Anesthesiology resident knowledge of transfusion medicine: A critical knowledge gap?
Myron Yaster MD, Alan Jay Schwartz MD MSEd, and Justin L. Lockman MD MSEd
As I scan journals for the PAAD, I frequently run into a slew of articles on a single, specific topic even in a non-themed issue of a journal. March 2024 was no exception. The March 2024 issue of Anesthesia and Analgesia had several articles on transfusion medicine and the management of massive hemorrhage. In today’s PAAD, Connelly et al.1 report on a U.S. national survey of anesthesiology resident’s knowledge of transfusion medicine. Before telling you what they found, do any of you want to lay a wager on their results? I don’t think so….It would be a sucker’s bet and I don’t think any of you will be surprised by the study’s results. Why then review it in the PAAD? Why pull the band aid off the wound? Blood and blood products transfusions are just too important and fundamental to our practice. (And much of next week’s PAADs reviewed an important paper on this topic.) Surely, we can do a better job of teaching and learning about this aspect of our practice. Indeed, I am reaching out to the first author of today’s PAAD, or if any of you know any of the authors of this article, to see if we can get the actual questions and repeat the study but this time of pediatric anesthesia fellows and a variety of Board certified attendings.
Because today’s PAAD focuses on resident education, I asked two of the PAADs executive council members with master degrees in education (MSEd), Drs. Alan Schwartz and Justin Lockman, to help. Finally, because this an article about residents and the match results were just announced I thought a word from my favorite opthamologist, Dr. Glaucomflecken, would be appropriate. Myron Yaster MD
Original article
Connelly NR, Adler AC, Vanderberg LE, Conlin F, Mitchell JD, Goldstein S, Haspel RL; ATEST Collaborators. Anesthesiology Resident Knowledge of Transfusion Medicine: Results From the Anesthesiology Transfusion Education Study. Anesth Analg. 2024 Mar 1;138(3):655-663. doi: 10.1213/ANE.0000000000006327. Epub 2022 Dec 12. PMID: 36729772.
As anesthesiologists we deal with hemorrhage and blood and blood component replacement products on almost daily basis. Today’s PAAD by Connelly et al. used a validated survey tool from the “BEST Collaborative” which “is an international organization that works to identify important questions in Transfusion Medicine, design and execute studies to address these questions, and provide critical thought and synthesis of the available evidence ( http://www.bestcollaborative.org ). The authors adjusted the question stems and answers to be relevant to “anesthesiology practice and the perioperative period.”1 “The final Anesthesiology Transfusion Education STudy (ATEST) examination included 23 multiple-choice questions each with 5 answer choices with a single correct answer. The questions represented 3 broad constructs: (1) assessing the requirement for blood products, (2) transfusion risks and reactions, and (3) general transfusion management. In addition to the examination questions, an 18-question survey was administered to assess the candidates’ prior knowledge, education, and comfort with transfusion medicine topics.”1
The survey was sent to American anesthesia residents in all regions of the United States and in all stages of training, from the internship year thru the 3 years of anesthesia training. The authors found major gaps in knowledge and broke down the results based on respondent performance to the American Board of Anesthesiology keyword topics and year of training. Surprisingly, the mean score across all respondents was 45% on the exam, and even among CA-3 residents was only 49% correct (median 52%)!
Where did the respondents do well? On indications for RBC transfusions (91%). Where did they do poorly (< 25% correct)? Massive transfusion, indications for cryoprecipitate and plasma, blood conservation, diagnosis and management of transfusion reactions, transfusion related cardiac overload, and transfusion related acute lung injury. These are some of the most important issues facing clinicians perioperatively! Equally disturbing was the finding that respondents “were unaware of institutional transfusion guidelines or the availability of local blood banking pathologists or phone numbers to assist with issues.”1 Perhaps most alarmingly, among the 55 trainees (13% of respondents) who self-identified as “experts” in transfusion medicine, the mean examination score was still only 50.6% correct!
Before you have a panic attack about the future of our specialty, consider a MAJOR limitation of this study which is not addressed in the discussion: only 423 residents were included in the study. While the authors tried to sample a larger group (inviting 159 residency programs to participate), only 37 programs were interested and even invited their residents to participate. Since the study was performed in 2019, we looked back at the anesthesia match data from 2019: There were 1839 matched applicants at US-based programs in anesthesiology that year.2 This means there are approximately 7300 anesthesiology residents in the nation across all four years; the 423 respondents represent only about 6% of that estimated number.
Nonetheless, because respondents were stratified by geography, program size and training year, we find the results compelling. So how should we proceed? Some obvious first steps would be to ensure adequate education about transfusion medicine for our own residents. We would also love to repeat the study evaluating transfusion knowledge in our pediatric anesthesiology fellows AND their faculty. Further, we wouldn’t limit this future study to American trainees and their faculty. Using the resources of SPA and the PAAD we would suggest that we follow up with our international colleagues and readers as well. If the ATEST data are even close to right. we need to raise this subject up our respective food chains and develop teaching modules and national meeting lectures to cover these essential concepts. Our patients deserve better.
What do you think? Send your responses to Myron who will post in a Friday reader response.
References
1. Connelly NR, Adler AC, Vanderberg LE, et al. Anesthesiology Resident Knowledge of Transfusion Medicine: Results From the Anesthesiology Transfusion Education Study. Anesthesia and analgesia 2024;138(3):655-663. (In eng). DOI: 10.1213/ane.0000000000006327.