George A. Fritsma1, Jin Ye Yeo2
1The Fritsma Factor, Your Interactive Hemostasis Resource,153 Redwood Drive, Trussville, AL, 35173, USA; 2AOB Editorial Office, AME Publishing Company
Correspondence to: Jin Ye Yeo. AOB Editorial Office, AME Publishing Company. Email: aob@amegroups.com
This interview can be cited as: Fritsma GA, Yeo JY. Readers’ Choice: Author Interview with Dr. George A. Fritsma. Ann Blood. 2024. Available from: https://aob.amegroups.org/post/view/readers-rsquo-choice-author-interview-with-dr-george-a-fritsma.
Expert introduction
Prof. George A. Fritsma (Figure) is a Consultant Associate Professor in the Division of Laboratory Medicine at the University of Alabama at Birmingham Hospital. He provides hemostasis lectures for clinical pathology residents and hematology fellows and has managed his Fritsma Factor blog since 2007.
Prof. Fritsma served as an editor of Clinical Laboratory Science, the official journal of the American Society for Clinical Laboratory Science (ASCLS) from 2002–2012. He founded and chaired the ASCLS Choosing Wisely Committee, which develops recommendations for healthcare providers to apply appropriate diagnostic tests to enhance patient outcomes. He has presented more than 100 national and international scientific talks for colleagues and has published more than 70 articles, handbooks, and chapter contributions to six editions and editorial support for two editions of Rodak’s Hematology; Clinical Principles and Applications, the most recent of which was released in July 2024.
Prof. Fritsma’s article titled “Labeling tubes before collection threatens patient safety” published in our journal has earned an outstanding readership and entered the journal’s Most Read Article List.
Figure 1 Prof. George A. Fritsma
Interview
AOB: What drew you into the field of laboratory hematology?
Prof. Fritsma: At the University of Illinois, early in my career in Medical Laboratory Science (MLS) education, I was assigned the hemostasis (coagulation) unit in the Advanced Hematopathology course. Over the years my fascination with hemostasis grew.
AOB: Your article titled “Labeling tubes before collection threatens patient safety” has gained significant attention. What motivated you to write about this topic, and what do you think made this article so well-received by readers?
Prof. Fritsma: I was acquainted with co-author Dennis Ernst, who recently retired from his agency, the Center for Phlebotomy Education. Dennis chaired an international committee that developed the seventh edition of Collection of Diagnostic Venous Blood Specimens—Approved Standard (GP41-A7), 2017; Clinical and Laboratory Standards Institute (CLSI). He grew concerned that some European countries published guidelines that permitted collectors to label specimen tubes with patient information prior to blood collection, often prior to patient arrival. This practice was contrary to the standards of the World Health Organization (1). Pre-labeling raises the risk of the collector selecting the wrong prelabeled tube, resulting in a mislabeled specimen. Along with Mr. Ernst, I received support from co-author David McGlasson, a recently retired researcher for the 59th Clinical Research Division, Lackland AFB, TX, who coached me about issues of specimen mixing, hemolysis, and underfilling.
AOB: How do you think the laboratory community can address the issue of pre-collection tube labeling? Are there specific protocols or best practices that you would recommend to improve patient safety in this area?
Prof. Fritsma: CLSI and WHO provide the above-referenced international specimen management standards. Local healthcare facilities and “circuit riders” must provide entry-level education and follow up with continuous quality improvement to ensure consistent specimen integrity.
AOB: You have contributed to numerous editions of Rodak’s Hematology and other major textbooks. From your perspective, how has hemostasis testing evolved over the years? What impact do these changes have on patients and laboratory scientists?
Prof. Fritsma: Several new approaches to hemophilia treatment have developed beginning in 2014. These include extended half-life coagulation factor concentrates, 2014; coagulation factor “bypassing” therapeutics, 2017, gene transfer protocols, 2021; and “rebalancing” RNA inhibition therapy, in development. These approaches have challenged MLSs to develop new assays capable of reporting consistent and clinically valid results.
Emergent research during the 2020–21 SARS-Cov2 pandemic established the interrelatedness of hemostasis and inflammatory mechanisms, raising our ability to manage thrombotic microangiopathies and “cytokine storm.” MLS researchers are eagerly working on assays that can predict, diagnose, and treat inflammatory sepsis secondary to these conditions.
AOB: What are some of the biggest challenges in the field today, and where do you see opportunities for significant improvement in the next 5-10 years?
Prof. Fritsma: Many specimens are collected at local clinics for transport to central laboratories by contract “circuit riders.” Besides accurate identification and collection techniques that avoid short draws, clotting, and hemolysis, specimens must reach laboratories within strict time and temperature guidelines to ensure clinically reliable results, and once received, must be properly prepared for testing or for temporary storage.
Molecular diagnostic protocols became available in 2000 as the Human Genome Project neared completion. Molecular diagnostic assays achieve nearly 100% sensitivity and specificity. Meanwhile, phenotypic testing, the backbone of laboratory services, is by nature incompletely sensitive or specific, generating “false positive” and “false negative” reports. Our goal is to maximize sensitivity and specificity. Meanwhile, MLSs and patient-facing providers try to “reign in” unnecessary screening practices. Screening is the use of laboratory assays in the absence of clinical indications. Providers, motivated partly by the risk of litigation, order, for example, prothrombin times (PTs) and partial thromboplastin times (PTTs) before proceeding with invasive procedures in an attempt to predict the risk of bleeding. Laboratories in tertiary care facilities perform scores of PTs and PTTs daily. When applied to an “unselected” population, the rate of false positives exceeds the rate of true positives, generating patient anxiety, delays, expensive follow-up testing, and inappropriate therapy. Meanwhile, false negatives lead to an inappropriate sense of safety. Numerous large clinical studies have consistently shown that a patient and family history is a better predictor of hemorrhage than laboratory assays in the absence of indications.
AOB: You have been a leader in the ASCLS Choosing Wisely Initiative, which developed recommendations to healthcare providers regarding laboratory testing. Could you highlight some of your works in this area and how they have impacted the field?
Prof. Fritsma: Realizing providers’ need for proper application of diagnostic laboratory and imaging procedures, the American Board of Internal Medicine Foundation (ABIM) and Consumers’ Reports® initiated Choosing Wisely® in 2012. In 2017, ASCLS joined the effort at my recommendation and formed a task force that emerged as a standing committee in 2019. We developed a series of recommendations based on clinical research and ASCLS members’ experiences. In 2023, ABIM discontinued Choosing Wisely, having produced over 500 validated recommendations, and transitioned to its current Building Trust initiative. A patchwork of clinical agencies adopted Choosing Wisely recommendations with varying outcomes. ABIM turned over the initiative to partner organizations, whereupon ASCLS, the American Society for Clinical Pathology, and the American Society of Microbiology adapted the laboratory-based diagnostic recommendations under the title, Effective Test Utilization®. We continue to produce recommendations.
AOB: You launched The Fritsma Factor as a resource for healthcare professionals, which is uniquely known for its community engagement. How do you foster communication and collaboration among hemostasis professionals through this platform? Are there specific initiatives or strategies that have proven to be particularly successful?
Prof. Fritsma: I am gratified that a blog and website with a narrow clinical focus has steadily gained in subscriber participation since I first developed it with my sponsor, Precision BioLogic Inc. of Dartmouth, NS Canada, in 2007. We encourage questions and comments from MLSs, clinical pathologists, and patient-facing providers and offer unbiased, authoritative information supported by international experts on hemostasis lab technology, clinical relevance, and diagnostic complexities. We “push” a monthly one-page “Cheat Sheet” to subscribers describing the previous month’s entries and upcoming events. A monthly “quick quiz” attracts scores of participants, and a series of entry-level and advanced informational audio modules serve MLS undergraduate and graduate programs and clinical pathology residencies.
AOB: As the landscape of laboratory hematology continues to evolve, what are your plans for the future of The Fritsma Factor? Are there any new features or initiatives that you are planning to include in years to come?
Prof. Fritsma: Fritsma Factor currently has 1500 participants and adds one or two per day, encouraged by colleagues, professors, or discovered through internet searches. We continue to offer Fritsma Factor as long as there is medical interest. In addition to our blog, we provide links to international hemostasis-related agencies, initiatives, online educators, and conventions. We offer a comprehensive glossary of hemostasis-related initialisms and we regularly update our informational modules to match hemostasis scientific developments. We thank Precision BioLogic Inc. for their continuing support and insistence on unbiased, market-neutral scientific information.
Reference
- WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy. Geneva: World Health Organization; 2010.