This International Women's Day we are celebrating all women who work within the haematology specialty.
To mark the day we take a moment to look at some of our women members making a difference in the world of haematology.
What led you to a career in haematology?
I qualified early in the spring of the final year as a medical student, by doing the “Conjoint exam”, which I don’t think is possible anymore. This meant I could do locum house officer jobs while everyone else was studying for finals. My favourite locum was covering “Tropics”- a ward where patients with tropical illnesses and haematological disorders had beds and run by Professor Alaistair Bellingham (later President of RCPath), who was a mentor and an inspiration to me.
I was also a House officer for Professor Bellingham on 7Y ward at the new Royal Liverpool Hospital at a time when 120 hours a week was the norm. One Saturday morning after a near sleepless night I overslept my alarm and came late to the ward to find “Prof “ had come in and done all my jobs - all the phlebotomy for the ward, and given all the cytotoxics and antibiotics to the patients.
After house jobs I spent many years in general medicine and gradually realised Haematology was my favourite subject - the ability to do the laboratory diagnosis as well as clinically manage the patient seemed a very holistic approach so I finally chose specialist training in Haematology.
Can you tell us more about how you came to specialise in thrombosis?
I spent my time in London rotating between a specialist hospital such as the Royal Postgraduate Hospital and district generals. I found the emotional trauma of caring for patients with leukaemia very harrowing. I was intellectually drawn to non-malignant haematology and spent a sabbatical organised by Professor Dame Marcela Contreras, looking at haemolysis in patients after solid organ transplantation.
It was here I met Professor Sir Magdi Yacoub who offered me space and funds to look wider at unstudied field of haematological issues in solid organ transplantation at the NHLI/Harefield. I jumped at this unique chance and can remember the exciting day when my very own Portacab (my future lab and office) was craned into the Harefield grounds! I got sucked into solid organ transplantation care and studied thrombotic, bleeding and transfusion problems in my lab.
I became interested in the basic haemostatic mechanism of the endothelial response to rejection and Prof used to call me to surgical theatre when a patient was bleeding, asking me to “sort it out”. Crazy but happy times, although I was a lone Haematologist in a world of Immunologists and Transplantors & had to learn to talk their language as they could not speak mine. Eventually I realised the science of thrombosis and haemostasis was the area where I wanted to spend a lifetime’s work.
What advances have you seen in the delivery of care to thrombosis patients during your career?
Where to start!
As a house officer we used to give bleeding patients with Haemophilia A transfusions of cryoprecipitate, then we had Factor VIII concentrates and then recombinant Factor VIII which was used to prevent bleeding and now we have a successful programme in London where patients are producing their own Factor VIII again through gene therapy.
In thrombosis we have enormous understanding of who gets venous thromboembolism (VTE), notably 60% are due to hospital admission and we can prevent much of this by giving thromboprophylaxis.
Tranexamic acid. My favourite drug. How many hours of my life have I spent working on it - incalculable! But it must be mentioned on World Thrombosis Day because nearly a million patients have been in studies of tranexamic acid and it reduces bleeding and bleeding deaths WITHOUT increasing with venous or arterial events - the near perfect haemostat.
Of course I can’t forget to talk about Thrombosis UK. In 2002 I was working on a new technique to diagnose DVT (now known as MR direct thrombus imaging) with Professor Alan Moody. We applied for grants to advance the technique, but no one would fund us. To paraphrase the responses: “this is a good grant but we don’t fund work on venous thromboembolism. So we set up Lifeblood: the thrombosis charity – now known as Thrombosis UK to increase awareness of VTE and raise research funds. Alan subsequently emigrated to Canada and I was left to soldier on and the charity slowly grew on. We all worked hard out of hours for free, and I can remember the multi-tasking we did, for example one summer I actually wrote all the content for our website.
Thrombosis UK campaigned on the postcode prescribing of thromboprophylaxis in the UK and precipitated a Health Select committee in 2005 with many experts giving evidence. One of my suggestions was that each hospital had a “thrombosis & thromboprophylaxis committee” which was one of the recommendations when the report was published. But the biggest demand of the final report was to mandate VTE risk assessment. This took another 4 years campaigning with many health professionals and the All Party Parliamentary Thrombosis Group. This became a reality in 2010 in NHS England when they introduced a target of 90% risk assessment with a financial penalty if Trusts did not reach it. and a fresh infrastructure developed with NICE guidelines and Quality Standards and the Exemplar network. This radical change led to a reduction on VTE events and a 9% reduction in death due to pulmonary embolism.
In 2018 Thrombosis UK has grown to a medium size charity with multiple functions including office staff supporting patients and their care.
But it doesn’t stop there, because the International Society of Thrombosis & Haemostasis on the back of the success of Thrombosis UK have set up World Thrombosis Day to increase global awareness of thrombosis. World Thrombosis Day is on Virchow’s birthday - the 13 October and is now in its 5th year. Last year we had 2.7 billion hits on social medial and thousands of events globally.
Part of World Thrombosis Day’s agenda is to improve global thrombosis care and engage with the World Health Organisation especially as regards to patient safety and the need to reduce thrombosis deaths. I currently lead the latter and am using the NHS England’s systematic approach to VTE prevention as a model of how other countries could go forward.
What advances in our understanding of thrombosis and delivery of care do you expect to see in the future?
Genetic engineering in the next 10 years will hopefully “cure” many of the rare bleeding and thrombotic disorders - from Haemophilia to antithrombin deficiency.
The hunt for the perfect anticoagulant will continue.
What advice would you give to someone considering a career in haematology?
Do it! It is such an exciting time, and the ability to run a laboratory to support clinical work is very seductive.
What is the most rewarding part of your job?
Patient contact always has been and will remain my number 1, but doing a study or clinical trial to answer a research question and campaigning to improve thrombosis and haemostasis care nationally and internationally, are tied jointly as number 2.
What is the most challenging part of your job?
Admin, bureaucracy and IT. Our IT systems are so clunky, they use up energies that would be more profitably spent elsewhere.
What do you get out of your BSH Membership, and what would say to someone who is thinking about joining BSH as a member?
As a British haematologist the BSH is your organisation and wants to support you in your training and education. It’s also a great place to meet like-minded people.
What led you to a career as a Clinical Scientist?
The short answer is the ESR test!
Following a childhood accident, I spent a long time in hospital and needed many blood and plasma transfusions (clearly worked well as I’m here writing this!) I found the whole process amazing. Some tests were carried out at the bedside and I have a clear memory of being very impressed as the skilful technician mouth pipetted the blood up a 20cm glass tube. The tube was placed in an ornate wooden rack and placed on the window sill – the measurement of uncertainty clearly was not considered important back then – spending an hour watching the red cells drift and settle was very entertaining. My paediatric nurse was related to the laboratory technician (official term back in the day) and when I started to recover she would allow me to come to the laboratory and count the cells down the microscope, these were the days before automation. This early fascination with blood stayed and I decided early on that I would be a blood scientist. So public engagement does work! Another factor was my Uncle was a research scientist working in NIH in America – he worked on leukaemia and cancer projects using cell lines and early culture experiments. My Uncle used to visit us regularly in Ireland as he flitted around the world attending meetings – scientific work appeared very glamorous.
Why are Scientists so important in advancing the field of haematology?
Haematology is a fascinating pathology specialism and incorporates a wide range of sub-specialisms. My particular area is lymphoma and leukaemia genetics - because blood is a liquid tumour it is very accessible and it means that haematology has led the way in the field of cancer genomics. One of the first proteins to have its molecular structure determined was haemoglobin, this work was carried out by Dr Max Perutz in Cambridge University in 1959. I was very lucky to cross paths with Dr Perutz during the 1990’s when I worked at Addenbrookes Hospital. The hospital was on the same site as the laboratory of Molecular Biology (LMB) and there was a lot of cross sharing of facilities and ideas. It was very exciting to be in at the beginning of molecular haematology. Now 20 years later, and having just attended the myeloid leukaemia multi-disciplinary team (MDT) meeting we are using high-through put sequencing (HTS) and quantitative PCR and SNP array in conjunction with more traditional morphology and multi-parametric flow cytometry to classify disease and risk stratify as well as direct treatment. My scientific job remains as exciting as the day I started work.
What advice would you give to someone considering a career as a Scientist practicing in haematology?
Go for it! I have never been bored in a 35+ year career in haematology. It is constantly changing and moving forward.
What is the most rewarding part of your job?
Ultimately I love teaching trainee scientists and medics so that they have a strong foundation in basic haematology before progressing on to the more specialist laboratory skills. Seeing the trainees understand some essential concepts.
It is also rewarding to make a correct diagnosis rapidly to enable treatment to start in clinically urgent diseases such as acute promyelocytic leukaemia (APL) - from receiving a sample in the laboratory we can provide a genetically confirmed diagnosis in approximately 2 hours (in most cases.)
What is the most challenging part of your job?
When you cannot carry out the work needed as the sample quality is too poor - that is so frustrating.
What does being a BSH member mean to you?
I have been a BSH member for 20+ years - it gives me a sense of pride to be a member. I have not managed to attend all the annual meetings but I remember my first meeting which was in Cardiff in the late 1980’s or early 1990’s. I have seen the meeting grow from a few hundred attendees to a few thousand. Having working in a few major centres around the UK attending the meeting also has a social aspect as I can meet up with colleagues. I enjoy the mix of scientific and clinical talks and I always make a point of attending educational sessions in general haematology and haemostasis to keep fairly up to date in non-malignant haematology.
What do you plan to do next in your career?
I’m at the stage of my career where I need to think about skills transference! I am doing a lot of teaching within my department at present for haematology and cancer genomics trainees.
Can you tell us about the project that you implemented that led to you winning the Advanced and Specialist Nursing Award?
I was nominated for my work in developing a nurse-led haematology ambulatory chemotherapy and transplant service for patients being treated in Cardiff. I had seen this model of care work very well in other parts of the country and felt that our patients would really benefit from receiving their treatment in this more normalised way. It has allowed them to spend as much time at home as possible, with their families, rather than being admitted into an acute hospital bed to receive their elective treatments.
Why was involving patients in this project so important to its success?
Throughout the project we have tried to capture the patient voice to learn from their experience – this has been key. We have held workshops for patients and families, undertaken patient stories, really sought any opportunity to learn from their experience and refine our process. Our ambulatory model is very similar to what other haematology centres do but we have further developed it to reflect the needs of our patients within South East Wales.
Can you give any advice to those who wish to introduce a similar service at their institution?
It was critical for us to understand from a patient perspective what we did well and what we could do differently with an ambulatory model of care. The patient voice has had a great influence on the service but also on the broader team and bringing them on board with the project.
Secondly, the whole multi-professional team has been essential to make the project a success. Our dieticians, pharmacists and physiotherapists have contributed to the project alongside the medics and nurses. Each professional brings something new to the table to learn from and contribute to developing a rounded model of care.
Finally, use your local improvement teams. Having someone outside of the speciality to bounce ideas off and help facilitate patient and team events has been incredibly useful and offered different perspectives on what we wanted to achieve.
What led you to a career in haematology nursing?
I was rotated to haematology as a student nurse and found somewhere that I was supported and promoted the nursing role, challenged me and allowed me to think, and offered continuity of patient care – something that I personally find rewarding. I had brilliant role models to aspire to and over the years have worked with many supportive teams who have developed and educated me. Personally, I have always felt stimulated and challenged within the speciality. Within my career, I have become particularly interested in young adult care and haven’t looked back since!
Why is this role so important in the delivery of excellent patient care?
I think increasingly the haematology nursing role is adapting to meet the needs of the ever-growing services. We have taken on training and developed our clinical and leadership skills. We are pushing the boundaries of nursing but remaining true to our profession. I think the nursing workforce offers a continuity with skilled, expert and holistic patient care. This doesn’t just have benefits to our patients but also supports our teams to deliver excellent patient care.
Can you give 3 practical pieces of advice for haematology nurses in delivering excellent patient care?
- Learn from your patients and champion their voice
- Don’t be afraid to take the lead
- Introducing different ways of working does take effort and time, but the rewards are worth it. Engage the teams around you in your project or idea.
What are the rewards and challenges of the role?
The patients are the most rewarding. I feel privileged to support patients and families, especially through difficult times. It is particularly rewarding when you see patients who are now in remission and moving on with life – back at university, buying a house, just doing the things they want to do. I also really enjoy service improvement and there have been many opportunities for me to be involved in this within haematology. Finally, developing other staff - I have always been so fortunate to learn from other brilliant and inspiring colleagues. To positively contribute to someone else’s development is very rewarding.
This biggest challenge is when things do not work out as we would hope for some patients and families, which unfortunately is part of this role. Another challenge is defining and championing advanced practice roles – I think sadly they are still not widely understood.
What does BSH membership mean to you?
BSH has given me an opportunity to meet other similarly minded people, share ideas and network. I have enjoyed the mixture of professions and backgrounds; the collaboration. This has been particularly prevalent for me within the Teenage and Young Adult Specialist Interest Group. I am also very grateful for the educational opportunities and expertise that BSH provides.
The aim of the session was to encourage reflection amongst haematologists on their practices with a theme of ‘How do haematologists do most harm to patients?’ The five best abstracts were selected for presentation, with the trainees then being questioned by a panel of experts.
We interviewed Dr Wolf to find out a little bit more about her journey in haematology and her Crucible Prize success.
What was your Crucible session presentation about?
My presentation was called 'Young, Black and Stigmatised' and was about how haematologists harm patients with sickle cell disease (SCD). I focused on three main areas: hospital admission, opiate use and lack of psychological input, but these come on a background of socio-economic deprivation, institutional racism and lack of research funding.
Why do you think your presentation theme on ‘how do haematologists do most harm’ is so important and why?
I think it’s important because although sickle cell disease is the most common disorder 'caused by a single inherited genetic mutation in the UK, we still don't really know how to treat it. I think patients with sickle cell disease are stigmatised, partly due to their age and ethnicity, and this directly impacts not only on their hospital care and ability to lead normal lives when they are well, but also leads to a lack of advances in the disease. I wanted to highlight this and start a conversation about how we can improve things for these patients.
What are three practical steps that can be taken to ensure this isn't reality for people with sickle cell disease in your organisation?
1. Examine your own prejudices. 33% of haematologists think over 10% of patients with SCD are addicts and 5% think it's over 90%! Is this you? If so, why? Is it based on your experiences or is there an underlying element of racial bias there? We cannot be effective advocates if we do not get our own house in order first.
2. Call out others. The language and behaviours used by staff to describe these patients is often pejorative. It can be seen across all staff groups, from the most junior member to the most senior. If you witness this behaviour, challenge it and ask the speaker to review their own beliefs about patients with SCD.
3. See the person, not the disease. Does your patient really need to be in hospital today? Maybe they have studies to get back to, or a partner, or children. These patients, who are mostly in their teens and twenties, are at the point in their lives where they should be building their educational and social futures. If we try to take their care out of the hospital as much as possible, we allow them the same opportunities that everyone else at that age has, and let them define themselves by their hopes and dreams, not their disease.
What led you to a career in haematology?
I graduated from Imperial College, London in 2008 not intending to do Haematology at all, in fact I wanted to be a Psychiatrist! I first encountered Haematology patients as an A&E doctor looking after patients with sickle cell disease at Guys and St Thomas hospital. This led me to want to know more so I spent a year in the green rolling hills of the Waikato in New Zealand where I did 6 months Haematology and fell in love with the specialty. What I loved best was the variety of patients, the liaison with other specialties and the problem-solving approach to diagnosis.
After Core Medical training back in London I started Haematology training in the North East Thames deanery in 2013. I am currently an ST6 trainee having had 2 babies along the way!
What advice would you give to someone considering a career in haematology?
Spend some time in the lab. If you enjoy looking at cells and trying to match it to the clinical picture, you'll enjoy haematology. Haematologists love to sit down and think about complex problems - we're not really adrenaline junkies - but if you like taking all the evidence and working it out from patient to lab you'll love haematology. It's a brilliant career and I am very happy with it as my choice of specialty.
What is the most rewarding part of your job?
Spending time with patients and seeing them through their journey - whether that's diagnosis of leukaemia to remission or getting to see a family with a new diagnosis of haemophilia gradually adjust to their disease. You end up building really strong relationships. When I think of my patients I like to remember things like the fact they played their guitar on the ward, or the fact they plan to go travelling after they finish chemotherapy, rather than just what disease they have.
What is the most challenging part of your job?
Seeing patients die, especially young patients, is hard. But it does make you realise that life is short and, although this is a cliché, you should live it to the full.
What does being a BSH member mean to you?
An opportunity to hear about and meet other inspiring members of the haematology community and their work.
What do you plan to do next in your haematology career
After finishing my maternity leave, I am going to start a PhD back at Imperial College in October.
