Transfusion medicine education in medical school: only the first of successive steps to improving patient care

Transfusion of blood components and/or derivatives and application of transfusion-related technology and/or procedures (e.g., therapeutic hemapheresis and phlebotomy) can be life-saving. However, transfusions and procedures pose risks, and their inappropriate use can result in serious morbidity and even death. Most health care professionals, working in transfusion medicine, believe that blood component transfusions and transfusion-related services are frequently used inappropriately by clinicians. In this issue of TRANSFUSION, O'Brien and colleagues¹ report marked knowledge deficits in transfusion medicine, identified by testing, of 116 medical school graduates who were beginning residency training and, based on their findings, state that “medical schools and graduate medical education programs are obligated to reevaluate their transfusion medicine curricula in the interest of patient care and safety.”

“Obligated” is a rather strong and directive word and, although at first glance reevaluation of curricula presumes that a meaningful benefit will be gained, a great deal of effort and commitment of resources would be involved in such a process. Accordingly, before expending such efforts and resources, the study design, results, and interpretation of the report of O'Brien and colleagues¹ must be critically assessed, as well as the evidence that formal education in transfusion medicine is likely to actually improve patient care.

Undoubtedly, all who read the article of O'Brien and colleagues¹ will conclude with the authors that medical school graduates, at the time they begin residency programs (i.e., interns), know little about transfusion medicine and, likely, will agree that little is taught about this area of medicine in medical school. However, the article of O'Brien and colleagues lacks sufficient details and/or information to conclude much beyond that and, on critical inspection, several critical points about the experimental design and conduct of the study raise questions about the quality of the results and/or data and whether all conclusions and recommendations are truly warranted. Five of these critical points are as follows:

First, it is not stated whether the 116 graduates and/or interns tested consisted of all graduates beginning the residency programs selected for study or whether interns had the option of either participating or opting out of the study. Presumably, 100% participated to ensure no possible “selection bias” of test subjects.

Second, only 58 of the 116 interns self-reported their prior medical school training in transfusion medicine. Much is made by the authors of their prior medical school training, or lack thereof, and the only explanation offered for the incomplete data (i.e., the 58 missing self-reports) is that it was “only available for the first year.” Why were data limited and/or incomplete?

Third, another point related to the study subjects' medical school training in transfusion medicine is the failure of the authors to validate the accuracy of the interns' memories (i.e., to contact the curriculum committees at the medical schools to confirm exactly how much transfusion medicine education actually was offered). Also, in this era of medical students not being required to attend lectures, it is of interest to know whether interns being tested actually attended the lectures and/or seminars in which transfusion medicine education was offered.

Fourth, the content and/or format of the patient scenario by which interns were tested is described incompletely, so that those reading the article by O'Brien and colleagues cannot completely assess the accuracy, quality, and/or rigor of the testing experienced by the interns—an extremely important factor because many of the findings, conclusions, and recommendations of the authors are based on test results.¹ For example, the information reported pertaining to the patient scenario explains how it was created and administered. However, the only information pertaining to content is a list of items in Table 4 of the article that the authors expected the examinees to address, along with a very subjective scoring system. Similarly in Table 5, several facts that authors expected examiners to know were listed. It would have been helpful to know details of the patient scenario to judge for oneself—presumably via the interactive nature of the test encounter—how likely the interns should have raised and/or addressed these expected points (or any other groups of examinees who might be tested by the patient scenario, including those with more extensive education such as graduates of clinical pathology residency and/or transfusion medicine fellowship training programs).

Fifth, as noted in the preceding paragraph for the patient scenario, similar questions can be raised about the content and/or format of the quiz given to interns. In Table 3 of the article,¹ the questions asked and the acceptable answers expected by the authors are listed, but no information is given as to how the answers were obtained from the examinees (e.g., by selecting from multiple-choice correct and incorrect possibilities or coming from within the interns' knowledge base via fill-in-the-blanks or essay formats). This is important because some of the acceptable answers expected by the authors would not be considered as correct—at least without some caveats—by transfusion medicine experts at all institutions (i.e., practices likely varied at the different medical schools from which the interns graduated and, undoubtedly, affected their memories, thoughts, and/or answers). For example, when an MD is told that a patient experiences a fever during a RBC transfusion—a question posed by the quiz—the MD should stop the transfusion, examine the patient, and notify the blood bank (acceptable answers the authors expected). However, at some institutions, it is the blood banks' responsibility to request and/or perform a direct antiglobulin test and repeat crossmatching, blood cultures, and tests for hemoglobinuria (other acceptable answers)—not the responsibility of the MD attending the patient. Thus, depending on how the answers were sought, failure to list these “acceptable answers” will not always reflect a knowledge deficit of the interns being tested—rather, it may reflect a legitimate difference in institutional practice. As another example, it is clearly stated in the literature that platelet (PLT) transfusions should be avoided whenever possible in patients with thrombotic thrombocytopenic purpura, immune thrombocytopenia, and when the PLT count is normal (acceptable answers expected by the authors in Table 3)—yet in clinical practice, PLT transfusions are often given when life-threatening bleeding occurs in patients with these disorders, including patients with normal PLT counts who have documented and/or suspected PLT dysfunction. Thus, it is difficult to predict how even the most knowledgeable transfusion medicine experts would have answered the quiz question “What are the contraindications to platelet transfusion?” Because transfusion practices vary among institutions, even when practices are evidence based, it likely would have been worthwhile for the authors to “field test” the quiz by giving it to a few transfusion medicine practitioners (independent of the authors and those developing the quiz) before testing the interns. There is no mention that this was done.

Because of these limitations and/or shortcomings of the report by O'Brien and coworkers¹ the specific knowledge deficits cited and the quantitative results (e.g., the percentages of interns failing to know certain facts) must not be taken literally when evaluating transfusion medicine education, in general, when comparing the article of O'Brien and coworkers to other reports in the literature or when designing future transfusion medicine educational programs and/or curricula.

TRANSFUSION MEDICINE EDUCATION AND PATIENT CARE

Excellent patient care, in terms of transfusion medicine issues, is determined by optimal transfusion of blood components and/or derivatives and use of transfusion medicine–related services. Most importantly, these procedures often vary considerably among patients managed by different medical and/or surgical specialties. Accordingly, it makes sense that the most extensive transfusion medicine education should be conducted during residency and/or fellowship training and continuing throughout practice of the specialty (e.g., the specific indications and contraindications for the transfusion of blood components and/or derivatives and/or use of transfusion-related services such as therapeutic plasma exchange and/or phlebotomy). The specialty and/or subspecialty boards that certify physicians should list required transfusion medicine goals and, then, examine applicants for achievement of these goals at the time of initial certification and later recertification—as has been suggested recently for pediatric transfusion medicine goals in pathology residency programs.² During specialty residency training, transfusion medicine education would be accomplished by rotations on the transfusion medicine service and also by lectures, by computer-assisted models, at the bedside, and by attending national and/or regional meetings.

After residency training, there is no universally accepted educational method for ensuring consistent and permanent and/or long-term optimal practices among practicing physicians. Short-term improvements in practice have been demonstrated after educational interventions, but without continuing reinforcement and/or reminders, physicians tend to relapse to “old ways.” Thus, repetitive education is mandatory. Because the vast majority of transfusions occur in a hospital setting (i.e., given to inpatients or to outpatients being managed in hospital-associated clinics), the bulk of transfusion medicine education should be offered via hospital activities. Departmental grand rounds and other regular lectures and/or meetings should be devoted to transfusion medicine topics. Problem and/or controversial patients should be discussed candidly and critically at regular M&M (morbidity-mortality) conferences and at CPC (clinical-pathology conferences) with strong encouragement for attendance by faculty, residents, nurses, and medical students. The hospital transfusion committee (or transfusion subsection of a hospital quality care committee) should develop guidelines for blood component and/or derivative transfusions and for use of transfusion-related services and, very importantly, should seek justifications and/or explanations when guidelines are not followed (i.e., when patients are managed as “outliers”). Appropriate use of blood components and/or derivatives and services, also, can be monitored and education offered by “order-entry” programs with hospital computer systems (e.g., blood components for nonemergency transfusions can be ordered successfully only for patients with characteristics that fit hospital guidelines or a justification and/or explanation is required for the order to be filled). Finally, practicing physicians can attend transfusion medicine sessions at regional and national meetings and/or can participate in computer-assisted learning modules—perhaps, with CME credits as an incentive.

Based on the concept that transfusion medicine education, with the focus on optimal patient care, is best offered during residency training and during the clinical practice of medical and/or surgical specialties, it is the responsibility of medical school training to provide medical students with sufficient knowledge to “hit the ground running” when they begin residency training. In my view, this foundation should include the basic and/or general information of why blood components and/or derivatives are transfused (e.g., RBCs to improve tissue oxygenation in patients with significant anemia or RBC dysfunction, PLTs to prevent or treat bleeding in patients with significant thrombocytopenia or PLT dysfunction, plasma and/or derivatives to prevent or treat bleeding in patients with significant deficiency or dysfunction of plasma clotting proteins). It is also important to include information about the risks of blood component and/or derivative transfusions (including transfusion reactions and their evaluation) and an overview of blood banking procedures and/or techniques used for pretransfusion compatibility testing. In my view, it is not mandatory, during medical school, to teach the specific and/or detailed indications for blood component and/or derivative transfusions, doses and/or volumes to be transfused, or use of special procedures such as therapeutic plasma exchange—with the exception of patient-linked education taught while on clinical service and/or elective rotations.

O'Brien and coworkers suggest that medical school education in transfusion medicine is inadequate and that curricula be reassessed.¹ It is not clear how transfusion medicine education can best be accomplished at the medical school level. The authors mention the Transfusion Medicine Academic Awards (TMAAs) as a national effort sponsored by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health.¹ The TMAA program began in 1983—likely in response to recognition of transfusion-transmitted HIV/AIDS—and extended through 1996, with awards being granted through 1991 to approximately 40 medical and veterinary schools as a means to provide 5 years of financial support to an individual (TMAA Program Director) while she/he developed a local teaching and research environment in transfusion medicine for students and clinicians. A key objective of the TMAA program was to encourage development of multidisciplinary curricula in transfusion medicine, with a stipulation that the institution must continue support for the program after NHLBI funding was terminated (i.e., as an effort to ensure long-term transfusion medicine education after a “jump start” with TMAA dollars).

Perhaps another round of federal funding via reinstatement of the TMAA program would improve medical school transfusion medicine education and prepare graduates for their continuing education during residency training and, then ongoing, as clinical practitioners. Before committing federal money and effort, however, it is important to examine the success of the original TMAA program—particularly, whether it had a long-lasting beneficial effect. I was a recipient of a TMAA and believe that my personal career development as an academician in transfusion medicine was greatly advanced by the award. I am not so sure about the long-lasting effects on transfusion medicine education at my institution. With TMAA support, I developed a local transfusion medicine curriculum that consisted of three 1-hour lectures for first-year medical students, three 1-hour lectures for second-year medical students, 28 one-hour lectures for third-year students, three clinical or research electives for fourth-year students, and eight departmental conferences per year for residents and faculty. This extensive and/or comprehensive curriculum was based on local education needs³ and was enthusiastically embraced by students, house staff, and faculty for several years—until the medical school curriculum was “revised.”

Currently, there is one lecture in the pathology course devoted to transfusion medicine at my institution. Undoubtedly, additional transfusion medicine education is offered by departmental conferences and bedside teaching, but the amount and/or time devoted is difficult to quantitate, and it does not fit within a defined transfusion medicine curriculum. Moreover, the effectiveness of this education—or lack thereof—in providing students with the knowledge they need to take the next steps intended to improve patient care is impossible to measure. If the situation is similar at other TMAA recipient institutions, questions could be raised about the long-term benefits of educational awards and/or grants with time limits on funding. In this vein, it would have been interesting to compare the test results, in the report of O'Brien and colleagues,¹ of interns graduating from medical schools who were awarded TMAA grants years ago versus interns graduating from medical schools not given TMAA grants. One might guess, because of the years elapsed from the original TMAA grants, that the scores would be similar.

As reported by O'Brien and coworkers,¹ medical school curricula offer little education earmarked specifically for “transfusion medicine” and, perhaps, this limited exposure is the most likely reason that, at the time of graduation, physicians entering residency programs know very little about transfusion medicine and/or blood banking practices. Exactly how much they should know can be debated, but it seems reasonable to ensure that they be taught enough basic and/or broad knowledge to prepare them for more extensive and/or in-depth training during residency and/or fellowship training about the appropriate use of blood components and/or derivatives and blood bank services that they will prescribe for the patients managed in their specialty of practice. To this end, medical schools should examine, and possibly revise, their transfusion medicine educational curricula—a task that might be best championed by the local blood bank physician, with support by the hospital transfusion committee. Educational grants from NHLBI or other funding agencies, undoubtedly, would stimulate this process. However, the goals of such grants and, very importantly, measures to document their effectiveness over long periods of time must be clearly defined.

CONFLICT OF INTEREST

None.