March 31, 2011 (Thursday) - Specialist Portfolio Presentation

Yesterday I was due to give a lunchtime talk, but a dodgy eye put paid to that. So I gave the talk today to a limited audience. My subject was the operating principles of the Sysmex XE2100 blood counter as part of Section 7.1a of the specialist portfolio, and my limited audience was my specialist portfolio students.
However with nine students (well, eight and one nearly there) getting them all together at any one stage is tricky. I had five today. I’ll do the others tomorrow or next week.

The talk went relatively well but, as one of them said, I was trying to get an awful lot of information over in a very short length of time. I was conscious that I was rather muddled in my explanations of some of the more esoteric points. But hopefully they will have got a feel for the subject, and (as always) the presentation I gave them is available on my specialist portfolio website.

March 30, 2011 (Wednesday) - At The Doctor's

Yesterday my eye was very bloodshot and so I phoned my G.P. who all but told me to F…off. So I went to A&E to get it looked at. Up till that point it didn’t hurt. I applied the cream that the doctor in A&E prescribed, and then the eye got really bloodshot and painful. I woke this morning unable to open it: it was gunged shut. So I thought I’d take the day as a sick day.
I had this theory that my eye was (relatively) fine until the doctor in A&E gave me the cream for it yesterday: I wondered if maybe I was allergic to what I’d been given. So I decided I’d go see my doctor today - whether they liked it or not. My G.P. surgery doesn’t like patients coming along, and in the past they have flatly refused to give appointments. Today was rather typical of my experiences with them.

I arrived at the surgery at 7.30am to find no one there but the builders, so I took a seat and waited for the surgery staff to arrive. In the meantime the builders regaled me with horror tales of the things they’d seen in that surgery, and how I was lucky the place hadn’t fallen down on me. It would seem that builders are neither subject to the Hippocratic Oath nor proud of their workmanship.
The receptionist arrived at 7.50am, and I tried to see if I could get an appointment. She snarled that the surgery didn’t open until 8am, so I sat and waited. And so did she. Exactly as the second hand of the clock got to 8am she asked if she could help me. I said I’d like an appointment. She asked if 11.50am would do. I asked if there was anything earlier. She said there were only emergency appointments available. I said I thought I qualified as an emergency, and showed her my eye. She grudgingly offered me a 9.30am appointment, whilst muttering to herself about it. I suggested that I might go home and come back at 9.30am, but was told that if I left the building they would cancel my appointment.
So I then sat and watched a succession of other people who wandered in, asked for an emergency appointment, and got seen before me. I consoled myself by trying to read my book. This wasn’t easy: firstly I couldn’t really see it, and secondly the “council harridan” was rather off-putting. This delightful lady was constantly shrieking at its daughter; said offspring having apparently stolen all of the family allowance to buy someone else a Mothers Day present. From what I could work out the child had stolen all the cash from its mother’s purse to buy a friend’s mother a gift on the understanding that when the friend’s mother got her child allowance, that cash would stolen to refund the original theft. What charming people one meets these days (!)

I eventually got in to see the doctor at 10am, and she concurred with my diagnosis. I probably was allergic to the cream I got yesterday, and she prescribed me some new stuff.
On the way out I read a letter on the wall from the surgery’s patient’s forum. My first thought was that they were a self appointed bunch of do-gooders. But on further reading it seems they are a self appointed bunch of self-servers. I got the distinct impression that being on that committee gave you a far better chance of getting an appointment at the surgery.

All of which is very interesting, but has no relevance to work. Or does it?

I suspect that every member of staff at the G.P. surgery considers themselves to be caring professional people. I’ll concede that they can hardly be held responsible for the conduct of the lower orders in their waiting rooms. However I came out of the place utterly unimpressed with them. I must make sure that people are not similarly unimpressed with me and my workplace….

March 27, 2011 (Sunday) - Cheating

Having done weekend and night work on a regular basis for twenty-odd years I gave up the night work a few years ago, and am trying to cut back on the weekend overtime too. I detest working at the weekends. However it was payday three days ago, and whilst there is still some money left, there’s not as much as I’d like. I have two alternatives: spend less or earn more. So overtime it is.
Another way of improving my finances is to do other people’s homework for them. It may come as a surprise to many of my loyal readers, but in my more lucid moments I’m a genius. I have degrees in mathematics and haematology, and post-graduate qualifications in teaching. It turns out that can use my expertise in my free time. I’ve found a website which caters for people who urgently need an original piece of academic work to be produced in a hurry. I could do that.

This website stresses that they are not in the business of helping students cheat, but rather they provide model answers to essay questions. Their specialty is providing model answers in a hurry.  And they offer a premium service whereby they try to provide these “model answers” within a day or so, so that the cheating student has the essay in time for when it’s due to be handed in.
I’ve produced proper “model answers” before, but in the past I’ve had weeks and months to provide them, because that’s how universities operate. It’s been my experience over the years that the only people who have such short deadlines to produce essay answers are the students. But the website stresses that they aren’t in the business of allowing students to cheat on their homework by charging them over one hundred quid to have an expert write the essay for them. So, with a clear conscience I might just sign up with

If I catch any of my students using this website I might just be able to have them sacked. Or am I being hopelessly naive …?

March 25, 2011 (Friday) - Pre Reg Portfolio Assessment

Yesterday I was very excited when my student passed her specialist portfolio. This was the first one I've been involved with, and was very much new territory for me.

Today another student passed his state registration assessment. Whilst I was nervous during his assessment, this was the ninth pre-reg portfolio I've overseen, and the twentieth state registration that I've overseen. I think it's fair to say that yesterday's verification was a voyage into the unknown, but today's was a foregone conclusion.

It’s so easy to write that. I need to watch myself. I must not get complacent with these pre-registration verification assessments.

March 24, 2011 (Thursday) - Specialist Portfolio Assessment

We had an inspector in at work today. Over the years I’ve had lots of inspectors to check that my trainees are of sufficient standard to become state registered. Today was a first – we had a specialist portfolio registration inspection. Today was the culmination of four years hard work, and was probably as nerve wracking for me as it was for the candidate. After a three hour assessment we were told she’d passed.

I was particularly nervous as, for all that my student had prepared the most excellent portfolio, we were neither of us entirely sure that it was actually what was required.
In my honest opinion, the guidance we’d received from the IBMS on the production of the portfolio was minimal, to say the least. I’ve produced a website of advice for students and mentors involved with this portfolio, but this website is purely my personal take on the thing. I’ve asked for those with experience of assessing these portfolios to give me help, suggestions and advice for this website, but (so far) have received nothing. So consequently today was very much a journey into the unknown. We didn’t know what to expect from the assessor, and were desperately hoping he’d like what he saw.

It was interesting that that the assessor shared our view of the IBMS – that they did not give enough guidance about this portfolio. He was under the impression that the idea was that mentors like me learn how these portfolios should be done from the experience gained as students complete them. The theory being that after you’ve overseen half a dozen, you get the idea. Which is all well and good for the poor students*provided* you’re not one of the first ones.
Mind you, I’ve still got eight other candidates preparing their own specialist portfolios. Hopefully that will be experience enough.

March 23, 2011 (Wednesday) - I.T.P.

A very interesting refresher on idiopathic thrombocytopenic purpura. The speaker was nervous, but did well. To keep these seminars going we need more people who are brave enough to stand up and have a go.

I learned loads. Now the condition isn't "idiopathic" - in many cases we know what the cause is. And opinion has changed dramatically on the preferred treatment. Years ago a friend mother had the condition, which was cured by steroid injections and a splenectomy. Nowadays splenectomies are frowned upon.
Also nowadays we rarely see the I.T.P.s with platelet counts less than twenty which were so common (relatively) ten to twenty years ago. Either medicine has improved, or the cases are referred to other  (non-factory) labs these days. I wonder which it is...

March 22, 2011 (Tuesday) - Mandatory Training

Having a spare five minutes this morning I thought I'd better get on with my mandatory training. First of all "Infection Control". It sounds like a particularly relevant topic, but the course was, like most of hospital life, geared up to the needs and aspirations of nurses. The relevance of the course material to my daily round was rather sparse.

And then "Clinical Governance". Even though I have the certificate, I find myself unable to concisely explain what "Clinical Governance" is. I think it's something about trying to do the best job that we possibly can and about learning from mistakes to improve our services. However I did actually laugh out loud when I read that Clinical Governance is (supposedly) NOT:

  • a stick to bash health professionals with
  • another management fad
  • a 'blame' thing
I do know that I can put the wind up the management every time I don't get my own way by announcing that their schemes have "governance issues", but eventually someone will wise up to what I am doing. Unless they are as in the dark as I am as to exactly what a "governance issue" is.

The training was provided electronically, and the final examination quizzes were rather risible. Rather than testing knowledge, participants are required to fill in the appropriate missing word. However it had to be the correct missing word. Synonyms would not do. "Large" would be acceptable, whereas "huge", "big", "enormous" or "gurt" would not.
Fortunately for us participants, whoever designed the program had left us with a loophole. It was possible to call up the course material whilst completing the final test. And so passing an irrelevant test became a mere formality.
It's a shame that serious topics have been reduced to no more than box-ticking exercises.

March 19, 2011 (Saturday) - Hidden Science

The IBMS sent out their newsletter today. It was rather dull, but it mentioned The Hidden Science Map: a map to tempt all scientists, engineers, technologists and mathematicians out of hiding to reveal how much science is out there in the UK.
I’ve signed up to the thing, but I don’t really know why… If anything develops from it, I shall keep my loyal readers updated

March 17, 2011 (Thursday) - Parvo Virus

PARVO VIRUS                                       
DOB  27/01/1935  Sex M Pat No 996699
Address   PROBABLY
Specimen No : AW999999T

15/03/2011 09:22  EDTA
  Haemoglobin               6.7    g/dl        (  13.0 to 18.0  )
  White Blood Cells         104.0  10^9/l      (     4 to 11    )
  Platelets                 95    10^9/l       (   150 to 400   )
  Red Blood Cells           1.95  10^12/l      (   4.5 to 6     )
  Haematocrit               0.220 ratio        (   0.4 to 0.50  )
  Mean Cell Volume          110.3 fl           (    80 to 100   )
  Mean Cell Haemoglobin     34.4  pg           (    27 to 32    )
  Mean Cell Haemoglobin Con 31.2  g/dl         (    32 to 36    )
  Neutrophils               4.0   10^9/l       (     2 to 7.5   )
  Lymphocytes               98.0  10^9/l       (   1.5 to 4     )
  Monocytes                 0.0   10^9/l       (   0.2 to 1     )
  Eosinophils               2.0   10^9/l       (  0.02 to 0.5   )
  Basophils                 0.0   10^9/l       (     0 to 0.1   )
  Reticulocyte count        15.8  10^9/l       (    50 to 100   )
  XE FLAG3                  ^Film made by HST                           

Here’s an interesting case. An adult with what appears to be an aplastic crisis. The white cell count is something of a red herring – the patient is known to have long-standing chronic lymphocytic leukaemia.
The salient feature here is the low haemoglobin and reticulocyte count. Utterly at odds with previous findings, but totally in keeping with the clinical picture. The cause of the anaemia – parvo virus infection.

A search of the internet shows that parvo virus is not an uncommon cause of anaemia in patients with a range of diseases. For myself (who sees all of health care being based around red cells, white cells and platelets) the message is that I need to broaden my horizons…

March 16, 2011 (Wednesday) - Blood Groups

Today's lunchtime seminar was a refresher on blood groups: their inheritance and expression. Also was a reminder about the genetics and inheritance of blood groups, and a bit about exactly what the various blood groups actually are, and what the antigens do in the red cell. Some are membrane receptors, some are involved with trans-membrane transport, some are structural.
I like refresher sessions - it always helps to be reminded of stuff: it gets me thinking...
And as ever, the presentation is available in the archive.

March 15, 2011 (Tuesday) - Specialist Portfolio

I spent a few minutes reviewing the specialist website. Specifically the advice on how to prepare the portfolio. I came up with:

How to produce a portfolio is very much a matter of personal choice, but students would be best advised to take a portfolio subject area and complete all related questions and associated work before moving to the next area.

Having said that students are reminded that a lot of the work which appears in section 7.1 is again duplicated in the subsequent sections. The following is as good a way as any to attack the haematology sections.

Section covered

7.1 a

ESR and Glandular Fever
7.1 b
7.1 d

7.1 e
7.1 f (in part)
7.4 a-c

7.4 a-c (in part)

Haemolytic Anaemias
7.3 a-b

Nutritional Anaemias
7.5 a-b

7.1 g-j
7.7 a-c

Haematological Malignancies
7.6 a-b


Perhaps recommending spending a month on each section is somewhat ambitious. Six weeks or two months may be more realistic.
Students should also bear in mind that they need to perform section 6 work too, and as much of the optional blood transfusion section as they feel appropriate.

Notwithstanding the above schedule, students are advised to keep their eyes open for anything which may lend itself to be written up as a case study, specifically:

  • a patient found to have an iron deficiency-related anaemia
  • a patient with an acquired haemolytic anaemia
  • a patient found to have either a serum vitamin B12 or folate deficiency-related anaemia
  • a case study of the progress of a patient found to have a haematological malignancy
  • a patient found to be polycythaemic

Which is all very well as far as the haematology goes. The blood bank sections are still incredibly weak, as are the more general Section 6 sections.
I really need to be addressing those – I now have nine students who are (or soon will be) tackling the specialist portfolio…

March 14, 2011 (Monday) - Websites of Advice

I spent a few minutes tweaking the pre-reg website this morning. I’ve added a couple of supervisor’s affidavit templates. One to affirm competence in workload management & interpersonal skills, and another to generally affirm competence.
I suppose I might go on to add several more of these, but I can’t help but wonder if just one general affidavit might be better than having several more specific ones. But having more stuff from supervisors makes for more evidence in the portfolio, which is usually what the verifier wants to see.

I also had a look at the specialist website as well. It struck me that the advice on how to actually produce the portfolio might be better off being at the top of the navigation bar, rather than at the bottom.

One of my loyal readers has offered to “help with the presentation of the websites”. I’ve given this offer careful thought, but at the risk of appearing ungrateful, I’m going to turn the offer down. The idea of my websites of advice is that they are exactly that – websites of advice. So many websites have flashing lights and Java applets and so many bells and whistles that one can easily lose sight of the object of the exercise. Which is something I’m not keen to do.

March 11, 2011 (Friday) - Skills Fest

Ursuline College (in Margate) was holding a careers fest today, and I was there to run a stall extolling the merits of a career pathological. Much as I (occasionally) moan about it, it’s not a bad old job, really. The idea was I would set up a microscope with some slides, some Petri dishes, some grouped bloods and a tapeworm in a jar (yuk!). The kids would then come round and talk to me about working in a path lab. The students would also have the chance to talk to a lady from the NatWest bank, a policeman, a magistrate, some soldiers, some builders, some civil servants from the European Commission, and people from half a dozen different colleges.
In retrospect I was treating the event as a bit of a jolly, a morning off work, and a bit of a skive. The twelve year olds (who came round first) had the same idea about the event, and weren’t really interested. But as the morning went on, the children coming round were older and older, and towards the end of the morning I had several kids who were quite interested in what I was showing, and several who asked about how one goes about becoming a biomedical scientist. On reflection I would love to have had such an opportunity when I was younger.

Mind you, there were several not-so-gifted children. At least twenty of them, on hearing that the slide under the microscope was showing cancerous cells, asked if they could catch cancer by eating the microscope. A particularly geeky-looking child accused me of bringing MRSA infection to his school. Another child asked me all sorts of questions about the navy, having mistaken my employer (NHS) for the prefix of the ship on which his cousin served (HMS Ark Royal).

But perhaps the sweetest child of the day was a small quiet girl who politely asked me if I could answer her question; but warned me her question wasn’t about blood. I said I’d have a go. The poor child was interested in emigrating to Australia, and wanted to know what job she should do. I suggested she contacted the Australian Embassy. In a very small voice she asked what the Australian Embassy was. The poor child had no idea what an embassy was - she hadn’t been told the first thing about emigration. I suggested she looked up “Australia House” on the internet: they would have all the answers to her questions. Her face lit up – no one (up till now) had been able to help her in the slightest. So I suppose my morning wasn’t entirely wasted.

March 10, 2011 (Thursday) - Borborygmus

I had a patient with a diagnosis I’d never seem before. Borborygmus is the rumbling sound produced by the contraction of muscles in the stomach and intestines. In excess, it can be symptomatic of a myriad of gastro-intestinal conditions.

I’m sorry, I realise it’s unprofessional of me, but I have had the giggles about this today. I suppose that this is the reason why the condition has an impressive sounding name….

March 9, 2011 (Wednesday) - Rheumatoid Arthritis

Today's lunchtime seminar was a tad out of the ordinary. We were lucky enough to get a consultant rheumatologist to give us a talk on the use of disease-modifying anti-rheumatic drugs in cases of rheumatoid arthritis. It was really interesting to see how what we do on a daily basis is put into use in the clinical areas.

I must admit I was a tad sceptical about today - it's been my bitter experience that (with one exception) the more senior the speaker, the more likely they are to let me down at the last minute. But today's speaker was a good 'un. After today's success, I'm left wondering if I might get other consultants to give us a session.

March 8, 2011 (Tuesday) - Odd cell revisited

On January 21 I posted a picture of a blood cell that looked weird. I mentioned this cell on an international mailing list to which I subscribe, and the blog entry for that day got hundreds of hits, and I received dozens of comments. The general consensus was that the cell could be ignored as it was a one-off oddity.

The patient has returned. The one-off oddity is back, and it has friends.

The medical opinion is that the patient has a marginal zone splenic lymphoma, but these cells are just plain odd…

March 6, 2010 (Sunday) - CML Again

On Feb 18th I mentioned that I’d joined an on-line morphology scheme. Today I got to do my first on-line exercise. I was presented with a screen of various blood cells and had to determine the nature of all of the cells, identify all abnormalities present, suggest further testing which should be carried out, and a possible diagnosis. Having made my judgements I got immediate feedback on how well I’d done.

At first I wasn’t impressed with my differential – 38% neuts as opposed to 13% neuts on the reference. But the reference had 25% baso and I’d put 4%. Bearing in mind the appearance of the cells on my VDU, I think I saw those cells as neuts rather than basos. My staging of immature myeloid cells was also somewhat at odds with the reference answer. I shall again blame the appearance on my VDU. Having submitted the answer I then discovered how to use the zoom / high magnification function.
Perhaps next time my differential will be closer to the reference.

However I spotted all of the abnormalities, correctly identified all the further testing that needed to be done, and diagnosed a CML in transformation correctly.

Overall I’m satisfied with my result, but do feel I could have done better. However I shall put that down to unfamiliarity with the software. Now I’ve found the zoom function I’m intrigued to see how much better I’ll do next time…

March 3, 2011 (Thursday) - Pre-Reg Portfolio Website

Yesterday I ended by saying “Now to re-vamp the website of advice for students tackling the pre-reg portfolio to include what I learned myself today…

I’ve made a start by adding a page to that website outlining what happens on the day the portfolio is verified, and a downloadable checklist of required information.

March 2, 2011 (Wednesday) - Portfolio Verification

Rather than going to work today, I went to another hospital to assess one of their trainees. I always say that I know when I arrive whether the trainee is going to pass with flying colours, and today I knew we had a good ‘un. Anyone who’s ever visited a hospital knows how bad parking can be. Today’s trainee had reserved me a parking space, so he was off to a flying start.

The initial interview and chat went well – I hope I managed to put people at ease. I know how nervous I am when I have an assessor (must call them “verifiers”!) to see one of my trainees.
Interestingly the paperwork has all changed since I last assessed (verified!) anyone. Prior to my doing an assessment (verification!), I email a list of questions to the lab I’m visiting so I can have all the information ready for me. I need to review that list of questions in light of the new report form I fill in.

Some verifiers like to look over the portfolio before having a tour of the department. Whilst that is the way it’s laid out in the official guidelines, I like to do the tour first: it gives me a feel for where the trainee is coming from in the work I shall be verifying.
The tour was interesting – it’s always good to see how the other half live. I must admit I was rather alarmed by the bracket fungi and toadstools on the insides of their windowsills. And the ivy coming in through the holes in the ceiling did give me grounds for worry. Whilst I wouldn’t hold that against the trainee, no matter how strapped the NHS might be for cash, I couldn’t allow that to go unnoticed. But I am reliably assured the entire department is moving to new premises in two months’ time, so I allowed them the benefit of the doubt.

Then came the portfolio assessment (verification!). I liked the Hob-Nobs!!
It seems that every verifier has their own way of working. I certainly have the way that I like a portfolio to be laid out. This chap had done his portfolio rather differently. He’d started by producing evidence for section 1a.1, and then for 1a.2, and 1a.3, and so on.
Whilst what he’d done was fine, there was so much duplication of effort in what he’d done. A diary to describe effective time management for section 1a.7 could have been used to demonstrate technical abilities in 2a.3 & 2b.4, QC knowledge in 2c.1& 2c.2, dealing with the unexpected in 3a.2, and health & safety in 3a.3. Similarly a case presentation offered to evidence only one section could have actually evidenced half a dozen sections. I’ve seen several portfolios done this way. They all start brilliantly with wonderful work for sections 1a.1 and 1a.2, and as they go on, so the evidences get weaker.
A classic example of the problem of a portfolio done this way is that the health and safety stuff (right at the end) would be rather weak; but because all the earlier work would have wonderful health and safety write-ups I give the trainees credit for that. If only they would cross-reference. Or if only their training officers would suggest it (!)

But for all that he’d done it differently to how I might suggest, he’d done good. He had included a reflection on how confidentiality applies to him personally, and a reflection on the need for informed consent when dealing with fetal material. I might just add those ideas to my ever-growing list of suggested evidences.
There were smiles all round when I told him he’d passed.

I could have gone to work after the assessment. But instead I went home to write it all up. After all, I’m assessing in works time: I should do the associated paperwork in work’s time too. I can never understand why verifiers who verify my trainees’ portfolios then go back to their places of work for the afternoon – it takes me a couple of hours to both do justice to the trainee when I produce my report and then to write the day up for my own C.P.D. purposes.
By the time I’d finished with the forms and one or two other work-related bits and pieces, far from having had a skive off of work; work was actually up on the deal (as far as my time was concerned).

Now to re-vamp the website of advice for students tackling the pre-reg portfolio to include what I learned myself today…

March 1, 2011 (Tuesday) - Dubious Results

A query from a GP. A patient having monthly blood counts was found to be a tad anaemic last Wednesday. Today they are feeling fine, and no clinical symptoms of anaemia. Which is in line with today’s blood count:

DOB  14/10/1066 Sex F Pat No 123456     
Address   YES     

  01/03/2011 23/02/2011 26/01/2011 24/12/2010 22/12/2010      
  Time u/k      10:25      12:00      u/k        u/k      

HB    13.7       8.2        13.3       12.5       12.4
WBC   8.8        8.0        8.6        9.7        10.5 
PLT   309        196        304        424        443 
RBC   4.84       3.37       4.75       4.55       4.46 
HCT   0.440      0.310      0.420      0.390      0.390
MCV   89.9       92.0       88.6       85.9       86.5
MCH   28.3       24.3       28.0       27.5       27.8
MCHC  31.5       26.5       31.6       32.0       32.1
NEUH  6.2        5.5        5.3        6.7        7.4
LYMPH 1.1        1.4        1.7        1.4        1.0
MONO  1.1        0.8        1.2        1.2        1.5
EOS   0.3        0.3        0.3        0.4        0.4

So what was the Hb of 8.2 all about last week? The GP was at a loss to explain what had happened. That's where I came in..

Last week’s results at first sight would indicate blood loss. Or would they? The Hb is reduced over a month, but so is the platelet count. Given the onset of a bleed over the last month, one would expect the platelet count to have risen. And that MCHC looks decidedly fishy.
Bearing in mind the patient’s clinical condition doesn’t match last Wednesday’s results, but is consistent with today’s and that of late January, I suspect that there was something wrong with that sample taken last week. Clotted, insufficient, short-sampled, taken from the wrong patient… the possible explanations for the spurious result are endless. But whatever the cause, the results are clearly not what was expected.

This case illustrates fallacy of taking the results of any blood analysis in isolation. They need to be taken with understanding of what can go wrong in pre- peri- and post analytical systems, in conjunction with the patient’s clinical condition, and in relation to previous and subsequent investigations (if available).