Asian Journal of Transfusion Science
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ORIGINAL ARTICLE  
Ahead of print publication
Is the curriculum of transfusion medicine in MBBS aligned with practical needs: A point of view of fresh graduates


1 Department of Pathology, Nishtar Medical University, Multan, Pakistan
2 Department of Hematology, University of Health Sciences, Lahore, Pakistan

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Date of Submission25-Mar-2021
Date of Acceptance29-Aug-2021
Date of Web Publication04-Jun-2022
 

   Abstract 

OBJECTIVE: The objective of the study is to assess the satisfaction level of doctors regarding their competence in the blood transfusion process and their reflection on training at the undergraduate level.
BACKGROUND: Transfusion errors due to suboptimal knowledge and lack of training can lead to grave outcomes. Therefore, to optimize patient care, a thorough understanding of transfusion medicine basics is highly imperative for all medical graduates.
METHODOLOGY: This survey was conducted online through Google forms with a questionnaire consisting of 15 questions. 8 medical colleges (4 government and 4 private) were selected by random cluster sampling technique. Data were analyzed with SPSS version 23.
RESULTS: Of 502 participants, 53.8% were females and 69.9% were graduates of public medical colleges. About 84.6% did not receive any formal training on transfusion during graduation. Almost 82% felt that the current curriculum is not designed to meet their practical needs of blood transfusion and 52% agreed that knowledge of transfusion medicine is required for undergraduates. The survey also revealed that 70.5% of participants believed that whole blood is required for most patients and 49.8% did not feel confident to manage transfusion-related complications by themselves.
CONCLUSION: Our survey showed that our undergraduate curriculum is not aligned with the practical transfusion needs of a young doctor. As transfusions are being carried out by these young doctors, this needs to be addressed by revising the current curriculum and incorporating teaching and hands-on training to our medical graduates.

Keywords: Curriculum, MBBS, transfusion medicine


How to cite this URL:
Saleem U, Naveed MA, Samiullah M, Tanveer U, Alam S, Zafar AF, Safdar S. Is the curriculum of transfusion medicine in MBBS aligned with practical needs: A point of view of fresh graduates. Asian J Transfus Sci [Epub ahead of print] [cited 2022 Jul 6]. Available from: https://www.ajts.org/preprintarticle.asp?id=345973



   Introduction Top


Transfusion of blood and blood products is one of the most important aspects of clinical care provided to patients. It is arguably the most employed procedure in hospitals the world over.[1] Although this is lifesaving in most cases, it is not safe from adverse effects such as transfusion reactions, alloimmunization, and transmission of infections such as hepatitis B, hepatitis C, human immunodeficiency virus, human T-cell leukemia virus 1, syphilis, malaria, and dengue.[2],[3] Therefore, a sound knowledge of the indications, handling, storage, administration of blood products, and alternative options cannot be over-emphasized.[4]

The decision to transfuse blood and transfusion is carried out in clinical setups.[4] Their knowledge and practice should align with recommended clinical practice.[5] Any deviations from standard practice can manifest in blood wastage, under-utilization, and adverse impact on the patient's health. A lot of effort is being made in transfusion medicine to ensure the appropriateness of blood transfusion in the form of reforms in centralized blood banking, but the focus is not on the undergraduate levels.[6] On the one hand, the government is advocating that they have given enough resources for training in transfusion medicine, and on the other hand, many studies conducted in Pakistan have described that we are lacking rationale use of blood components and we are also on the rise to blood transfusion complications.[2],[7],[8] The current practice in our country is that most of the transfusions are carried out in our hospitals by house officers (HOs) and 1st-year residents without any formal theoretical knowledge or hands-on training in transfusion medicine.[9]

We surveyed the adequacy of knowledge of blood transfusion among HOs and 1st-year residents in various hospitals of Punjab. The rationale was to see the satisfaction level of these doctors regarding their competence for blood administration and management of the transfusion process along with their reflection on training at the undergraduate level. This survey is a first step to raise a voice to incorporate transfusion medicine as an essential component in our undergraduate curriculum.


   Methodology Top


We surveyed to get the point of view of fresh medical graduates regarding their practical needs of transfusion medicine and its alignment with transfusion medicine curriculum, teaching, and training at the MBBS level. A random cluster sampling technique was used. A total of 8 medical colleges (4 government and 4 private) were selected by using this technique. Ethical approval was obtained from the institutional ethical review board. All the graduates who were present in Punjab and were doing house job or residency for at least 3 months were contacted.

A questionnaire was designed for reflection of fresh medical graduates on their training of transfusion medicine in MBBS curriculum and current practices in wards. This questionnaire was designed keeping in view the following points; indications of blood components, requisition of blood, handling, storage and administration of blood, positive patient identification, identifying, management, and reporting of transfusion reactions. The questionnaire was validated by an expert panel of hematologists. The reliability of questionnaire was determined by Cronbach's alpha, which was 0.75. The questionnaires were formulated following AMEE guide No. 87 developing questionnaires for educational research with 5-point unipolar response scales of each question.[10] The questionnaire consisted of 15 items.

The questionnaire was distributed online through Google forms. The purpose of the study was explained to the participants in a statement at the start of each questionnaire. The data of participants were kept anonymous. The data were entered and analyzed in SPSS version 23. (IBM Statistical product and service solution version 23.0 SPSS, Chicago, IL, USA).


   Results Top


A total of 502 participants participated in the survey. Out of 502, 270 (53.8%) were females and 232 (46.2%) were males. A total of 351 (69.9%) participants were graduates of public medical colleges and 151 (30.1%) were graduates of private medical colleges while HOs were 423 (84.3%) and 1st-year postgraduate residents were 79 (15.7%). These are represented in [Figure 1].
Figure 1: Distribution of participants according to gender, nature of medical institute, and designation of the graduates

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We stratified the data based on gender, designation (HO/PGR), and the nature of the institution (public/private). Based on gender, answers were similar for both males and females except for item No. 14, i.e., “Do you think checking of the identity of the patient and of the component bag is important?” where females gave answers more in favor of checking the identity with P = 0.015 shown in [Table 1].
Table 1: Percentages of responses of survey participants

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Data stratification based on designation (HO/PGR) also showed similar results for both groups except for item No. 6,11 and 13, i.e., “Do you know when to prescribe which component of blood for different patients and different clinical settings? “Do you know about any document present in your ward regarding standard operating procedures of administration of blood components?” and “Do you practice “Positive Patient Identification” while administering blood components?” Here, 1st-year residents showed better knowledge compared to HOs with P = 0.001, P = 0.03 and P = 0.02, respectively, for item numbers mentioned earlier and shown in [Table 1].

Data stratification based on the nature of the institution (public/private) also showed similar results except for item No. 12, 13, i.e., “Are you aware of the term “Positive Patient Identification?” and “Do you practice 'Positive Patient Identification'” while administering blood components?” In this set of data, HOs and PGRs of the private institution were more familiar with the term and were practicing positive patient identification as compared to HOs and PGRs of public institutions with P = 0.001 and P = 0.015, respectively, shown in [Table 1].

We combined the options of Likert scale into two groups “not satisfied/insufficient knowledge” (not at all, to little extent, and to some extent) and “satisfied/sufficient knowledge” (to moderate extent and to great extent) for analysis from another angle. This data is presented in [Figure 2].
Figure 2: Reflection of medical graduates on their training of transfusion medicine in MBBS curriculum and current practices

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   Discussion Top


Transfusion medicine is a field, the expertise of which is required for the majority of medical graduates in their career for optimal management of patient.[1] Human errors due to inadequate knowledge and insufficient training result in transfusion mishaps.[11] To date, clinical use of blood is indispensable in almost every specialty as an important aspect of patient care. Therefore, the fresh medical graduate must have a basic understanding of the practical aspects of transfusion medicine, especially transfusion thresholds, indications, requisition of blood, handling, storage and administration of blood, positive patient identification, identifying, management, and reporting of transfusion reactions. Studies have shown that patient outcome directly depends on the clinician's knowledge of blood transfusion.[12]

The present survey was designed for fresh graduates to know their point of view about their training and teaching on transfusion medicine in their MBBS curriculum and current practices at the hospital.

The results of our survey revealed that 262 (52%) of participants agreed that a sound knowledge of transfusion medicine is required in the undergraduate curriculum. An overwhelming majority of participants, i.e., 434 (86.4%) out of 502 revealed that they did not receive any formal training before their house job which shows a major loophole in our education system in Punjab; the same has been advocated by Saboor.[9] Almost 411 (82%) felt that the existing curriculum failed to meet their practical requirements in the blood transfusion process which is a big question mark on our curriculum.

Regarding the requirement of blood transfusion support, 354 (70.5%) believed that whole blood is required for most of the patients. This is particularly alarming as it shows a major drift in our practice compared to the current recommended practices worldwide.[13] The same has been reported by Afzal that no private or public sector hospital was rational in the use of blood, which shows that we are not training our students according to the latest guidelines.[7]

Unfortunately, 414 (82.4%) did not know about the hospital transfusion committee of their hospital and 419 (83.4%) did not know the role of the hospital transfusion committee. This raises a serious question on the functioning of hospital transfusion committees in most of our hospitals. This also reflects that our hospital transfusion committees may have not been active as part of the hemovigilance network as doctors are not aware of such committee, although the Punjab blood transfusion authority has asked for the full functioning of these committees.[14] The second possibility is that doctors are not given an orientation to different bodies and committees of the hospital.

Almost 250 (49.8%) did not feel confident to manage transfusion-related complications of their own. This could translate into increased morbidity and mortality in case a senior colleague is not available around which can otherwise be prevented.

A total of 343 (68.3%) agreed that antihistamines and steroids are required for the management of all blood transfusion reactions which is against the protocols of management of transfusion.[15] This again reflects our current practice going on in clinical setups and reflects the training of medical students.

Out of a total of 502, 326 (64.9%) were aware of the term “positive patient identification” while 176 (35%) were not aware of this terminology. Out of the total participants, only 307 (61.1%) practically employ this in their clinical practice and 195 do not. Failure to identify the importance of positive patient identification in blood transfusion specifically and laboratory medicine, in general, is a potential cause of transfusion errors, blood wastage, and incorrect patient sampling.[16]

Another important finding is that 393 (78.2%) participants did not know how to check the quality of platelet concentrates in the ward which is again a serious question mark on our teaching and training of transfusion medicine at the MBBS level and is advocated in BSH guidelines for administration of blood components.[13]

Although the majority of the doctors acknowledged the importance of checking the identity of patients and blood components are important, the percentage of female doctors was more, and the difference was statistically significant.

Answer patterns to the questions were similar between HOs and 1st-year PGRs except for items No. 6, 11, and 13. In these items, PGRs showed better knowledge than HOs and the difference was statistically significant. This difference may be due to more experience and on-job training/hit and trial learning of PGRs as compared to HOs.

Data stratification based on the nature of the institution (public/private) also showed similar results except for items related to positive patient identification which may be attributed to the fact that in Public sector hospitals there is more workload and less monitoring as compared to private sector hospitals where there is less workload and strict monitoring of the staff is done.[17]

A lot of emphasis have always been placed on safe blood transfusion practices. Transfusion medicine has flourished immensely in the recent decade from extended testing of blood products to prevent transfusion-transmitted diseases on the one hand to antigen typed blood inventory management at the other extreme. This survey has given insight from fresh medical graduates' perspectives on transfusion practices and their training.


   Conclusion Top


This study has given an insight into the misalignment of transfusion medicine curriculum (teaching and training of medical students) with practical needs of hospitals and wards from the point of early career/fresh doctors. It's high time that we upgrade our clinical practices, according to standard principles to optimize patient care. These clinical practices cannot be changed if we do not upgrade curriculum, teaching, and hands-on training at the MBBS level.

Limitations and way forward

The perspective of transfusion medicine specialists has not been taken which may be a way forward for further research.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Fettah A, Kara D, Pinar Reis G, Cansu Certel A, Sertan Kara S. Assessment of physicians' knowledge in transfusion medicine in eastern part of Turkey. Med Sci 2017;6:208-20.  Back to cited text no. 1
    
2.
Arshad A, Borhany M, Anwar N, Naseer I, Ansari R, Boota S, et al. Prevalence of transfusion transmissible infections in blood donors of Pakistan. BMC Hematol 2016;16:27.  Back to cited text no. 2
    
3.
Borhany M, Anwar N, Tariq H, Fatima N, Arshad A, Naseer I, et al. Acute blood transfusion reactions in a tertiary care hospital in Pakistan – An initiative towards haemovigilance. Transfus Med 2019;29:275-8.  Back to cited text no. 3
    
4.
Szczepiorkowski ZM, Dunbar NM. Transfusion guidelines: When to transfuse. Hematology Am Soc Hematol Educ Program 2013;2013:638-44.  Back to cited text no. 4
    
5.
Flausino Gde F, Nunes FF, Cioffi JG, Proietti AB. Teaching transfusion medicine: Current situation and proposals for proper medical training. Rev Bras Hematol Hemoter 2015;37:58-62.  Back to cited text no. 5
    
6.
Zaheer HA, Waheed U. Blood safety system reforms in Pakistan. Blood Transfus 2014;12:452-7.  Back to cited text no. 6
    
7.
Afzal S. A comparison of public and private hospital on rational use of blood in Islamabad. J Pak Med Assoc 2013;63:85-9.  Back to cited text no. 7
    
8.
Baig MI, Javed A, Asif Naveed M, Nawab K, Anwaar Alam S, Asif M. Wastage of blood units at tertiary care hospitals of Lahore. Cureus 2020;12:e8040.  Back to cited text no. 8
    
9.
Saboor M, editor. Hematology for the undergraduates higher education commission Islamabad. 1st ed. Higher Education Commission – Pakistan; 2015. Available from: http://prr.hec.gov.pk/jspui/handle/123456789/39. [Last accessed on 2021 Jul 24].  Back to cited text no. 9
    
10.
Artino AR Jr., La Rochelle JS, Dezee KJ, Gehlbach H. Developing questionnaires for educational research: AMEE Guide No. 87. Med Teach 2014;36:463-74.  Back to cited text no. 10
    
11.
Ferrera-Tourenc V, Lassale B, Chiaroni J, Dettori I. Unreliable patient identification warrants ABO typing at admission to check existing records before transfusion. Transfus Clin Biol 2015;22:66-70.  Back to cited text no. 11
    
12.
Philip J, Kumar S, Chatterjee T, Mallhi RS. Knowledge of transfusion medicine among resident doctors in clinical specialities: A cross-sectional study from a tertiary care centre. Indian J Hematol Blood Transfus 2015;31:374-7.  Back to cited text no. 12
    
13.
Robinson S, Harris A, Atkinson S, Atterbury C, Bolton-Maggs P, Elliott C, et al. The administration of blood components: A British Society for Haematology Guideline. Transfus Med 2018;28:3-21.  Back to cited text no. 13
    
14.
Hemovigilance | Punjab Blood Transfusion Authority. Available from: https://pbta.punjab.gov.pk/hemovigilance. [Last accessed 2021 Jul 24].  Back to cited text no. 14
    
15.
Tinegate H, Birchall J, Gray A, Haggas R, Massey E, Norfolk D, et al. Guideline on the investigation and management of acute transfusion reactions. Prepared by the BCSH Blood Transfusion Task Force. Br J Haematol 2012;159:143-53.  Back to cited text no. 15
    
16.
Stout L, Joseph S. Blood transfusion: Patient identification and empowerment. Br J Nurs 2016;25:138-43.  Back to cited text no. 16
    
17.
Hassan R, Rehman A. Doctor patient relationship in gynecology department of public and private hospitals of Rawalpindi and Islamabad. Pak J Med Res 2011;50.  Back to cited text no. 17
    

Top
Correspondence Address:
Umera Saleem,
Department of Pathology, Nishtar Medical University, Multan
Pakistan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_120_21



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