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EDITORIAL

Transfusion medicine education: an integral foundation of


effective blood management

edical education and continuing medical


education (CME) for transfusion medicine
are integral and necessary elements for
quality patient care. The misuse and
overuse of blood components, and the sequelae resulting
from this inappropriate use, increases the risk for patient
morbidity. Unwarranted blood transfusions also add
avoidable costs for hospitals at a time of diminishing
financial resources. Prudent and conservative blood
product use further helps to control inventory and prevent
blood shortages. As education and direct intervention are
required to ensure the appropriate use of pharmaceutical
agents, we are also driven in a similar manner to inform
our colleagues about the appropriate use and adverse
effects of blood products. The current economic and regulatory climate demands that we act to facilitate and lead
transfusion education for our clinical colleagues, and if we
do not, hospital administrations soon will demand that we
do so. In fact, the growing enthusiasm for patient blood
management has created a long sought opportunity
to enhance transfusion education for a more receptive
audience.
Decades have been spent discussing the necessary
incorporation of transfusion medicine into medical education programs. The Transfusion Medicine Academic
Awards (TMAA) program was started in 1983 by the
National Heart, Lung, and Blood Institute to provide
financial support to medical schools who wanted to
strengthen transfusion education for their students.1 The
participating medical centers published proposed transfusion medicine curricula twice: once in 1989 and again in
1995.1,2 Additional transfusion medicinefocused educational programs have been suggested for pediatrics
(PedsTMAA) in 2006 and for laboratory medicine in
2010.3,4 These publications, however, only provided recommendations and did not dictate standards for medical
trainee knowledge.
Not surprisingly, these efforts have resulted in
minimal changes to transfusion education or medical
education requirements. As defined by the United States
Medical Licensing Exams (USMLE), knowledge of blood
components or transfusion practices is not identified as a
fundamental topic for minimum competency standards
for medical practice (Table 1).5-7 The USMLE does not

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require that students know the appropriate use of blood


products during medical school at any level, and the only
exam that specifically mentions blood products is the
exam that occurs after the second year of medical education, before any direct clinical experience in many programs (Step 1).5-7
Perhaps as a consequence of these limited requirements, medical schools do not emphasize transfusion
medicine education, making room for the more heavily
tested topics. Karp and coworkers8 determined that 17% of
medical schools provided no didactic lectures on transfusion medicine topics, and of those that do, only about 50%
of them provided more than 1 or 2 hours of content. Also,
more than 41% of students do not recall ever having a
transfusion lecture, regardless of whether the student
actually received one.9 Despite the limited number of
formal training hours in transfusion medicine, medical
school curricula do provide enough material for successful completion of USMLE exams. According to the USMLE
Web site, in 2012, greater than 96% of MD degree first-time
test takers pass all three of the Step exams on their first
attempt.10 Knowledge of blood products and transfusion
indications are simply not tested by the USMLE as an indicator of a new physicians ability to assume independent
responsibility without supervision.
The deficiency in medical education for transfusion
medicine starts early and is continued into professional
life for housestaff and attendings. With little or no training
in medical school with evidence-based practices to guide
decisions, the use of transfusions are often based on individual clinical experience. Defining the extent of this deficiency has been the focus of multiple publications. Bryant
and coworkers11 prospectively identified that 85.3% of
referrals to the blood bank physician on-call required
some form of physician education regarding the appropriateness of blood component orders. OBrien and colleagues9 found that nonpathology PGY-1s at one
institution scored 24.0% to 67.1% correct on a standardized test that evaluated knowledge of the red blood cell
(RBC) consent process and transfusion medicine general
knowledge. Of particular concern, they found that none of
the tested physicians could define the use of blood irradiation, and less than 10% knew the transfusion transmission risk for HIV and HCV.9 Salem-Schatz and
coworkers12,13 found that less than 31% could answer
questions regarding transfusion indications and, perhaps
more revealing, found that attending physicians
performed worse than residents, but revealed greater

EDITORIAL

TABLE 1. The knowledge of transfusion medicinerelated principles required of medical trainees as defined by
national USMLE Step exam content*
USMLE step
15

2 (CK)6

37

Suggested fundamental knowledge related to transfusion medicine as defined by USMLE content outlines
Blood and blood products
Drugs affecting blood coagulation, thrombolytic agents, and anti-PLT agents
Nonimmunologically mediated transfusion complications
Production and function of RBCs, Hb, O2, and CO2 transport and transport proteins
Production and function of PLTs
Production and function of coagulation and fibrinolytic factors
Rh and ABO antigens, including genetics
Anaphylaxis and other allergic reactions
Anemia, disorders of RBCs, Hb, and iron metabolism (e.g., blood loss; iron deficiency anemia, nutritional deficiencies;
pernicious anemia, other megaloblastic anemias; hemolytic anemia; anemia associated with chronic disease; aplastic
anemia, pancytopenia; thalassemia; sickle cell disease; polycythemia vera; hemochromatosis)
Bleeding disorders, coagulopathies, thrombocytopenia (e.g., hemophilia, von Willebrand disease; qualitative and
quantitative PLT deficiencies; disseminated intravascular coagulation; hypofibrinogenemia; immune thrombocytopenic
purpura; hemolytic-uremic syndrome)
Anemias and cytopenias (e.g., iron deficiency anemia, hereditary spherocytosis, hemoglobinopathies,
thrombocytopenic purpura and immune thrombocytopenic purpura)
Bleeding disorders (e.g., coagulation defects, congenital factor VIII disorder/hemophilia, von Willebrand disease,
disseminated intravascular coagulation)
Heparin-induced thrombocytopenia
Immediate postpartum hemorrhage
Reactions to blood components (e.g., transfusion reaction, ABO incompatibility reaction, Rh incompatibility reaction)
Trauma

* Adapted from References 5, 6, and 7.

confidence in their inaccurate opinions. Arinsburg and


coworkers14 similarly used a 14-question electronic survey
evaluating transfusion knowledge where they found that
the mean score was 31.4%, with participating attending
physicians scoring slightly worse than their fellows, residents, and interns. Finally, Rock and colleagues15 and
Gharehbaghian and colleagues16 found that these educational deficits extend outside the borders of the United
States.
Unlike the USMLE exams, however, the exams and
surveys used in these studies were neither standardized
nor validated to be used as educational or competency
tools. While the physicians clearly performed poorly on
these surveys of transfusion medicine knowledge, the
study methods used were varied, and one could question
the reproducibility of the individual study methods.17
More importantly, perhaps, it is not clear that the surveys
and exams used tested transfusion knowledge that
nonpathologist clinicians truly need to know.
To this aim, Haspel and colleagues,18 in this issue of
TRANSFUSION, report the first validated transfusion
medicine knowledge exam. They describe the development and validation of a 23-question exam for
nonpathologists. Unlike previous studies, test topics were
rigorously scrutinized using the opinions of international
transfusion medicine experts (Biomedical Excellence for
Safer Transfusion Collaborative, a.k.a. the BEST Collaborative). Moreover, the exam was validated using pilot data
from three different hospitals and analyzed using modern
test development theories (Rasch psychometric analysis).
This new transfusion knowledge tool represents a significant advancement for the field of transfusion medicine

education as each question evaluates a topic considered


important by a panel of experts, and each question has a
predictive quality not previously obtained. Despite this
clear advance, the test remains imperfect. First, less than
half of BEST Collaborative physician experts participated
in the initial test design surveys (36%-48%), which may
have introduced selection bias to the topic selection
process. Second, only transfusion medicine experts determined the critical topics and not expert clinical physicians
who order transfusions, which may ultimately alter the
validity of the test (what transfusion experts think is
important may not be what senior surgeons, oncologists,
or internists consider critical transfusion knowledge).
Third, the exam was validated, in part, using 19 pathology
residents. The use of pathology residents in their test validation process is problematic given that their training
offers specific instruction in transfusion medicine that
nonpathology residents and attendings do not receive.
It would seem preferable to ensure that all subjects used
to validate a test for nonpathologists should be
nonpathologists. Fourth, the test is brief and does not
clearly establish a minimum competency score. Finally,
the test does not appear designed for repeat testing so
that the efficacy of educational interventions could be
evaluated.
Regardless of these limitations, the needs assessment
exam, as designed by Haspel and colleagues, is an important component for the future advancement of transfusion education. Transfusion education will require
aggressive improvement in multiple areas. First, transfusion medicine, as a medical discipline, needs to be
granted greater weight on the USMLE exams, especially
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EDITORIAL

later in a physicians training, such as Step 3. At a


minimum, transfusion indications and blood component
selection should be tested. These changes will likely drive
medical training programs to incorporate more time for
transfusion education in their curriculum either through
required medical school rotations in blood banking or
through transfusion medicine expert-driven educational
sessions during their clinical years. Second, postmedical
school needs assessment exams for nonpathologists, such
as the one developed by Haspel and colleagues, will need
to be regularly and universally used by nonpathology
residency training programs to define and remedy gaps in
transfusion medicine knowledge before a new physicians
ability to order blood. Minimum competency standards
need to be established, and subsequent in-service training
will need to be developed. Third, attending physicians will
need continuing education through a combination of
strategies including audits with specific feedback, one-toone discussions, grand rounds lectures, dissemination
of hospital transfusion guidelines or algorithms, and
transfusion medicine physician participation in clinical
rounds; these tools have already been shown to
be effective when carefully implemented, continuously
monitored, and strongly supported by hospital
administration.19-22 Electronic ordering safeguards supported by hospital blood management committees have
also recently been established as an effective tool to
monitor and limit inappropriate transfusion practice.23,24
Transfusion represents the most common medical
procedure in the United States,25 and the American
Medical Association has recently identified transfusion as
one of the five most overused medical treatments.26 The
increasing concern over adverse events associated with
transfusion and its overuse has given rise to the field of
blood management, and in 2010, blood management was
determined to be one of the 10 key advances in transfusion medicine over the past 50 years.27 Major organizations have taken note. The Joint Commission, as of
October 2013, is offering a Patient Blood Management
Certification program (in field review),28 and AABB has
recently announced its intention to create standards for
patient blood management programs.29 The goal of blood
management programs is to improve blood safety and
patient outcomes, preserve the blood inventory, and limit
escalating blood costs.30
Changing clinical practice will be one of the main
objectives of hospital blood management programs, and if
a blood management committee is not already being
established or efforts incorporated into existing transfusion practice committees, these changes will be arriving
soon. Transfusion medicine education at all stages of
medical training will be required. The tools necessary for
these educational initiatives, such as that developed by
Haspel and colleagues, are ready for use. Transfusion
medicine professionals take note! Education activities for
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physicians and other nonphysician clinical staff need to


grow to make patient blood management programs effective, and our long lamented lack of recognition of the need
for education is finally becoming acknowledged.
CONFLICT OF INTEREST
The authors have disclosed no conflicts of interest.

Matthew S. Karafin, MD1,2


e-mail: matthew.karafin@bcw.edu
Barbara J. Bryant, MD1,2
1
Medical Sciences Institute
BloodCenter of Wisconsin
2
Department of Pathology
Medical College of Wisconsin
Milwaukee, WI

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EDITORIAL

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