Pathology Careers in Focus - Transfusion Medicine

Dr. Yasmeen Butt:

Hi, everyone. My name is Dr. Yasmeen Butt. I'm a thoracic pathologist at Mayo Clinic in Arizona, and today we're bringing you one of a series of interviews of different careers in pathology. Something that I think a lot of people don't realize is pathology is a field that lends itself to so many different possibilities. You can be an anatomic pathologist and diagnose cancer all day to transfusion medicine, where you are patient facing. And so that leads us to today's topic is we have the wonderful Dr. Theresa Kinard with us, and she is a transfusion medicine pathologist, and so we're going to hear from her about what that career entails. Theresa, do you want to introduce yourself?

Dr. Theresa Kinard:

Sure. So I'm Theresa Kinard. I'm currently a transfusion medicine specialist here at the Mayo Clinic. I did my training at UT Southwestern in Dallas in anatomic and clinical pathology, and it was really my exposure in my residency program where I learned about clinical pathology, specifically transfusion medicine, and it piqued my interest and where I really found my passion, and that's where I decided to do a fellowship in transfusion medicine. And so, straight out of fellowship, I came here, and I am extremely happy. I can't imagine a career in any other field.

Dr. Yasmeen Butt:

Glowing endorsement. So just a quick step back. So how did you actually become interested in pathology in the first place for any medical students that might be listening?

Dr. Theresa Kinard:

Yeah, so I think that's a great question, and I guess I'll have to start at the very beginning. So going into medical school, I really thought that I would pursue a career in primary care, specifically geriatrics. But going into medical school with a very open mind, I was going through basic science classes, which I thoroughly, thoroughly enjoyed. One of my most favorite classes was histology. So going through histology, I was trying to think about how I can incorporate my love of looking at these beautiful slides into a future career. And now we go into our second year, and I take my first pathology course taught by pathologists, and I was totally amazed and surprised that pathology was even a career field, and I was really, really excited about that.

I left the opportunity open to have a more clinical career. I thought maybe going into internal medicine at some point, but really my passions really always took me back to pathology, and that was really solidified in my selective experiences early on in medical school: being in the lab, really enjoying anatomy, and seeing what grossing was like for the first time. I remember my first selective as a third-year medical student, I got thrown into pathology. No one was there to tell me what to do. They just told me, "Okay, go to the grossing room and start grossing." I'm like, I don't even know what grossing means.

And so they just handed me this binder, and I remember walking in, gowning up, and they gave me five specimens. I think one was a placenta, one was an appendix, and a couple of small little didis. And it took me literally all day trying to figure out what I was supposed to do. I'm not sure that they would let a medical student do that these days, but I think that they were really desperate to get the work done. But just figuring it out for myself was a huge learning experience for me, and it really solidified that I really did enjoy the work, even though it was a very steep learning curve. And so from there, I had some extra experiences working at the forensics institute down there, where I trained, or I did medical school actually. So that was a little bit of an interest of mine.

So going into pathology, I thought maybe I would do forensics. So I knew very early on, when I selected a program for residency training, that I wanted to be very strong in AP and CP with a very good connection to a good forensics institute. And I knew that I had to really show my interest in that particular field very early on. So taking those early electives in forensic science was really important. But that was also really good for me because that showed me that I did not want to go into forensic science after all. So going into AP and CP training, the CP world was completely foreign to me. That's not something that you really learn about in medical school.

You get maybe a little bit of transfusion medicine; maybe one lecture in medical school about that. So having those mandatory rotations in clinical pathology, transfusion medicine really opened the door for me to see an opportunity to be more interactive with our clinical colleagues. Getting an opportunity to learn about something that I think that, I don't know, maybe avoided is not the right word, but it's just something that is, we can't expect our clinicians to know everything. I'm not sure a lot of clinicians really like the coagulation cascade, but I do.

Dr. Yasmeen Butt:

We need somebody who does.

Dr. Theresa Kinard:

Yeah. So I felt like since I really enjoy this material, I enjoy speaking and being that consultant for the clinical colleagues that this would be a good career for me. I just really enjoyed learning the material, and I had really good mentors in my residency program that really made my learning experience and my potential in my career. I could see it as something that would always be very exciting. So that led me to a transfusion medicine fellowship and eventually here at a job at the Mayo Clinic.

Dr. Yasmeen Butt:

Thank you. I really appreciate all that background. I didn't know you were originally interested in geriatrics, so definitely you've come quite a 180 360, I don't know, somewhere far away from that. So I'm curious, so if you could just for the people listening, tell us what exactly your job involves, what do you do on a day-to-day basis? I do think that it's a little black box, especially for perhaps medical students listening.

Dr. Theresa Kinard:

So I think that for anyone listening, just understanding that the job description will be slightly different depending on the practice. But I think here, from my role currently at the Mayo Clinic, I get to do a little bit of everything involving transfusion medicine. So we have four consultants in transfusion medicine currently, and we share responsibilities in the oversight of the blood bank. So that's the blood bank staff calling us for review of workups, patient issues. When clinicians call the blood bank for advice, they forward those inquiries to us.

We also are responsible for managing patients in apheresis, so we get consulted for apheresis, for therapeutic apheresis, in particular. We don't have a donor center here, so we see patients inpatient and outpatient for apheresis. And we do a full range of services here, therapeutic plasma exchange, red cell exchange, cellular depletions. We do a lot of stem cell collections here. We also perform ECP and LDL apheresis. On top of that, we also have a cellular therapy lab. So as transfusion medicine specialists, we are there to support our lab and to support the BMT program here. And we are also involved a lot in a lot of the research activities that occur on our campus in terms of BMT and immune effector cell therapies. So a lot of dynamic changes constantly in growth in that area. I would say another component of the job is coagulation.

We get coagulation training in transfusion medicine, so we are there to direct the lab and to guide clinicians in ordering the right tests for the right patient. We are on call, and usually that covers the entire clinical lab, not just apheresis and blood bank, but since we do have that CP training, we can triage some of the issues that occur with our patients in the clinical lab. So for my day-to-day activities, it just depends on what service I'm on, but we try to really focus it here on a particular area so that our staff knows who to go to for a particular week at a time, and we rotate through all the different areas of our services so that we maintain our skills in every area. So we have someone that is mainly in charge of blood banks, stem cell lab, apheresis, coagulation, but we all take turns on service.

Dr. Yasmeen Butt:

It certainly sounds like more than enough to keep you busy and interested in your job. I'm curious, where and how much patient contact do you think you get? Do you feel like you actually do build relationships with your patients? Just what are your thoughts on that? And I, myself, am curious just how that goes since I essentially don't ever see patients in anatomic pathology.

Dr. Theresa Kinard:

Yeah. So in apheresis, that's where I get all of, I would say most, not all, most of my patient interactions. We have patients who are with us for a very long time, months to years. And so we form very close relationships with those patients. And then we have a smaller portion of patients who are here for just a very short course of treatment. And even though we see these patients perhaps maybe just for one to five to seven procedures, we still form very close relationships with them because as a consulting service, we only have a handful of patients at a time. So we have the ability to really get to know our patients where they're seeing their physician in transplant, solid organ, or BMT. A lot of times we're the easiest point of contact for them, and triaging a lot of their other medical issues. And so I think that that's something that we do offer to our apheresis patients that maybe some other patients might not get; that VIP treatment in apheresis.

But I think that just seeing these patients, having that clinical interaction with patients on a regular basis has really made me comfortable in seeing other patients outside of apheresis. When we get consulted for unusual coagulation issues or chemistry issues, the easiest way for me to get to the source of the information is to go to the patient because when we're reviewing labs, I have a lot of questions, and when I give my recommendations to the clinical team, okay, this is the information that you need to find out for me. It might not be easy for them to do that or to really understand what I'm getting to when I ask my questions. And so a lot of times I just go and see the patient so I can help out the clinical team. So I would say that half of my time I would consider clinical, and really, that is dependent on how you want to function as a transfusion medicine specialist. We can do a lot of things without seeing the patient actually, but how much interaction you get is really dependent on how you choose to have your practice.

Dr. Yasmeen Butt:

It seems like you've struck a nice balance. It's interesting because it seems even in transfusion medicine, just like in pathology as a whole, there does seem to be quite a bit of variability in how your practice can look depending on where you work and what areas you're particularly interested in. Speaking a little bit on that, I'm curious, what is your perception of the job market in transfusion medicine today? I know this is a topic that comes up quite a bit for all areas of medicine, but pathology in particular, just because there tend to be fewer jobs and fewer people that go into pathology.

Dr. Theresa Kinard:

Yeah, no, that's great. I think that since the time that I was applying, so when I was applying for jobs, I think that I really had to recognize that there is a need, but I had to be very open to exploring a different geographic area because transfusion medicine is a specialized part of a very specialized half of pathology, right? And so I had to be very open when I was looking at different job opportunities, which turned out great for me. And I feel like it's not where we have a lot of options. It's either a donor center or an academic center with a transfusion service, essentially.

Currently, I think that the job market is great because I think that the community recognizes the need in the specialized services and training that a transfusion medicine-trained physician pathologist can offer to a practice because I think a lot of maybe smaller hospitals or communities might rely on someone who is boarded in clinical pathology but might not have that background in transfusion medicine, and they really rely on allied health staff for a lot of the key decisions, and they recognize that they need additional help in that area.

So it's not infrequent where we would get consulted by community hospitals because they just don't have that level of expertise, and they recognize that having someone in transfusion medicine can really elevate their practice. I think recently we were just serving the job openings in transfusion medicine, and it's pretty significant, I would say at least almost 50 positions opened in a variety of places all over the country. Even within transfusion medicine, like I had mentioned, there are just so many different things that we have to take care of that even in our practice, we like to have someone who is specifically passionate about blood banking, someone who is passionate about coagulation, so that we can take ownership of those different areas.

Dr. Yasmeen Butt:

For somebody thinking potentially about a career in transfusion medicine, whether a medical student or a pathology resident, what characteristics do you think would lend themselves well to a career? And it may not be one-size-fits-all, but in general, what have you noticed among yourself and your colleagues?

Dr. Theresa Kinard:

I'm not going to say whether someone is introverted or extroverted. I think that's a whole spectrum, right?

Dr. Yasmeen Butt:

Certainly.

Dr. Theresa Kinard:

And I think that, at least from my definition of introverted, has changed a lot over the years because I consider myself introverted, but I think that that just means that we process information a little bit differently and communicate differently than an extrovert. But I definitely would have to say that someone going into transfusion medicine would have to be very comfortable interacting with clinical colleagues and potentially being a part of very difficult discussions about patients with clinical colleagues. And I think that one of the things that has helped me and which is great here where I currently work, is that everyone understands that we all have our own areas of expertise, and we are here to share that information to make the best decision for our patients.

And so, having that mindset, no one I feel like is offended about learning something new. We don't hesitate on providing education in certain areas to our colleagues. So I think that feeling comfortable with having these interactions a lot and spontaneously throughout the day is something that potential future transfusion medicine specialists might want to consider. Other than that, I think that they just have to have a love for the area and recognize that, like all other areas of pathology, it's constantly changing. Regulations in blood transfusions, blood donors. It's constantly changing with the current environment, and feeling that you can be active in staying on top of the new stuff, to making sure that you're running the blood bank, you're running the lab up to standards, and providing the best care for your patients.

Dr. Yasmeen Butt:

Oh, that sounds excellent. Another question I wanted to ask, and this touches on what I think is not often perceived in a potential pathology career, is the so-called emergency situation. I was fortunate enough to train with you at the same institution at UT Southwestern, and I recall as a resident being on call oftentimes, major transfusion protocols being initiated, and things along those lines. I am curious if you could just touch on that portion of your job where sometimes it's very, very emergent and important that you answer a complex question from a clinical colleague.

Dr. Theresa Kinard:

I think that's just accepted as part of the job, and fortunately, because we can anticipate situations that are emergent, that there are policies and procedures in place that can really streamline it. And it's important in our position to educate our clinical colleagues about these policies and where the gaps in knowledge are so that when we do have to come and be a part of the decision-making, it's because of a very unique situation for the patient. I would say a majority of the time, we really don't have a lot of emergent things happening because we already have something in plan for those situations, whether it's a massive transfusion or someone with a really complex workup that needs urgent blood or someone that needs urgent reversal for an anticoagulant.

We as a team have worked very closely with the clinical practice in determining, okay, for a majority of the cases, what is going to be the best practice? Okay, what is the policy and procedure that we're going to follow? And when it falls out of that 95%, that's when we get involved. But since we were involved in the beginning of the development of these policies, I think that the clinical practice feels very comfortable in contacting us and take our direction, and our advice, and how to manage these patients. I think that with time, I think as a resident, it was really stressful, right, Yasmeen? Trying to get these calls, and you're like, oh. And so I think if you're considering going into clinical pathology, where you're going to be interacting with a lot of the clinical practice, it's really important that you choose a residency program that will give you that experience because, even though it was really stressful in residency, I always knew that I had someone that I could call for help, right? Eventually.

Dr. Yasmeen Butt:

Yes, so true.

Dr. Theresa Kinard:

So I think that just with a lot of practice, you build up your confidence, and over time you see the impact of your decisions on patients, and you see the positive outcome, or you learn from an outcome that wasn't what you anticipated. So I think it's all very manageable, and sometimes you still lose a little bit of sleep at night thinking about your patients and the decisions that you made, but that's all part of the job.

Dr. Yasmeen Butt:

Yeah, I totally agree. I think that's just an integral part of medicine in general.

Dr. Theresa Kinard:

Yeah.

Dr. Yasmeen Butt:

So thank you so much for your thoughtful answers to these questions. As we bring this to a close, do you have any words of advice for people considering transfusion medicine or any other tips or thoughts you'd like to share?

Dr. Theresa Kinard:

No, I think that regardless of what specialty in pathology a trainee might choose, I think it's just be very open-minded about learning something foreign and allow yourself to love a new field of pathology, and don't be afraid to pursue it. Because, really, I think that when I initially thought that transfusion medicine could possibly be a career for me, I was really scared. I was like, who in their right mind would like transfusion medicine? These calls are awful, but I really liked the challenge, and I think as a trainee, this is the best time to explore all these different opportunities because once you make that decision and you graduate, now you're the attending. You might be the last stop in the decision-making tree.

Dr. Yasmeen Butt:

Right.

Dr. Theresa Kinard:

So I think having an open mind is probably going to be my biggest recommendation. And not to shy away from challenges in the training; just remember that it is temporary and that really it's only going to make your future a lot easier when it's your time to make that final decision for your patients. Something to consider for trainees considering transfusion medicine, that the possibilities are really limitless. The growth in the need for transfusion medicine specialists is huge today, and I don't see that it will stop growing just because of the direction of our medical therapies for our patients.

We're seeing a huge growth in cellular therapies, particularly immune effector cells, and we're seeing it as a part of a lot of treatments for patients, not just blood disorders, but solid organ diseases and not just malignancies, where a lot of our clinical colleagues are calling on us for help and being a part of these research protocols. Of note, our association used to be called AABB, and now it has been rebranded as the Association for the Advancement of Blood & Biotherapies. And that really just indicates the direction that transfusion medicine is going and how it's going to impact future care and treatment options for our patients.

Dr. Yasmeen Butt:

Well, thank you so much. Well, we really appreciate you answering our questions today, and hopefully there'll be some people out there that will listen to this and consider transfusion medicine as a career.

Dr. Theresa Kinard:

Well, thank you so much for the invitation.

Julie McDowell:

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