What does a day in Hematology look like?

S ince I’ve been working on my focus about Cancer at The Knowledge Society (TKS), the theories connected to this part of medicine known as the field of Oncology, has attracted and convinced me to dive deeper in this topic than I ever have before. After finding out about cancer and the kind of cancers that are taking people’s lives every day, I’ve gotten and created an affinity for the field of Hematology. Not just because it is interesting, but also due to the fact that a field really turns out to be multiple fields of Medicine and that it is more of an art than you could possibly imagine in the first place. I’ll explain to you why in this article. Let us start, shall we :)

To begin this article: I feel like I have grown tremendously after shadowing a pediatric-hematologist, Mr. Dr. Arian van der Veer at Maastricht University Medical Centre (MUMC+). During his PhD, Dr. Arian van der Veer focused on the implementation of molecular markers in the treatment of children with b-cell precursor acute lymphoblastic leukemia (BCP-ALL). Based on his results and conclusions, IKZF1 deletions are now used as an unfavorable risk marker for relapse in BCP-ALL. Therefore, patients with these deletions receive one year elongation of maintenance therapy (Dutch Oncology Group ALL-11 protocol). Because of this impact, this project was nationally awarded by the Tom Voute Award (KIKA). Meanwhile, Dr. Arian van der Veer volunteered in the board of the Zuiderzeevaart (www.skov.org) as medical officer and thereby organized the medical part of a sailing camp for children with a malignancy. Until now Arian is a pediatrician — hematologist in Maastricht UMC+ in the Netherlands. It was an absolute honor and nice experience to have lived a small time frame as a “doctor”.

Dr. Van der Veer’s publications:

• Independent prognostic value of BCR-ABL1-like signature and IKZF1 deletion, but not high CRLF2 expression, in children with B-cell precursor ALL
• IKZF1 status as a prognostic feature in BCR-ABL1-positive childhood ALL
• Assessment of need for hemostatic evaluation in patients taking valproic acid: A retrospective cross-sectional study
• Transfusion burden in early childhood plays an important role in iron overload in Diamond-Blackfan anaemia
• Disturbed CXCR4/CXCL12 axis in paediatric precursor B-cell acute lymphoblastic leukaemia
• Copy number alterations in B-cell development genes, drug resistance, and clinical outcome in pediatric B-cell precursor acute lymphoblastic leukemia
• Tumor suppressors BTG1 and IKZF1 cooperate during mouse leukemia development and increase relapse risk in B-cell precursor acute lymphoblastic leukemia patients
• Heterophilic antibodies leading to falsely positive D-dimer concentration in an adolescent
• Transfusion burden in early childhood plays an important role in iron overload in Diamond‐Blackfan anaemia
• Independent prognostic value of BCR-ABL1-like signature and IKZF1 deletion, but not high CRLF2 expression, in children with B-cell precursor ALL

A day as pediatric-hematologist starts with the handover by the night-shift team regarding what has happened with patients on the wards and their current condition or status. For example, the PICU, NICU and the Pediatric Ward.

The PICU is the pediatric intensive care unit where children of ages 0–17 years old get treated. All of these patients are either in a critical condition or must be attentively monitored to make sure that their health remains in balance and that their internal environment can maintain that balance.

The NICU, also known as the Neonatal Intensive Care Unit, is a kind of like the PICU. However, there’s a difference: premature babies or newborn babies who are extremely ill are admitted to the NICU and in the PICU there could also be adolescents and toddlers whom are older, of course.

The Pediatric Ward has patients that aren’t critically ill, but also aren’t doing that well. If I had to describe what kind of patients are admitted there, I would say that they’re patients who are more stable or tolerant for going through certain things. Although, that does have to happen with the assistance of doctors, nurses, PT’s (PT = Physical Therapist), dieticians and more.

I myself was shadowing Dr. Arian van der Veer at the outpatient clinic for a duration of four hours. Throughout this time, I saw how Dr. Van der Veer communicated, treated and provided care for these patients. I saw a variety of clinical cases which were pretty interesting.

Before I continue sharing my experience, I want to inform all of you about what the field of hematology in Medicine entails and how it is connected to other branches in Medicine.

Hematology is a branche of medicine which focuses on blood disorders or issues with blood-related parts that the body needs to function properly.

When we look at the anatomy of how blood cells are created we have to start at the bone marrow. This is a spongy substance which is found in the center of many bones. It manufacturers bone marrow stem cells which can turn into different types of blood cells.

Blood consists of:

• Red blood cells
• White blood cells
• Platelets
• Bloodplasma

Fun fact: Blood is one of the most slippery substances on planet earth!

This is what blood consists of.

In the red bone marrow, red blood cells are made. These bloodcells possess a protein called Hemoglobine which binds and lets loose of O2 that is breathed in through the lungs. In these lungs, the O2 first passes the bronchi and goes to the alveoli, kind of like a bunch of grapes. Now these “grapes” have blood vessels around them and there are two types of bloodvessles: arteries and veins. The arteries have blood which is rich of or has a high concentration of O2 and it is poor of or has a low concentration of CO2.

The blood that flows through the artery connected to the alveoli arrives in the left atrium. Then the heart valve preventing blood from flowing in the opposite direction in the left side of the heart goes to the left ventricle. The aortic valve starts to open up and with a high contraction of the heart muscle the blood flows at a high speed throughout all cells and parts of the body. Here, the oxygen is given to thesecells.

The CO2 that isn’t needed gets transfered via a capillaries which converts the “O2 rich blood” into “CO2 rich blood” and then arrives at the inferior vena cava. The same goes for the capillaries in the head where the brain is located. The blood from the jugular and arm veins go to the superior vena cava.

The blood in the veins that comes from the kidney (renal veins), leg veins, the portal vein and other veins all end up in the inferior vena cava. The portal vein is the bloodvessle that connects the liver with the veins of the intestines, milt, pancreas and gallbladder. It is deprived of oxygen and rich of nutrients, because the intestines extract vitamins, minerals, glucose and water effective immediately to provide the cells with fuel. The blood goes from the intestines to the liver where the blood is processed which you can compare to a coffee filter.

Prior to the extraction of nutrients which food contains, gets passed down into the stomach, through the duodenum a.k.a. the 12-fingery intestine, connecting the stomach with colon’s big and small intestines. In here digestives juices like gastrine from the stomach, secretine and cholecystokinine of this duodenum contain enzymes which can help form the product that is needed like proteins, fats and glucose. Fats are emulsified by bile from the gallbladder in the small intestines. After metabolism the small intestine absorbs all nutrients that have become the product. In the large colon the final amount of remaining water is extracted and put into the blood. The undigested remaining biomass will eventually be excreted.

Once the blood that went through the inferior and superior vena cava has gone through the “tubes”, the blood enters in the right atrium. The valves of the right atrium open up and the CO2 rich blood reaches the right ventricle. Afterwards, the valves in the right side of the heart close and the pulmonary valve opens up. The blood with “waste” e.g. CO2 goes back to the alveoli through the veins, not the arteries! Then it goes to the trachea twigs and then reaches the bronchi. Finally, the CO2 and evaporated H2O in the form of ATP (adenosinetriphosphate) go through the throttle to the pharynx leading to the oral and nasal cavity where the air gets breathed out. This process is called gas exchange.

The circulatory system in our body where blood gets passed around until it ends up at the center which is the heart and then processes everything again.

The Respitory System and gas exchange.

White bloodcells are also produced by the red bone marrow. They provide as protection, making sure that these immune cells fight viruses, bacteria and fungi when it enters our body internally. These white cells have sensors that can detect whether there’s a inavdor and when that happens the immune cells will “eat” the invador, thereby killing it. This phenomenon is common in biology and known as endocytosis. White bloodcells have no permanent structure or form which has many advantages.

The advantages are as follows: White blood cells are able to … because of their non-existent form.

• go through capillaries
• small cavities in cells
• tiny pores in the body

As you may have now read, you can see that there is a direct correlation between cardiology along with pulmonology, gastroenterology and hematology.

Blood cells, also known as leukocytes, are a crucial part of the immune system that protects the body from infections and diseases. There are five main types of blood cells: neutrophils, leukocytes, monocytes, erythrocytes, basophils, and eosinophils.

Here is a detailed overview of each type:

1. Neutrophils: These are the most abundant white blood cells, making up 60–70% of circulating leukocytes. They are granular leukocytes that develop from the myeloid cell lineage within the bone marrow and are primarily involved in the immune response against bacterial infections.
2. Leukocytes: Leukocytes are a type of white blood cell that includes lymphocytes (B cells and T cells). Lymphocytes are further subdivided into helper T cells, memory T cells, cytotoxic T cells, plasma cells, and memory B cells.
3. Monocytes: These cells are part of the myeloid cell lineage and are further subdivided into dendritic cells and macrophages. Monocytes are phagocytic and help fight infections.
4. Erythrocytes: Also known as red blood cells, these cells are responsible for carrying oxygen from the lungs to the body tissues and carrying carbon dioxide as a waste product away from the tissues and back to the lungs.
5. Basophils: These are granular leukocytes of myeloid lineage and are similar in function and appearance to mast cells, which are found within tissues. Basophils contain histamine granules and cause local inflammatory responses through their role in the immune system which is poorly understood but they potentially mediate type I hypersensitivity reactions.
6. Eosinophils: These are granular leukocytes that make up 1–3% of circulating leukocytes. Eosinophils are mainly present in tissues and spend around an hour in peripheral blood. They play a role in fighting parasitic infections and are involved in allergic reactions and some autoimmune diseases.

Each type of blood cell has a specific function and distribution in the body, working together to protect against infections and maintain overall health.

The different types of blood cells in the circular system.

Yellow Bone Marrow (YBM)

T he YBM is a type of bone marrow that primarily contains mesenchymal stem cells, also known as marrow stromal cells, which can turn into cartilage, bone, fat, or muscle cells if necessary. It also houses adipocytes, which are fat cells responsible for storing fats.

The structure of the bone, the marrow and the blood cells in these parts.

Yellow bone marrow plays a crucial role in maintaining the right environment and providing the necessary substances for bones to function properly.

Key points about yellow bone marrow include:

• It is located in the cavities of long bones and stores fat in adipocytes.
• Yellow bone marrow contains mesenchymal stem cells that can produce cartilage, bone, fat, or muscle cells.
• Adipocytes in yellow bone marrow aid in the storage of fats, helping to maintain the appropriate environment for bones to function.

Yellow bone marrow is essential for the proper functioning of bones, as it provides the necessary stem cells and fat storage capacity. This allows for the continuous regeneration and repair of bones and cartilage, ensuring their strength and flexibility.

Additionally, in life-threatening situations, such as severe blood loss, yellow bone marrow can convert to red bone marrow and produce red blood cells to support the body. As a person ages, red bone marrow is gradually replaced by yellow bone marrow, but the yellow marrow retains the potential to convert back to red marrow when necessary.

I also observed the fact that there is a connection between bone marrow and cartilage. The amount of cartilage is increased in people with a younger age compared to someone who’s an adult. Also, the amount of yellow bone marrow increases significantly once a person becomes older and more older in age. In the image down below you can observe the evolution of bone marrow in a human’s life.

The correlation between age and yellow marrow as well as cartilage.

What is hematology exactly?

H ematology is a complex and interdisciplinary field that focuses on the diagnosis, treatment, and management of blood disorders. It has a strong correlation with various departments, including oncology, cardiovascular medicine, interventional radiology, and surgical services, as hematologists often collaborate with experts in these areas to provide comprehensive care for patients with blood disorders.

Some key aspects of the correlation between hematology and other departments include:

• Collaboration: Hematologists work closely with professionals in other departments, such as internal medicine, radiology, transplantation, oncology, radiation oncology, pathology, reumatology, immunology and others, to accurately diagnose conditions and tailor appropriate care plans.

• Systems-based hematology: This approach aims to improve care delivery for patients with blood disorders by focusing on the interaction between hematology and other medical disciplines.

• Mentorship and career development: Clinical, research, and mentorship experiences in hematology are positively associated with fellows’ plans to pursue hematology careers.

• Interdisciplinary care: Mayo Clinic hematologists, for example, provide care for the whole patient, looking beyond blood diseases to address their needs in areas such as nutrition, patient education, psychiatry and psychology, social work, rehabilitation, and cancer survivorship.

• Research and innovation: Hematology research often involves interdisciplinary collaboration, leading to advancements in the field and improved patient outcomes.

There are a few conditions that require the help of multiple departments in the healthcare industry:

• Blood cancers: Hematologists work closely with oncologists, radiation oncologists, and surgical services to diagnose and treat blood cancers such as leukemia, lymphoma, and myeloma.

• Bleeding disorders: Hematologists collaborate with specialists in gynecology, colorectal surgery, cardiology, and others to address the root of bleeding problems.

• Blood clotting disorders: Hematologists work with cardiovascular medicine specialists to diagnose and treat blood clotting disorders such as thrombophilia.

• Red blood cell disorders: Hematologists collaborate with experts in internal medicine, pediatrics, and genetics to diagnose and treat red blood cell disorders such as sickle cell disease and thalassemia.

• White blood cell disorders: Hematologists work with infectious disease specialists to diagnose and treat white blood cell disorders such as leukocytosis.

In summary, hematological conditions require collaboration with other departments to provide comprehensive care to patients. Hematologists work closely with experts in oncology, cardiovascular medicine, interventional radiology, surgical services, and others to diagnose and treat blood disorders. The interdisciplinary approach in hematology allows for better diagnosis, treatment, and management of blood conditions, ultimately improving patient outcomes.

The study of Hematology

(Hereditary) condition: Spherocytosis

S pherocytosis is a condition that affects red blood cells, causing them to be spherical rather than the normal bi-concave disk shape. This change in shape makes the red blood cells more fragile and prone to breaking down faster than usual, leading to hemolytic anemia. Hereditary spherocytosis is an inherited form of the condition, usually caused by genetic defects that result in a faulty protein component of the red blood cell membrane. Symptoms of hereditary spherocytosis can include anemia, jaundice (yellowing of the skin and eyes), and an enlarged spleen. Treatment for hereditary spherocytosis focuses on managing symptoms and may include folic acid supplementation, blood transfusions, and, in some cases, surgical removal of the spleen. It is important for individuals with hereditary spherocytosis to receive lifelong medical care to manage the condition effectively.

The difference between a healthy blood cell compared to the blood cell of someone with spherocytosis.

What stood out to me during my experience with Pediatric Hematologist, Dr. Van der Veer — was that many patients who had hematological conditions were often caused by something else, like a mutated gene or a hereditary gene.

According to KidsHealth Hereditary Shperocytosis is an example of a genetic condition which causes a child or person to deal with hematological challenges.

Quote:

“Hereditary spherocytosis is an inherited blood disorder. It happens because of a problem with the red blood cells (RBCs). Instead of being shaped like a disk, the cells are round like a sphere. These red blood cells (called spherocytes) are more fragile than disk-shaped RBCs. They break down faster and more easily than normal RBCs. This breakdown leads to anemia (not enough RBCs in the body) and other medical problems. Anemia caused by breaking down of RBCs is called hemolytic anemia.”

When you have spherocytosis, the body lacks the sufficient amount of RBCs in the body leading to a decline of the oxygen concentration in the blood. This can cause other issues such as: difficulty breathing, paleness, slowed healing, damage to cells and growth problems.

When RBCs are broken down, they release a colored substance called bilirubin. Bilirubin is a yellowish pigment that occurs in the normal catabolic pathway that breaks down heme in vertebrates. It is produced during the process of breaking down old red blood cells.

This is what happens to red blood cells and the aftermath of what effects bilirubin can have.

Bilirubin is a waste product and is normally expelled from the body through the intestines. However, if bilirubin levels become too high, it can indicate liver or biliary disease. A bilirubin test measures the levels of bilirubin in the blood or urine. High bilirubin levels may indicate liver or biliary disease, while low levels are generally not a cause for concern. Certain medications can lower bilirubin levels, including antibiotics, birth control pills, sleeping pills, and seizure medications.

Bilirubin is toxic if it builds up in the blood, and very high levels in newborns can be dangerous. Treatment for high bilirubin levels in newborns typically involves phototherapy, where the infant is placed under a lamp that emits fluorescent white or blue-spectrum light. This light converts bilirubin into a more water-soluble form, which can be easily eliminated from the body.

The effects of Bilirubin on pediatric patients, in this case: infants.

A higher level of bilirubin in the body can lead to:

• yellowing of the whites of the eyes and skin, called jaundice
• gallstones

Some people also might experience having:

• low folate levels because the body uses more of it to compensate for the lack of RBCs
• an enlarged spleen because it’s working harder than normal to break down and filter RBCs
• aplastic crisis, which is when very few RBCs are made (usually caused by infection)

Example: The effect of a spherocytosis blood-cell on the spleen.

When treatments are administered, they may include:

• Folic acid supplements
• Removing some or all of the spleen to slow the breakdown of red blood cells
• Removing the gallbladder to get rid of gallstones
• Blood transfusions to deliver healthy red blood cells to the body

What we find out as well based on this treatment image that we can see above, is that this can also be treated and dealt with a lot better when detected during the pregnancy of the mother who bears the child up to nine months. Based on various cases and experiences, it is my conclusion that mothers who take Folic Acid during pregnancy prior to the birth of the child, have a higher chance of success when dealing with spherocytosis. In contrary to those who do not or have not taken the Folic Acid during pregnancy - e.g. because they did not know their child had spherocytosis or weren’t presented the possibilities and solutions by their care provider - it is more than safe to say that these groups of people go through many difficulties and challenges to battle the severity of their child’s illness. More so in people who have parents with the same spherocytosis-genes leading to a more severe form of the mutation. It is my observation that genetics and genomics play a huge role into the diagnostics, diagnosing and treatment of patients with spherocytosis.

In order to understand how this genetic passing down works, I suggest you watch a brief videoclip about inherited genetic disorders as I’ve shown below.

For babies with severe symptoms, the following treatments may be necessary:

• Ultraviolet (UV) light (phototherapy) for jaundice
• An exchange transfusion for very severe anemia or jaundice to replace the baby’s blood with healthy donated blood

Because of the complications, treatments and the test results, we have come to the conclusion that we need other departments to help hematology in spherocytosis.

A few of these departements may include:

• Radiology;
• Infectious diseases;
• Gastroenterology;
• Gynaecology;
• Urology;
• Cardiology;
• Surgery;
• et cetera…

Sometimes more invasive treatments, for example a bone marrow biopsy must be performed in order to determine what malignant or benign condition a patient may or may not have.

BM Biopsy

A bone marrow biopsy (BMB) is a medical procedure that involves removing a small sample of bone marrow from inside the bone and testing it for signs of disease. The procedure is used to diagnose blood disorders, cancer, and other conditions that may affect the bone marrow. During the procedure, a needle is inserted into the bone, and a small sample of bone marrow is removed. The procedure usually lasts around 30 minutes and can be performed in a healthcare provider’s office or a hospital. The sample may be taken from the pelvic or breast bone, and a local anesthetic is used to numb the area. A bone marrow biopsy can also detect abnormalities in chromosomes and vitamin deficiencies, which can trigger the bone marrow to produce misshapen or too large red blood cells. The procedure is usually performed by a hematologist or oncologist, but nurses who are specially trained in this procedure can also perform bone marrow biopsies.

Test results can be complex to comprehend and summarise, therefore I have found a video which explains and talks about the understanding of Blood tests done by using bone marrow. Look at the videos down below!

While a bone marrow biopsy is an essential and relatively quick procedure for diagnosing various blood disorders and cancers, it carries a small risk of discomfort, bleeding, infection, and allergic reactions. However, these potential complications are generally rare and only happen every once in a while when we look at a variety and wide range of patient populations who have needed a BMB.

Malignant blood disorder

As we all might know leukemia is one of the most deadliest causes of death around the world. Leukemia is a group of blood cancers that usually begin in the bone marrow and result in high numbers of abnormal blood cells.

There are four main types of leukemia:

• Acute Lymphoblastic Leukemia (ALL): This is the most common type of leukemia in young children and can also occur in adults.
• Acute Myeloid Leukemia (AML): AML is a common type of leukemia that occurs in children and adults, and it is the most common type of acute leukemia in adults.
• Chronic Lymphocytic Leukemia (CLL): With CLL, the most common chronic adult leukemia, a person may feel well for years without needing treatment. However, eventual treatment is necessary as the disease progresses.
• Chronic Myeloid Leukemia (CML): CML mainly affects adults and may cause few or no symptoms for months or years before entering a phase in which treatment is needed.

The visual view of blood cancers on microlevels.

Leukemia begins when the DNA of a single cell in the bone marrow changes (mutates) and can’t function properly. As a result, leukemia cells keep multiplying, leading to an uncontrolled growth of abnormal blood cells.

Treatment for leukemia depends on the type of leukemia, the patient’s age and overall health, and whether the leukemia has spread to other organs or tissues. Treatment may involve some combination of chemotherapy, radiation therapy, targeted therapy, bone marrow transplant, supportive care, and palliative care as needed. Treatment for leukemia depends on factors such as the type of leukemia, the patient’s age and overall health, and whether the leukemia has spread to other parts of the body.

Common treatments for leukemia include:

• Chemotherapy: This is the main treatment for many types of leukemia and uses chemicals to kill leukemia cells.
• Radiation therapy: This treatment uses high-energy rays to damage leukemia cells and stop them from multiplying. It can be used to target areas where leukemia cells have built up and to prepare the bone marrow for a stem cell transplant.
• Stem cell transplant: This treatment is used for some people with certain types of leukemia and involves replacing the affected bone marrow with healthy stem cells from the patient or a donor.
• Targeted therapy: This treatment is offered for some types of leukemia and focuses on specific abnormalities present within cancer cells, causing them to die.
• Immunotherapy: This treatment uses the patient’s immune system to fight leukemia cells.
• CAR T Cell Therapy: This is a type of immunotherapy that uses specially designed T cells to target and eliminate leukemia cells.
• Supportive therapy: This treatment is given to manage problems (complications) from some types of leukemia and their treatments.

Leukemia patients can experience various complications, both as a result of the disease itself and its treatment. Some common complications include low blood cell counts (anemia, low platelet count, low white blood cell count), increased risk of infection, bone pain, peripheral neuropathy, graft versus host disease (in patients who undergo stem cell transplantation), and tumor lysis syndrome. Additionally, leukemia and its treatment can weaken the immune system, leading to a higher vulnerability to infections and excessive bleeding. Furthermore, some treatments can affect fertility and lead to early menopause in women. It’s important for patients to be aware of these potential complications and discuss them with their healthcare team. The severity and specific nature of complications can vary from person to person (individually).

A healthcare team will create a personalized treatment plan based on the patient’s health and specific information about the cancer. Clinical trials are also available to test new cancer treatments, and patients should discuss the potential benefits and risks of enrolling in a clinical trial with their healthcare team.

Communication and dedication

During my observations on the “shadowing day,” I also examined Dr. Van der Veer’s approach to interacting with patients and his pre-appointment, during-appointment, and post-appointment procedures. Due to HIPAA regulations or the “Wet geneeskundige behandelingsovereenkomst” (WGBO) in the Netherlands, specific information cannot be disclosed and is in fact prohibited. Therefore, the focus of my observations will remain objective, centered on the theoretical and partially practical aspects of medicine.

Consultation hours at the outpatient clinic is something that can be looked at in a very interesting way. When I was seeing patients, Dr. Van der Veer and I had a sort of routine if you’d say. To me it was completely new, but for someone who’s a doctor it can be “another day”.

When really for the doctor:
"Every day is a matter of life and death. Be ready, you're in charge now."

It starts with preparation, meaning that you look at what the name of the patient is, their medical history, what was done during the child’s last visit and what are the test results now. Then we go to the waiting room to call out the patient and their guardians to follow us into the room.

The guardians and their child take a seat and we dive into what the results are of the tests that had been taken which we looked at beforehand. Now we ask how the patient and their guardians are doing, if anything has changed and whether there are other things that caught the child’s or guardian’s attention.

Soon after the questions, the doctor will do a physical examination of the patient in order to check if there’s any signs on the skin, whether breathing sounds and rhythm are good, and whether the heart is functioning under compatible conditions.

After the physical examination, the doctor will write down his findings and the current state of the patient during this specific visit in the highly-secured system in order to keep track of the patients progress. While this happens, the parents have the opportunity to ask the doctor more questions or share any thoughts about their child’s condition and the treatment of the illness.

If the doctor deems that is needed to get a blood draw, a scan/X-ray or prescribed medication(s) — then, the doctor will proceed to print laboratory-papers for the patient to use when going to the diagnostic department.

The doctor will give a recommendation on when he would like to see you again and whether there has or had to be a specific time stamp when this happens.

The patient or their guardians can ask the secretary to plan a new appointment based on their availability right before they leave. (That is, if necessary.) Or, the doctor will just do a virtual or call appointment to check in and determine the status of the patient. This decision is influenced by a variety of factors which isn’t quickly chosen for since it is not precise and unreliable.

Prior to the patients leaving the doctors office, the doctor can ask the patient and/or guardians whether there are unclear things, questions about what they should do. The physician will also let them know what to do when the patients condition deteriorates and who to contact during workdays and weekends.

The main insights I took from Dr. Van der Veer which I learned and observed is the following:

• Be a professional. However, make sure your patients are comfortable communicating with you.
• It is okay to be informal when not talking about the reason why the patient is there today, it makes them open up more.
• Trust, empathy, sympathy, hope and duty are qualities that every patient will search for in a doctor in order to find it sufficient to put their life in someone else’s hands.
• Be transparent, tell the full truth and reality of things.
• Have patience, sometimes the workload can be huge and have a toll on you.
• Mistakes happen, doctors and medical personnel are also human beings. You can’t control everything.
• Talk to someone as a professional if you need to, because what a doctor sees on a daily basis isn’t always easy or nice.
• Stay true to yourself and those around you at all times no matter what.
• Celebrate victory’s with your patients, because it doesn’t happen often :)
• It’s okay to say: “I don’t know.”
• Strive to perfection and meanwhile have self-reflection. It is okay to be harsh on yourself sometimes.

Lastly, there were three huge takeaways which made me think a lot more about how we treat patients and that it is important to look at other aspects of treatment. And based on the insights, I thought of quotes that in my opinion matched what’s written above.

Three important takeaways:

1. "Treat the patient, not the disease."

2. "Communicate like a human being, not like a corporation."

3. Question: "What's the difference between a doctor and God?"
   Reply: "What?"
   Answer: "God knows he's not a doctor."

I hope that you — my (prospective) follower — enjoyed reading my article and that I’ve informed you enough about what hematology looks like in real-life!

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