilias.

The book is written in short, manageable chapterscovering one case each, and are written by well respectedauthors from the US. This may have an impact on the advicegiven, with practices often differing across the Atlantic. Theway the book has been written means that it can easily bedipped into for advice on a certain topic without having toread the accompanying chapters. Although this is a usefulfeature, it does mean that those reading cover-­‐to-­‐cover willdiscover a fair amount of repetition in chapters coveringsimilar topics.

On the whole this book is a useful tool for dailypractice, particularly for those planning to work outside of ahaemophilia comprehensive care centre, where regularexposure to haemophiliacs is limited.

Having not beenintroduced to this titlebefore reviewing it, Iwas expecting andlooking forward tosome form ofmorphological atlas tocompare against thelikes of Blood Cellsand Bone MarrowPathology by

Professor Bain et al. Initial inspection revealed that this wasnot the case, but that in fact this was a true atlas of allthings haematological -­‐ a visual representation of the manycomplexities encountered in daily practice.

My initial disappointment gave way to excitement,as I browsed through the many colourful glossy pages -­‐ themajority of which did contain morphological detail -­‐ withimages of patients displaying all manner of syndromes,signs and symptoms: a real treasure trove of information. Itis clear that a book like this can only be produced after a

career full of careful documenting and photographing, andexposure to the whole range of haematology. Itsproduction is therefore no mean feat. Each section comeswith an explanatory text, which in itself is detailed andthorough, and the atlas is fully up-­‐to-­‐date with images ofgenetic pathways, molecular signalling and other detailsrelevant to each condition being described.

As with many of the other Elsevier imprints, thisMosby book comes with online full access atExpertConsult.com, which is particularly useful as thisbook’s page size is a fraction bigger than standardtextbooks, and it is a weighty tome. It is perfect for dippinginto and reading around a topic or condition recentlyencountered. Its detail is sufficient but not overbearing inthe text provided, and the images really help in theretention of the information. It is an excellent aid forteaching, and the images can be downloaded from theExpert Consult website for use in presentations. This bookshould therefore be seen as an investment, and is likely tobe well used by anyone purchasing it.

Hemophilia and Hemostasis: A Case Based Approach toManagement2nd Edition. Eds Alice D. Ma, Harold R. Roberts and Miguel A. Escobar.Wiley-­‐Blackwell (2013). ISBN 0470659769, £64.99

Color Atlas of Clinical HematologyA.Victor Hoffbrand, John E. Pettit, and Paresh Vyas. 4th Edition(2009). Mosby. ISBN: 0323044530, £169.00

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The FRCPath Crisis in HaemWhat should we do as trainees? -­‐ a personal viewpoint from AustraliaThe way I see it there is no easysolution to what is becoming a near-­‐crisis situation in haematologytraining. Time and time again failurerates are flaunted in front of us twicea year by the Royal College ofPathologists and consultants alike andwe’re told something must change.I’ve not been around long but therearen’t many changes on the horizon.And what’s more you’re probablythinking whose problem is it – thetrainee or the trainer? The reality isthat a lot of us when we pass ourexams may never want to look downa microscope again, and it looks like inthe near future, a simple blood testand genome sequencing could bediagnosing our patients, both with amore accurate prognosis and withoutthe pain of a bone marrow biopsy. Orso we’re being led to believe.

So what should we do? Well let's dealwith the here and now first. We haveto pass the FRCPath to get our CCT soI think as a body of trainees we haveto take practical approaches toincrease the pass rate. Pleaseremember that these are suggestionsand ideas that I think should helppeople in their quest to do that.These ideas are in part or whole takenfrom the Australian system where thepass rate is much higher. Their part 1is a combination of our part 1 and 2and is spread over three to fourmonths with separate exams inmorphology, essay questions, apractical in transfusion, a paper ofshort questions as well as an oral.

So first of all the one thing the Ozzieshave reminded me is that this is apathology exam which unfortunately Ithink the JCPTRB curriculum does notemphasize. So not only do you needto know how to diagnose and treatthe disease but you have to know how

your laboratory works. Qualitycontrol and assurance, what machinesyou use, how they work, whatinterferes with accuracy and the listgoes on and on. If you don’t knowwho Coulter is and the Coultermethod, you need to learn, and that'sjust history really. Dacie and Lewisand your senior lab scientist is yourfriend here and should be regularlycalled on for tutorials, explanations ofQC as well as regular participation inQA. My experience in severalcountries is that if you ask they will behappy to help as long as you don'tsound too stupid – been there, gotthe t-­‐shirt!

In coagulation, I am planning to usetwo sources, one is the websitepractical-­‐haemostasis.com which hasbecome an essential source ofinformation on techniques and moreimportantly questions. Secondly Ithink trainees should consider the‘guide to competency in haemostasisand thrombosis for SpRs’ documenton the British Society for Haemostasisand Thrombosis website. If you knoweverything in that document then I

don’t think there’s much you can missin coagulation. Again time in yourcoagulation lab as well as the regionalhaemophilia centre lab will help youhere.

In morphology I think the critical thingis exposure to abnormal films andpattern recognition. Every week inSydney from February to August theyhave a tutorial from a differentconsultant in the city who is also anexaminer. It's like a personal tutorialon film reporting, and moreimportantly an exam tutorial andadvice from the people who areactually going to be examining you.Can you make that happen in yourdeanery? A basic idea would be toget a once a month tutorial for examcandidates in your region in eachdifferent hospital on morphology. Thiscould be for four to six months priorto the exam with an agreement thateveryone would attend (the trainee’sobligation) and the the trainer wouldbe willing to send out slidesbeforehand so that you could studythem and learn form your mistakes(the trainer’s patience!). It could of

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course be done using MDT facilitieswith a bit of planning which wouldmean that travelling would be less ofan issue. There should be at least oneperson in every hospital in thecountry who could be cajoled intoparticipating.

In transfusion, the course is probablyenough, it certainly seems longenough!

Please do not forget all the otherexcellent resoucres that are availableto you including the BCSH guidelines,ihaematology and BSHT websites andothers.

For our future colleagues I do thinkthere are things we should consider.Should there be more required labtime? In Australia you have to workin a lab for twelve to eighteen monthsbefore you can sit the exam; andthat's typically with only one clinic aweek rather than the usual three orfour that most of us do in the UK andno ward commitment. Is the systemtoo stressed to make that work?

Should we just split the training andtake the American approach wherewe just train as clinicalhaematologists? This is an optionthat I think a lot of us might opt forand then panic and do the lab trainingwhen we see where the jobs are! Iwould advise you to think of all thedual trained ID/microbiology

registrars you know! The reality isthat laboratory haematology is likleyto become more and more centralisedespecially with recent reports (http://tinyurl.com/ncatpdf) as well as theintroduction of genomics into routineclinical practice. The one service thatmust always be provided, though, istransfusion and so I think to escapelaboratory training altogether wouldbe difficult.

Does anyone have a detailedcurriculum for the exam? I’ve had alook around and one of the things Ithink we should consider addressing isthe lack of a curriculum from theRoyal College of Pathologists. I thinkthe JCPTRB curriculum is too vagueand as the RCPath are organising theexam they should also provide adetailed curriculum. Themicrobiologist has an eighty-­‐plus pagedocument on training and detaileddescriptions as do thehistopathologists. In Australia theRCPA has a similar document withdetailed requirements of knowledgein all aspects especially labmanagement and day to day runningof the lab with a focus on serviceprovision. I’m planning on using thatas a study guide for the exam nextyear as I think it fills in a lot of blanks.

Should the exam be split up? Threedays of papers and orals is a long timeto maintain concentration. InAustralia the exam is split up over 3

months with some provided locallyand one other at a regional centre(usually Melbourne or Sydney). Oneof the main advantages of this is thatif you fail only one part of the exam,you only repeat that part. Why doyou need to repeat everything if youfail only one part? Surely that fallacyshould stop.

Past exam papers or mock examquestions would be useful. Doesanyone have ideas on how to getthose from the RCPath on an officialbasis? Again the FRPA publish pastpapers yearly.Should we do regional monthly studygroups? And lastly the one area thatworks well in Sydney is the conceptthat nearly every candidate is in astudy group. Not every study group isperfect but if nothing else you havesomeone else to panic with! Thealternative would be to have monthlyHIT meetings for exam candidateswhere topics are highlighted anddiscussed.

This is my approach from what I’velearned here in Australia where I’m onan OOP. It's not perfect but at thevery least it is an approach. I think wereally need to start somewhere andmainly with ourselves. Good luck toeverybody preparing for exams.

Tracy MurphyHaematology SpR

OOP in Sydney, Australia

your Haem Trainee needs youWe are looking for others to join the team, coming up with ideas for articles, and hopefully also writingthose articles. Don't worry if you haven't written for a magazine before, we can edit your work before

publication, and they can range from a few hundred words up to around one thousand.

This magazine is designed to be written by Haem SpRs for Haem SpRs -­‐ if you found something interesting-­‐ a course, book, resource etc -­‐ your colleagues probably will too, so write about it and let them know.

Contact us with your ideas and articles -­‐ editor@haemtrainee.com