w w w . r b h h . o r g
Revista
Brasileira
de
Hematologia
e
Hemoterapia
Brazilian
Journal
of
Hematology
and
Hemotherapy
Original
article
Transfusion
medicine
in
medical
education:
an
analysis
of
curricular
grids
in
Brazil
and
a
review
of
the
current
literature
Marcella
Martins
de
Vasconcelos
Vaena
a,∗,
Vinicius
Cotta-de-Almeida
a,b,
Luiz
Anastacio
Alves
aaInstitutoOswaldoCruz,Fundac¸ãoOswaldoCruz(IOCFIOCRUZ),RiodeJaneiro,RJ,Brazil
bUniversidadeEstáciodeSá(UNESA),RiodeJaneiro,RJ,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received27April2016 Accepted31May2016 Availableonline27June2016
Keywords:
Education Medical
a
b
s
t
r
a
c
t
Background:Bloodtransfusionsareoneofthemostperformedmedicalproceduresinthe
world.Thus,aseducationintransfusionmedicineisvitaltomedicalcare,itshouldaimto promotearesponsiblepracticewiththerationaluseofbloodbydoctors.Thisstudyaims toinvestigatethesituationoftheteachingoftransfusionmedicineinmedicalschoolsin Brazil.
Method:Thewebsitesofthe249BrazilianmedicalschoolsinoperationinJune2015were
visitedandthecurriculaofthemedicalcourseswereinvestigatedinrespecttothepresence orabsenceofatransfusionmedicinediscipline.Whenavailable,thesubjectgridswere analyzedtoverifywhetheradescriptionofcontentregardingtransfusionmedicinewas givenwithinotherdisciplines.
Results:Ofthe249medicalschoolsitesvisited,informationonthecurriculumwasobtained
from178.Ofthemedicalschoolsthatpublishedtheircurriculum,132(74.1%)didnothave disciplinesoftransfusionmedicineorhematologyandonlyseven(3.9%)hadadisciplineof transfusionmedicineinthecurriculargrid.
Conclusions:Educationontransfusionmedicineisoffundamentalimportanceforsafeand
efficienttransfusionpractices.Deficienciesinmedicalknowledgeofthissubjecthavebeen foundworldwide.Theresultsofthisstudyindicateapossibledeficiencyinteachingthe basicsofthisspecialty.Thus,additionalprospectivestudiestoassesstheknowledgeand practiceoftransfusionmedicineinBrazilianmedicalschoolsarewarranted,whichcould promptadiscussion ontheimportanceofofferingtrainingintransfusion medicineto medicalstudents.
©2016Associac¸ ˜aoBrasileiradeHematologia,HemoterapiaeTerapiaCelular.Published byElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗ Correspondingauthorat:LaboratóriodeComunicac¸ãoCelular,Fundac¸ãoOswaldoCruz,4365Manguinhos,21045-900RiodeJaneiro,
Brazil.
E-mailaddress:[email protected](M.M.VasconcelosVaena). http://dx.doi.org/10.1016/j.bjhh.2016.05.013
Introduction
Bloodtherapy,hemotherapy,ortransfusionmedicineisthe medicalspecialtythatdealswiththeuseofblood,blood com-ponentsandblood productsastreatment.InBrazil,despite the first transfusions dating from the early twentieth cen-tury,thisspecialtyonlygainedrealimportanceinthe80swith theadventofacquiredimmunodeficiencysyndrome(AIDS).1
Transfusionmedicineisaheavilyregulatedpractice,with spe-cificlawsguidingthecompleteprocessofbloodmanipulation, fromcollecting,processingandstoragetothetransfusionof bloodcomponents,asdescribedintheBraziliannorms.2–4
Bloodtransfusionsarethemostperformedprocedure in American hospitals.5 InBrazil, according tothe
Hemovigi-lanceReportoftheBrazilianGovernmentHealthDepartment (AgênciaNacionaldeVigilânciaSanitária–ANVISA)published in2014,3,127,957transfusionswereconductedduring2012.6
Despitebecomingincreasinglysafeduetotheimprovement ofserologicaltests,transfusionsstillexposetherecipientto numerousriskssuchas transfusion-transmittedinfections, sepsis,hemolytictransfusionreactionsduetohumanerror, immunomodulationandothers.Asmostmedicalspecialties requesttransfusions,criticalknowledgeregardingthecorrect indicationofbloodproducts,potentialrisksandexpected ben-efitsoftheprocedureisimportantinallareasfortherational useofblood.7,8
Despitetherelevanceoftheaforementionedfactors, stud-iesconductedindifferentcountriesaround theworldhave demonstrated insufficientknowledge ofphysicianson this subject.Studieshavebeenconductedincountriessuchasthe UnitedStates,UnitedKingdom,Tunisia,CanadaandIranto assessthedegreeofknowledgeabouttransfusionmedicine ofnewlygraduateddoctors;allstudies reportedlowerthan expectedresults.9–12Inapollconductedin86medicalschools
intheUnitedStates,mosthadlessthanthreehoursinthe curriculargriddedicatedtotransfusionmedicine.5Thisstudy
aimstoinvestigatethesituationoftheteachingoftransfusion medicineinmedicalschoolsinBrazil,byanalyzingcurricular gridsavailableontheinternetandreviewingtheliterature.
Method
Thewebsitesofthe249Brazilianmedicalschoolsinoperation inJune2015werevisited.Thenumberofmedicalcourseswas obtained by accessing www.escolasmedicasdobrasil.com.br andtheMinistryofEducationwebsite,www.emec.mec.gov.br. Thecurricula of the medicalcourses were investigatedon thewebsitesofmedicalschoolsinrespecttothepresenceor absenceofatransfusionmedicinediscipline.Ifsuchaspecific disciplinewasnotfound,thesubjectgridsweresearchedfor anymentionoftransfusionmedicine(transfusionindications ortreatmentofbloodloss)withinotherdisciplines,suchas hematology,internalmedicineorsurgery.
Eachundergraduatecoursewasclassifiedinoneofthe fol-lowinggroups:
(i) Thecoursepresentsatransfusionmedicinedisciplinein thecurriculum.
1%
27%
72%
No access to the website
No information about curriculum grid
Information about curriculum grid available
Figure1–ProfileofthewebsitesofBrazilianmedical schools.
(ii) The course presents transfusion medicine as a topic withinthe hematology discipline, but doesnot havea transfusionmedicinediscipline.
(iii) Thecoursedoesnotpresentatransfusionmedicine or hematologydisciplineinthecurriculum.
(iv) Thecoursehasnotransfusionmedicineorhematology disciplineinthecurriculum,butcontentontransfusion medicineismentionedinthegridofanotherdiscipline.
Results
Ofthe249 medicalschoolsitesvisited,informationon the curriculum wasobtainedfrom 178,nearly70% ofthe total. Informationonthecurricula ofthemedicalcoursewasnot availablein68sitesofmedicalschools,andaccesstothree sites was unavailable and so they were excluded. Figure 1 showstheprofileofmedicalschoolswhosesiteswerevisited. Of the schools that displayed their curriculum, about three-quarters(74.1%)didnothavetransfusionmedicineand hematologydisciplines.Asmallerportion,17,4%ofthe med-ical schoolshad a hematology disciplineand 4.4% didnot presenttransfusionmedicineorhematology,butblood trans-fusionswerementionedinthegridofanotherdiscipline.Only 3.9%hadatransfusionmedicinediscipline.Thedistribution frequencyfortherespectivegroupsisshowninFigure2.
Discussion
Therationaluseofbloodisregardedasamajorissuefor pub-lichealth,duetopoorinventory,highcost,andconcernson patient safety.Another factor tobenoted isthat blood,in mostcountries,isaproductthatcannotbebought,thatis,its availabilitydependsondonations.Therefore,theappropriate useofbloodcomponentsavoidswaste,providingproperstock maintenancetomeettheneedsofpatientswhoactuallyhave indicationsforbloodtransfusions.11
Severalstudieshaveshowntheinappropriateuseofblood and blood componentsby healthprofessionals.13 Two
Has a transfusion medicine discipline
4% 4%
17%
74%
Has a hematology discipline
Does not have a transfusion medicine or hematology discipline and transfusion medicine is not mentioned in other disciplines
Does not have a transfusion medicine or hematology discipline and transfusion medicine is mentioned in other disciplines
Figure2–Profileofmedicalschoolsaccordingtotheteachingoftransfusionmedicine.
Althoughthiscurrentstudyisanevaluationofthecurricula ofmedicalschools availableonline, thefact thatonly3.9% have the discipline in the curriculum indicates a possible weaknessinBrazilianmedicalschoolswithregardto trans-fusionmedicine education.Evenforthosecurricula having ahematologydiscipline,itcannotbeguaranteedthat trans-fusionmedicine is included. Thesecurricula were grouped separately because, in Brazil, hematology and transfusion medicineareasinglespecialty,andthereforecouldbetaught together.Asfortheschools groupedaslackingtransfusion medicineand hematologydisciplines,althoughmentioning transfusionmedicineinthegridofanotherdiscipline,in gen-eral,thissubjectwasinsertedintothegridsofthesurgeryor internalmedicinedisciplines.Asthesedisciplinescomprise majormedicalareaswithextensivecontenttobetaught,itis questionablehowmuchtimeisactuallydevotedto transfu-sionmedicine.
Concerns about the level of knowledgeof doctors with regardtotransfusionmedicineareuniversal,andseveral stud-ieshaveshownthatknowledgeofdoctorsfallsshortonbasic hematologyissues.O’Brienetal.,16inastudyconductedin
2010withfirst-yearresidentsinWashington,noteda signifi-cantlackofknowledgeabouttransfusionmedicineregardless ofthe medical specialty, with scores ranging from 24% to 67% (average of 39%). In this study, 41.4% of the medical residentssaidtheyhadreceivednoformaltrainingin trans-fusionmedicineduringtheirgraduatecourses.Anotherstudy conductedinNew Yorkwithdoctorsfrom various internal medicinespecialtiesshowedalackofknowledgeofthe spe-cialty, and indicated that participantswith morethan five hoursofformaleducationintransfusionmedicineobtained betterresults.9
AstudyinIran7conductedin2007notedthatknowledge
onhematologywasaboutathirdlessthantheexpectedlevel. Shafieeetal.,17inanotherstudyalsoconductedinIran,
ana-lyzedtheinternalmedicinedisciplineregardingknowledgeon
transfusionmedicineandreportedscoresoflessthan50%in issuesrelatedtotransfusionreactions.
A survey conducted in the United Kingdom10 assessed
knowledge about transfusion medicine of resident physi-cians using questionnaires, and noted that higher scores were achievedbyphysicianswho receivededucation about hematology during their graduate courses. Rebel et al.,18
in a study conducted in the United States, found that knowledgeofanesthesiologyresidentsrelatedtotransfusion medicineincreasedaftertheyspentaperiodinahematology service.
InastudyconductedinSouthAfrica,itwasobservedthat the lackofbothexpertsand formaltraining intransfusion medicine hasconsequencesduetoinadequate hemothera-peuticpractices.19AstudyinTunisiaassessedthedegreeof
knowledge about hematology ofinterns and physiciansin differentspecialties;the overallscorewas2.9out of7.11 In
Canada,48%ofresponseswere consideredinadequateina studythatassessedtheknowledgeof294doctors.12
Panzer et al. conducted a study that, by using ques-tionnaires sent to experts, sought to obtain information about transfusion medicine education in several countries, including Brazil, Iran, Australia, Sweden, Germany, India, Indonesia,Israel,JapanandFrance.8Theauthorsconcluded
that the education in hematology of students and resi-dents in most countries is not universal, as the curricula varygreatlybetweencountriesandbetweenmedicalschools. Interestingly, the main reason might be ascribed to the lack of a national curriculum, with the exception of Iran. The main conclusion of the forum was that transfusion medicine education shouldbe intensified forstudents and residents.
receivedmorethantwohoursoftrainingduringthemedicine course had higher scores than those who did not receive training.20
In Brazil, an assessment of the participation of health professionalsintransfusionpracticesandtrainingof profes-sionals,held in auniversity hospital, showed that doctors areinvolvedintheapplication,prescription,monitoringand compliance.However,56%didnotattendanyrefreshercourse ontransfusions,89%had notreceivedtraining atthe insti-tution and 33% did not feel well enough informed about thesubject.21Thisstudysuggeststhatmorecomprehensive
educationstrategiesareneededformedicalprofessionalsof differentspecialties.22,23
The document on the Brazilian Curriculum Guidelines for graduate courses in medicine, published in 2014, is verygeneric whenit addressesthe curricularcontent.The guidelinementionsthe“diagnosis,prognosisandtherapeutic approachtodiseasesthataffectthehumanbeingconsidering prevalence,mortality,potentialpreventionand educational importance”.24Thus,itisuptoeachinstitutiontoprioritizeor
notparticularareas,suchastransfusionmedicine.Although thecurriculumhasimprovedinareassuchasmanagement andtherapeuticmethods,transfusionmedicinecontinuesto betaughtinformallyinmostBrazilianmedicalschools.23The
topicislearntinpracticewithoutadequatetheoreticalbasis andwithoutrealknowledgeofthenumerousrisksrelatedto transfusions.
Conclusion
Lack of knowledge about transfusion medicine has been reportedworldwide.InBrazil,thoughfewstudies are avail-ableonthesubject,anevaluationofthecurriculaofmedical schoolsdemonstratedthatonlyasmallpercentagehasthis subject asa discipline. This indicates that medical educa-tionstillpresentschallenges.Future researchmay assistin assessingthe significanceofformal training intransfusion medicineinthecurriculaofmedicalcourses,byevaluating theknowledgeofBrazilianphysiciansaboutthissubjectand theimpactinthemedicalpractice.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
e
s
1. JunqueiraPC,RosenblitJ,HamerschlakN.HistoryofBrazilian hemotherapy.RevBrasHematolHemoter.2005;27(3):201–7. 2. Brasil.MinistériodaSaúdePortarian◦.1.353,de13dejunho
de2011.AprovaoRegulamentoTécnicodeProcedimentos Hemoterápicos.D.O.U–DiárioOficialdaUnião,Poder Executivo,Brasília,DF,14Jun2011.Availablefrom: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt1353 13 062011.html.
3. Brasil.MinistériodaSaúdePortarian◦.2712,de12de
novembrode2013.Redefineoregulamentotécnicode procedimentoshemoterápicos.D.O.U–DiárioOficialda União,PoderExecutivo,Brasília,DF,13Nov2013.Available
from:http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/ prt271212112013.html.
4.BrasilAgênciaNacionaldeVigilânciaSanitária.RDCn◦.51,de
07denovembrode2013.AlteraaResoluc¸ãoRDCn◦.57de16
dedezembrode2010,quedeterminaoregulamentosanitário paraservic¸osquedesenvolvematividadesrelacionadasao cicloprodutivodosanguehumanoecomponentese procedimentostransfusionais.DiárioOficialdaUnião;Poder Executivo,13denov2013.Availablefrom:http://bvsms. saude.gov.br/bvs/saudelegis/anvisa/2013/rdc00510711 2013.pdf.
5.KarpJK,WestonCM,KingKE.Transfusionmedicinein Americanundergraduatemedicaleducation.Transfusion. 2011;51(11):2470–9.
6.BrasilAgênciaNacionaldeVigilânciaSanitária.Unidadede BioeHemovigilância.NúcleodeGestãodoSistemaNacional deNotificac¸ãoeInvestigac¸ãoemVigilânciaSanitária(Nuvig). BoletimdeHemovigilâncian◦.6,Brasília,outubro2014.
7.GharehbaghianA,JavadzadehShahshahaniH,AttarM, RahbariBonabM,MehranM,TabriziNaminiM.TransfusMed. 2009;19(3):132–8.
8.PanzerS,EngelbrechtS,Cole-SinclairMF,WoodEM,Wendel S,BiaginiS,etal.Educationintransfusionmedicinefor medicalstudentsanddoctors.VoxSang.2013;104(3):250–72. 9.ArinsburgSA,SkerrettDL,FriedmanMT,CushingMM.A
surveytoassesstransfusionmedicineeducationneedsfor clinicians.TransfusMed.2012;22(1):44–9,quiz49–51. 10.GrahamJ,Grant-CaseyJ,AlstonR,BakerP,PendryK. Assessingtransfusioncompetencyinjuniordoctors:a retrospectivecohortstudy.Transfusion.2014;54(1):128–36. 11.BenSalahN,ElBorgiW,AounallahSkhiriH,BenLakhalF, MouelhiH,ZoueriB,etal.Connaissancesmédicalesem matièredesécuritéimmunologiqueemtransfusion érytrocytaireemTunisie:évaluationd’unCD-ROM d’auto-enseignement.TransfusClinBiol.2013;20(4):448–53. 12.RockG,BergerR,PinkertonP,FernandesB.Apilotstudyto
assessphysicianknowledgeintransfusionmedicine.Tranfus Med.2002;12(2):125–8.
13.VerlicchiF.Evaluationofclinicalappropriatenessofblood transfusion.BloodTransfus.2010;8(2):89–93.
14.TinmouthA,MacDougallL,FergussonD,MohammedA, GrahamID,HebertPC,etal.Reducingtheamountofblood transfused:asystematicreviewofbehavioralinterventionsto changephysicians’transfusionpractices.ArchInternMed. 2005;165(8):845–52.
15.WilsonK,MacDougallL,FergussonD,GrahamI,TinmouthA, HebertPC.Theeffectivenessofinterventionstoreduce physician’slevelsofinappropriatetransfusion:whatcanbe learnedfromasystematicreviewoftheliterature.
Transfusion.2002;42(9):1224–9.
16.O’BrienKL,ChampeauxAL,SundellZE,ShortMW,RothBJ. Transfusionmedicineknowledgeinpostgraduateyear1 residents.Transfusion.2010;50(8):1649–53.
17.ShafieeA,NazariS,MogharrebanM,KoupaeiMT.Evaluating medicalinterns’knowledgeofcommonbloodtransfusion complications.TransfusApherSci.2013;48(2):253–6. 18.RebelA,HassanZU,BoralL,LinY,DiLorenzoA,SchellRM.
Initialresultsofastructuredrotationinhematologyand transfusionmedicineforanesthesiologyresidents.JClin Anesth.2011;23(6):469–74.
19.LouwVJ,NelMM,HayJF.Factorsaffectingthecurrentstatus oftransfusionmedicineeducationinSouthAfrica.Transfus ApherSci.2013;49(3):665–72.
20.HaspelRL,LinY,MallickR,TinmouthA,CidJ,EichlerH,etal. BEST-TESTInvestigatorsInternalmedicineresident
21.SilvaKF,SoaresS,IwamotoHH.Transfusionpracticeandthe instructionofhealthcareprofessionals.RevBrasHematol Hemoter.2009;31(6):421–6.
22.NovarettiMC.Learningperceptionintransfusionmedicine. RevBrasHematolHemoter.2009;31(6):405–6.
23.FlausinoGF,NunesFF,CioffiJG,ProiettiAB.Teaching transfusionmedicine:currentsituationandproposalsfor
propermedicaltraining.RevBrasHematolHemoter. 2015;37(1):58–62.
24.Brasil.MinistériodaEducac¸ãoConselhoNacionalde
Educac¸ão–Resoluc¸ãon◦.3,20dejunhode2014–DiárioOficial
