Anesthesiologist and patient blood management expert Aryeh Shander, MD, FCCM, FCCP is a clinical professor of anesthesiology, medicine and surgery at Icahn School of Medicine at Mt. Sinai in New York City. He also serves as chief of the Department of Anesthesiology, Critical Care Medicine, Pain Management and Hyperbaric Medicine at Englewood Hospital and Medical Center in Englewood, NJ; executive medical director of the Institute for Patient Blood Management and Bloodless Medicine and Surgery at Englewood Hospital; and previous president of the Society for the Advancement of Blood Management.
Dr. Shander felt the call to a career in medicine from an early age. By the time he was in high school, he was dedicated to the path and did not consider other career options. He attended medical school at the University of Vermont, where he appreciated the program’s emphasis on primary care, care delivery, and ethics. As he progressed into residency training, eventually serving as chief resident, Dr. Shander developed an interest in critical care medicine. From there, he chose to specialize in anesthesiology.
Importance of patient blood management
As a practicing, hospital-based anesthesiologist, Dr. Shander joined his organization’s Blood Utilization Committee. There, he realized that there were significant inconsistencies in the way providers approached blood transfusion. He recognized the need for increased education and changes in practice across the hospital – and across healthcare as well.
When I got interested in transfusion medicine through the Blood Utilization Committee, I realized that many patients were receiving transfusions of major blood components, but it was really unclear what the needs were as well as what the benefits were for those patients. So, I started looking into other ways and means to address the needs of the patient through defining what their underlying disease was.
Through research, Dr. Shander became convinced proper blood utilization should not be thought of as product-centered – it can’t be just about transfusion. Rather, health systems and providers have to understand the etiology of anemia and how to best treat it through comprehensive patient blood management (PBM).
Overcoming PBM misunderstanding
When a health system first starts to look at PBM, Dr. Shander advises that health systems look well beyond reductions in transfusion rates. What we need to do is go back again to thinking in terms of not transfusion reduction and not even an appropriateness of transfusion, but to ask the question, what it is that we’re treating, and where would the best benefit be for that patient?
In most cases of iron deficiency anemia, patients might do as well or better by replacing the patient’s iron stores rather than transfusing blood. Overcoming the thinking that patient blood management is just about transfusion is an ongoing education process. It also requires a shift from product-centered culture to patient-centered culture.
PBM is everyone’s concern
Why should all healthcare providers care about modifiable risk factors like anemia and bleeding? For Dr. Shander, it’s all part of medicine’s goal, which is to improve the community’s health.
While some risk factors, such as age, aren’t modifiable, there are others that are modifiable. For example, if you have diabetes and you come into the hospital for surgery and your sugar is out of control, your risk of mortality under any stressful situation increases dramatically. These can be modifiable risks. So, if we see that your diabetes is not well controlled, we’re going to try to change that, to reduce your surgical risk.
In the same way, providers should think about anemia as a modifiable risk, according to Dr Shander. That means that if the patient comes in anemic, we can actually make a diagnosis and apply the appropriate therapy. The same goes for bleeding, especially for surgical patients. We have thought of bleeding as part of doing business in surgery for not decades, but centuries. It is time for us to take another look at that, because it is also modifiable. If health systems pay attention to anemia and bleeding, using the same approach organizations take to other modifiable risks, it will improve patient outcomes and reduce morbidity and mortality.
Profoundly impacting healthcare, moment by moment
Throughout his career, thinking about patients as individuals has been Dr. Shander’s guiding principle. There are going to be patients who have different needs, and it is our job to align their needs with what it is that we’re going to give them. Whether it be the poor who have no insurance, whether it be people who have specific hereditary diseases that put them at risk. I always try to keep this quote in mind: “There’s never a wrong time to do the right thing.” He exhorts his colleagues, and his students, to always think about the right thing to do – not for the provider, but for the patients, for their community, and for healthcare as a whole.
Dr. Shander has profoundly impacted healthcare patient by patient, and he has passed that commitment on to his students as well. If there’s any impact that I’ve had in my career in medicine, it’s not only teaching my colleagues, which I value very much, but teaching the community about again, making the right decisions, about right and wrong.
PBM critical during COVID-19
First of all, we’re recognizing that at least today, we’re not done with COVID. I think we’re also recognizing that the first phase of this pandemic has taught us a lot, but at the same time, we’ve also had a lot of confusion, not just in the United States, but around the globe.
The issue of the blood supply becomes critical at times like these, underscoring the importance of PBM. We have to really change how we look at the blood supply versus its usage. During epidemics, pandemics, and disasters, the shortage that occurs in terms of the reduction of donor blood clearly is a considerable concern and worry. However, if we look at the history of all of these events, the use of blood also either remains the same or goes down.
PBM is not about reduction of transfusion, although that is one of its effects. Implementing patient blood management during the COVID pandemic in institutions would have extended further the reduction in demand for blood, while the issue of supply is being addressed. But in the meantime, one of the things that we can implement other than calling for donors during the time of a pandemic is an approach to implementing patient blood management modes. This approach, Dr. Shander said, may reduce the overall use of allogeneic blood and thus make existing inventory available for those individuals who may benefit most from transfusions.