Chapter 07: Chair of Laboratory Medicine: Bringing Automation, Customer-Based Services, and Transfusion Guidelines
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Description
In this Chapter, Dr. Lichtiger outlines his role as Chair of Laboratory Medicine from 1999-2008. He begins by sketching his responsibilities, noting how difficult it was to make decisions about assigning salary raises to faculty, dilemmas that gave him “many sleepless nights” because of their human dimension. He then talks about bringing automation to the Department and developing a concept of a de-centralized laboratory that would be more appropriate to MD Anderson than the centralized system in use. He was not successful in effecting this change, but notes that it is coming: the new operating room and ICU will both have laboratories, for example. From this discussion, Dr. Lichtiger again affirms that Transfusion Medicine services operate from the question “What do customers want and when?” He talks about the frustrations of dealing with new faculty at MD Anderson who do not understand that this institution’s Transfusion Medicine service operates as a collaborative clinical specialty, rather than a lab that blindly fills orders. He mentions the Transfusion Guidelines, created by the Transfusion Committee. He also speaks about his own concept of the “Prospective Review,” a process by which all of a patient’s information is examined to determine which blood products will integrate most therapeutically into the patient’s treatment. At the end of this Chapter Dr. Lichtiger talks about the Fellowship Programs he administers, the difficulty of selecting Fellows with real drive, and the challenge of teaching Fellows clinical interactive skills.
Identifier
LichtigerB_01_20120611_C07
Publication Date
6-11-2012
City
Houston, Texas
Interview Session
Benjamin Lichtiger, MD , Oral History Interview, June 11, 2012
Topics Covered
The Interview Subject's Story - The Administrator The Administrator Professional Values, Ethics, Purpose Character, Values, Beliefs, Talents Overview Definitions, Explanations, Translations Institutional Processes Devices, Drugs, Procedures Institutional Mission and Values MD Anderson Culture Building/Transforming the Institution Multi-disciplinary Approaches Growth and/or Change Professional Practice The Professional at Work Mentoring Discovery and Success This is MD Anderson Education
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
Tacey Ann Rosolowski, PhD :
Now in 1999 you became chair of Laboratory Medicine, and I was wondering if you could tell me how that opportunity came about. What was that process like?
Benjamin Lichtiger, MD :
There was a search, and Dr. [Stanley R.] Hamilton came on board, I don’t know, a couple of years earlier, a year or two. I don’t remember exactly. And apparently he knew I wanted to be the chair. I was the acting chair, and he wanted to help, and apparently in his mind, other people’s minds, I must have been the best candidate and was named the chairman, and I always operated like the chairman, waiting until the definite chairman comes in. But it was not something I would have killed myself over—not something that—so that was a marvelous experience. I could work with Dr. Hamilton, the whole administration. It was more global, but it was difficult because I’d been chair of the department, and I also was chair of blood banking, so it was very difficult to wear both hats, and I had to be fair because Microbiology had needs, and Chemistry had needs. Everybody had needs. It’s like having many children. They all have needs and who do you give the—and the way it operates here they give you a pot of money, and you decide what equipment to buy for Micro, for the blood bank, here, there. That was the tough part.
Tacey Ann Rosolowski, PhD :
What was an instance in which it was—? Benjamin Lichtiger, MD Well, I had to decide, buy a $300,000 bus or buy a $300,000 machine for Microbiology. What was important? I had to make very, very tough decisions. I had to assign salary raises for faculty because they give—here the system is they give the chair a pile of money, and now you divide it, and there are people who are not good performers, but I knew they had family problems. They had children with—handicapped children with some problem, and I used to spend sleepless nights. I knew they needed the money for special education, things like that, but there were other ones who were high producers, academically active, and how do you reach the right thing? Sometimes I had to close my eyes and just jump, and that was the most stressful part of the job—not handling the technicians, not handling the complaints, but making decisions about the faculty and supervisors. That was very hard because one gets to know the human side of the people one works with, and that is very, very difficult. One cannot be cold. I mean, I have children. I have grandchildren, seven, and some of them needed help in school, special education. None of them have major problems, but they need a boost, and so I understand that. It was very, very hard. That was the toughest part, and that’s why I felt relieved when I retired of not having to deal with that particular human aspect. That’s the hardest part.
Tacey Ann Rosolowski, PhD :
What were some of your goals? What did you want to achieve in the Department of Laboratory Medicine when you became chair? You said you’d already been operating as chair but what were the projects you wanted—?
Benjamin Lichtiger, MD :
First I knew that the institution was expanding, so I wanted to bring in automation, bring in new technology, a new information system, new tests. I knew they were sending out a lot. There were multiple projects I wanted. Finally towards the end we brought in automation. This transitioned over to the new chair, and she’s carrying on that project very wisely, and we were changing the information system, new tests. It’s a continuum. One thing I wanted to do but I was not successful is I felt that the laboratory centralization model is no longer effective, that we need to have small laboratories serving the different areas. Leukemia is a high intensity area. We should have a laboratory there—surgery, ICU—and it requires an investment. Maybe after three o’clock, four o’clock, five o’clock, the equipment you’ll have to turn off because sleeping equipment is losing money because you’re paying for it. But the customer is happy, and that is very valuable. The customer writes good reviews, writes feedback, surveys. The chairman, Dr. Hamilton at the time, did not agree with me and the administrator of the division—well, now we are going in that direction because the clinical services are saying, “We want that,” and the OR says, “We want that in the OR.” Something I’ve been trying to foster, and there are ways today with micro equipment that you can put it on a rolling table and go from bed to bed and do the testing. There are smaller and smaller tests, and we have infrared technology to transmit the data to the information system, so we have it. But the problem is some people just still think on the big central lab where everything comes, and I think that the big central lab operates after five o’clock. Everything comes, and you finish up the work. I was not successful. But now I can observe that we are going that way.
Tacey Ann Rosolowski, PhD :
Last week I interviewed Dr. Bruner, and she was talking about the move to subspecialize in pathology. It sounds like an analogous kind of thing.
Benjamin Lichtiger, MD :
Yeah, exactly. That’s a need. The institution is so big, because if you look at the transportation time from the patient’s bedside to the lab—I mean—sometimes you have to walk a mile. We need to change. We need to move. So what if—annuitization of equipment—you’ll do it in five years, seven years. So what? The clinicians and the patients say this is—because then it increases the volume. They increase the volume, they increase their revenue, so they say we need to offset that, but they have to make the investment.
Tacey Ann Rosolowski, PhD :
But you said they’re going—?
Benjamin Lichtiger, MD :
Now they’re trying to go in that direction because I know the old OR will have a lab, and the ICU will have a lab, and now they are demanding—the clinicians—and I always tried to be prospective. Now we are going to do it because we are reactive, and I think that the lab and the blood bank—no. But the lab, now they say we have to be prospective. You have to scan the horizon and see what does the patient want? What does the clinician—what does the customer want when, and what can we do? Let’s talk to them. I had my difference about that with Dr. Hamilton. He’s a very nice guy. He treated me very well. I cannot say anything about—but philosophically—and the administrator, the previous administrator, we had differences of opinion about the perception—the business model. They are the chiefs. They won, so that’s fine. I continue with my work. I did what I could, though.
Tacey Ann Rosolowski, PhD :
That must be exciting. Benjamin Lichtiger, MD Yeah, it is exciting. Exactly, it’s exciting. You may notice that I’m passionate about that because I believe in that. As I told you at the beginning, if I don’t believe in something, I don’t get passionate. It’s dead. But we are advancing, and sooner or later things that make sense come up to the surface, in spite of people’s effort not to.
Tacey Ann Rosolowski, PhD :
Well, it just seems with everything now it’s compartmentalized but in a healthy way, because there are lots of links between departments.
Benjamin Lichtiger, MD :
Absolutely, absolutely. And there are things that we need to talk to each other, have better communication, and we bring many physicians on board now and bring the APN people that have no tradition—knowledge of the traditions of the institution. They bring their own guidelines for transfusion. We have to educate them constantly, talk to them and say, “This is not the way you do that.” Tacey Ann Rosolowski, PhD How are people educated differently?
Benjamin Lichtiger, MD :
Now there’s a law—I read and I notice that there is an intense mentoring program here. They’re mentoring faculty. I don’t know how that’s going, but we mentor them. We teach them the hard way, because we tell them, “This doesn’t make sense. You need to have the physician who put the order talk to us.” And then we discuss the case, and we’ll give them alternatives. Do you agree or disagree?
Tacey Ann Rosolowski, PhD :
That must be—I mean, that’s a very intense process basically of educating incoming people on how to interact.
Benjamin Lichtiger, MD :
When they have to—at least in the blood bank it is very intense.
Tacey Ann Rosolowski, PhD :
What’s an example of a case where you had to shepherd somebody through your process, like a newcomer?
Benjamin Lichtiger, MD :
Right now today when they paged me out there’s a patient that has a platelet count which is okay, and I get a call from the APN. “We need to give him platelets because we need to give him chemotherapy.” That’s not the clinical criteria. You give platelets when the patient is bleeding. Where did you come up with that one? That’s a new one on me. I said, “Have you read the guidelines from the transfusion committee?” “No, why?” “You need to read it.” Then I got a page from the doctor, and he discussed the case with me, what’s going on, the disease. Okay, so I said to him, “Okay, this is a particular case then. It’s not a standard of care, because she gave me the impression, the APN, that’s your guidelines, and we don’t have departmental guidelines. It’s institutional guidelines.” “No,” he said, “that’s one case.” “Okay, I will back you up. Go ahead and give him chemotherapy. We’ll back you up.” We discussed the case. In other places, I know in other centers, the order comes in, they give it to them, no question. Here you question every order.
Tacey Ann Rosolowski, PhD :
You mentioned these guidelines. Are there—?
Benjamin Lichtiger, MD :
Transfusion guidelines created by the transfusion committee in the institution, not by us. We are members of the transfusion committee. We gave our five cents into the idea, and these are the guidelines for the transfusion. That’s required by joint commission that each institution have guidelines, transfusion committee. If not—I can notice every new physician that comes from a different place, they have their own guidelines. Oh, I want twenty units of platelets. “Okay,” I tell them—I call them back. Well, I don’t call them. I send a message, “We need to talk.” You call them and say, “Tell me your mathematical formula. How have you arrived at twenty units of platelets?” They don’t have it. They don’t even know that there is a formula, so I have to tell them, “What do you want to do? When are you going to do it?” I tell them, “You go ahead, take the patient, and we’ll infuse it during the procedure slowly, and you’ll be okay. Put my name there that I told you that. Page me. I’m available twenty-four hours, seven days a week. You want to talk? Any time.”
Tacey Ann Rosolowski, PhD :
You’re kind of providing ongoing education.
Benjamin Lichtiger, MD :
Continuous, myself and my two partners.
Tacey Ann Rosolowski, PhD :
Yeah, who are your two partners?
Benjamin Lichtiger, MD :
Dr. Martinez, Fernando Martinez, and Dr. Fleur Aung, A-U-N-G. They are two junior members, but they are very good. They are nicer than I am. (laughs) Well, after forty years doing this you get—and hearing the same story time after time after time. Today at three o’clock in the morning—I’ll show you for you to see—3:38 in the morning. [Dr. Lichtiger shows the Interviewer his phone and queue of incoming messages.]
Tacey Ann Rosolowski, PhD :
Auto notification of expense reports.
Benjamin Lichtiger, MD :
No, no. This one. I was called at three o’clock about platelets for somebody so I asked them—from Pediatrics—“What is the platelet count?” “Well, the platelet count three or four days ago—” I said, “No, I need today—how can you even order platelets if you don’t know the platelet count? How do you know the patient needs that?” I said, “After you get platelets, you can call me back again.” He never called. These are the new people. They think that they will send the order and we’ll—no, that’s why I said we do prospective reviews. We intercept it immediately. In this way we practically do away with twenty to twenty-five percent of the requests per day. We save the institution a lot of money.
Tacey Ann Rosolowski, PhD :
Now, how did you develop this particular philosophy of the prospective—essentially the prospective review?
Benjamin Lichtiger, MD :
I saw that the retrospective review didn’t work, because once you release a transfusion and you enter a patient and you write a letter to the doctor two months later, it doesn’t do any good. So I went to the transfusion committee and said, “This does not work.” They said, “Okay, we’ll change it.” We have a rotating pager, and it’s built into the guideline, that pager. If it’s about a set level you have to call and talk to the transfusion medicine physician. Now the orders electronically come through. We take a look. It makes sense. If it doesn’t make sense we put in a number in the computer. It goes and they know they need to talk to me—to me or to my—whoever.
Tacey Ann Rosolowski, PhD :
How quickly are those requests processed?
Benjamin Lichtiger, MD :
Minutes. Tacey Ann Rosolowski, PhD In minutes.
Benjamin Lichtiger, MD :
Yeah, there’s no delay.
Tacey Ann Rosolowski, PhD :
Okay. Now, when did you begin—it sounded like you began to—
Benjamin Lichtiger, MD :
Easily about twenty years ago.
Tacey Ann Rosolowski, PhD :
Twenty years ago.
Benjamin Lichtiger, MD :
We started that, and they are accustomed. They know, and people know, the blood bank will not honor that. They will not give you platelets.
Tacey Ann Rosolowski, PhD :
Was it a radical idea at the time? Benjamin Lichtiger, MD At that time, yes, at the time it was, and I was warned it was going to consume my time. There was a time for a number of years I was the only one in the blood bank, and I was on call seven days a week. But I said, “We need to break the backbone of this monster. Sooner or later we need to break it.” And we did, and then they got one partner and another one. One retired, one moved to another department.
Tacey Ann Rosolowski, PhD :
Why did people find that a radical thing to do at the time?
Benjamin Lichtiger, MD :
Because many of the blood bankers, by coming from pathology, they are not accustomed to dealing with the patient, with the clinician. Now I have to go and see a patient. I told you. I deal with the clinicians. I see them on the floor. I go on rounds. I go to conference. I argue with them, and my partners too. The magic disappears. We are on the same level here. Now you tell me why you want that, and I’ll come back and tell you why you don’t.
Tacey Ann Rosolowski, PhD :
Yeah, so it’s kind of making—
Benjamin Lichtiger, MD :
I’m going back to the old blood banking. The initial blood bankers were hematologists, clinician hematologists. I’m going back and I think—and I have proposed that to some places, some environments that we need to go back to train the blood banker in hematology and not in pathology because we get here fellows from pathology that want to come to blood banking, and when they tell them they have to see patients and discuss with the family, they turn green because they are not accustomed. They have not done it. They’ve only dealt with the bodies, and transfusion medicine is an intensively clinical discipline.
Tacey Ann Rosolowski, PhD :
I was going to ask you about the fellows program. Could you tell me about—because you have a fellowship program.
Benjamin Lichtiger, MD :
Yeah, we do. I used to be the director at one time. After that I stepped down and different people—so we had some success, some failures. We had some fellows that did not work out well.
Tacey Ann Rosolowski, PhD :
Why didn’t they work out well?
Benjamin Lichtiger, MD :
Well, apparently the passion was not there. Frankly, they came with us, they misled us, and they came here just to make time until they found something else. Some of them were successful. Some of them direct our blood bank. Some are very good. The two partners I have came from our transfusion program. We have only one position because at one time the institution was cutting positions because of funding, so they only have one fellowship position.
Tacey Ann Rosolowski, PhD :
You were involved in both the transfusion medicine and chemical pathology fellowship programs.
Benjamin Lichtiger, MD :
Yes, yes.
Tacey Ann Rosolowski, PhD :
What is the educational process like for the fellows, and how does it differ in those two programs? Benjamin Lichtiger, MD Well, one is going to be people just want to concentrate—like in blood banking they want to concentrate in the clinical lab, and there’s a subspecialty, clinical pathology. That’s also where there’s a massive shortage in the country with that, so they train in the procedures and how to use them, when to order them. They understand the results, recommend further testing, the same as us but in the lab work general—laboratory aspect—and we teach the fellow not only how to do the work in the blood bank but also how to talk to a patient, to the clinician, how to talk to everybody, how to write notes in the chart and how to pick up the phone and sometimes hear an irate donor, an irate patient. “How come you didn’t give me the units of blood that my relative gave for me?” And you have to tell them, “Sorry. That unit broke in the centrifuge.” No, that’s not true. That unit is positive for syphilis. I cannot say that. I have to guard the confidentiality. Maybe he doesn’t have syphilis. Maybe it’s because the person has rheumatoid arthritis. People with rheumatoid arthritis give a false positive syphilis test, but we can’t elucidate that at that time. The unit has to be destroyed, so we go and tell them that. We won’t go and tell somebody that that person has a false positive syphilis. That false positive will never register. The only thing—so you cannot do it, so you have to learn diplomacy, how to handle the donor, the patient, the doctor. They have to present clinical history. They have to rotate to Pediatrics or have to rotate in Cardiovascular Surgery. They go to Ben Taub, to emergency rooms, emergency room transfusion medicine. They all have different needs. It’s a totally different patient population.
Tacey Ann Rosolowski, PhD :
Now, did you feel that—was it in transfusion medicine or in chemical pathology that you were a little disappointed in the way that—?
Benjamin Lichtiger, MD :
In transfusion.
Tacey Ann Rosolowski, PhD :
In transfusion.
Benjamin Lichtiger, MD :
Yeah, the people came here, and they thought they were going to have a vacation, just sitting in a cubicle, and read books. No, not with us. You read books at night like I do. Go home and spend another three or four hours reading, studying.
Tacey Ann Rosolowski, PhD :
Were there some changes that you made to the selection process as a result of that experience?
Benjamin Lichtiger, MD :
The only change I think that worked and I recommended to Martinez, who is now the director, is to call on the phone and talk to the people that write the recommendation. Sometimes they write a letter of recommendation because the guy is in front of them. Talk to them and see. Ask them, “Are you going to hire him back? Would you take him back again? What do you suggest I do? What should I be looking for?” And then when the people start spilling stuff, you know who you’re dealing with, and after that it’s just a tossup.
Tacey Ann Rosolowski, PhD :
We’re going on ten of 12:00, and I wonder if you would like to stop for today?
Benjamin Lichtiger, MD :
Okay.
Tacey Ann Rosolowski, PhD :
I have a few questions left to ask, but we can work with those tomorrow. It will be a short session.
Benjamin Lichtiger, MD :
Okay, very good.
Tacey Ann Rosolowski, PhD :
Thank you. It’s ten minutes of 12:00, and I’m shutting off the recorder. (End of Audio 1 Session 1)
Recommended Citation
Lichtiger, Benjamin MD, PhD and Rosolowski, Tacey A. PhD, "Chapter 07: Chair of Laboratory Medicine: Bringing Automation, Customer-Based Services, and Transfusion Guidelines" (2012). Interview Chapters. 1462.
https://openworks.mdanderson.org/mchv_interviewchapters/1462
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