Transfusion medicine (TM) knowledge varies widely among resident physicians in both the theoretical and practical contexts [1, 2]. This can lead to the inappropriate utilization of blood products, thereby increasing both the costs and risk of adverse events posed to patients. Our academic medical center is also subject to these problems; many orders received at our blood bank do not align with evidence-based national transfusion guidelines. American medical schools lack standardized TM educational programs. There is also great variability in the number of hours and settings in which TM is taught [3]. Thus, residents and fellows are often left to learn TM principles in actual applied settings while caring for patients with blood product needs.

The most recent dedicated TM curriculum for medical students was published in 1995 by the Transfusion Medicine Academic Awards (TMAA) group and sponsored by the National Heart, Lung, and Blood Institute. This effort represented an update to the curricula previously published in 1983 and 1989 (hereinafter referred to as the TMAA curriculum) [4]. While the group has since disbanded, the Academy of Clinical Laboratory Physicians and Scientists (ACLPS) proposed another curriculum that was published in 2010 in the context of general laboratory medicine education for medical students [5]. There were many challenges in implementing each of these proposed curricula, with few publications detailing the development of structured programs. One recent successful program involved case-based patient simulations [6]. Other institutional attempts to increase general laboratory medicine education for medical students have received mixed feedback from students. One study found that only 41% of graduating students who participated in a 1.5-day course (based on the 2010 ACLPS curriculum) agreed that laboratory medicine would be useful for their future practices [7]. This contrasts with findings suggesting that more than 70% of all clinical decisions are guided by laboratory tests [8]. It is thus of high importance to induce a major shift in the level of appreciation medical students have for the indispensable nature of laboratory medicine education, including TM.

It can be very challenging to meaningfully assess the curricular changes related to this type of education. Here, experience in the field of TM has been particularly scant. In 2014, the Biomedical Excellence for Safer Transfusion (BEST) Collaborative developed and validated an exam designed to assess the knowledge of medical students and physicians (hereinafter referred to as the BEST exam) [9]. The BEST exam was validated for use among test-takers equipped with expected basic, intermediate, and advanced TM knowledge, ranging from first-year medical residents to TM physicians. Some publications have recently begun utilizing the BEST exam to assess post-graduate medical trainee knowledge [10, 11].

In an effort to support TM education for senior medical students, we developed a novel course based on the 1995 TMAA curriculum within our medical school. The course covers the most practical aspects of the TMAA curriculum, targets indications for blood product transfusions, presents scenarios requiring special blood product modifications, and requires the identification and management of transfusion reactions. This article thus reports on our creation of this one-hour course, which should easily be adaptable at other institutions.

From our study population, 63 students (35% of the total graduating class) attended the course. Of them, 62 (98.4%) completed the BEST exam and self-efficacy assessments after the lesson was completed. The mean exam score was 50%, while the median score was 50%. The 25th and 75th percentiles were 43.8% and 60%, respectively. For the comparison group evaluated the following year, 91 students (50.6% of the total graduating class) attended our course. Of them, 88 (96.7%) completed the BEST exam prior to the start of the class. This comparison group was used as our pre-intervention baseline. Here, the mean exam score was 27.5%, while the median score was 25%, and the 25th and 75th percentiles were 15% and 35%, respectively. Results indicated a significant post-intervention increase in overall TM knowledge (P<0.0001).

Confidence levels rose significantly for all objectives among our study population (i.e., from a mean of 3.1 to 7.0) (P<0.0001) (Table 2). Student answers to the BEST exam were evaluated to assess performance in the tested topics. Students performed poorly for three of the 20 questions, with fewer than 20% of respondents answering correctly. These topics included the diagnosis and management of allergic transfusion reactions (10% answered correctly), red cell transfusion thresholds in acute anemia (11% answered correctly), and massive transfusions (11% answered correctly). The remaining questions were answered correctly by an average of 56.2% of students in the study population (ranging from 26–82%).

Out of the total 63 students in our study population, 53 (84.1%) course attendants submitted anonymous evaluations to the medical school. Here, ratings were given for content presentation clarity, session organization, active learning opportunities, and the overall session. Items were rated on a scale of 1–5 (1=not at all/poor, 3=somewhat/good, 5=completely/ excellent); all parameters were rated at 4.7 or above. Students universally found the curriculum enjoyable, relevant, effective, and time-efficient. Some representative comments are as follows: “This session was very clear and well-run. The slides were fantastic!”, and “A gem of a lecture - I think this should be a required lecture for all 4th year medical students - absolutely the most bang for your buck in a single hour”.

This study was an initial effort to assess the impact of a novel TM course by conducting a validated exam on medical student TM knowledge. Our findings demonstrated that, immediately after completing the course, graduating medical students possessed significantly improved TM knowledge between the previously reported basic and intermediate levels associated with the BEST exam [9]. Fewer than 20% of all students correctly answered three questions on the post-course BEST exam (i.e., diagnosis and management of allergic transfusion reactions, red cell transfusion thresholds in acute anemia, and massive transfusions). We thus modified our educational plan to include additional lecture time on these areas and expanded the question-and-answer session to improve student understanding.

The medical students that attended our lecture significantly increased their confidence levels in performing TM-related tasks. Notably, the three topics most poorly answered received some of the highest self-reported confidence ratings based on post-course evaluations, ranging from 7.2 to 7.6 out of 10. This suggests that this metric is a non-specific measure of improved understanding. Self-assessments are widely acknowledged to be ineffective and inaccurate methods for identifying personal areas of deficiency [13, 14]. Thus, while self-assessment confidence ratings significantly improved for all objectives after our course, these self-reported results should be interpreted wisely. External assessments also remain vital when attempting to accurately characterize student understanding of education materials.

Since our course contents were based on national evidence-based guidelines and were not institution-specific, the lecture can easily be adapted for use at other medical schools. This course would best be applied at medical schools that dedicate minimal instruction time for TM education. This is because it covers highly practical aspects of transfusion in only one hour. It may be challenging to adapt this course at medical schools that do not have TM physicians on staff to provide routine instruction. The slides used in the complete presentation are available from the corresponding author by request.

This study was somewhat limited in that we were not able to perform a pre-intervention assessment of our study population prior to the lesson. As already noted, we did not want to administer the validated BEST exam prior to the course to avoid biasing the assessment of respondent TM knowledge immediately afterward. However, we believe that assessing the fourth-year medical student group at our course the following year in addition to characterizing their TM knowledge via the BEST exam prior to the lesson to serve as our pre-intervention baseline was a reasonable solution to this dilemma. It is reasonable to assume that the fourth-year medical students in both the study population and in the comparison group had identical levels of TM knowledge. This is because both groups completed identical medical education curricula for four-year periods prior to taking our course and were accordingly tested at corresponding progress levels (i.e., approximately one month after Match Day). We thus concluded that this comparison group could equitably serve as a pre-course baseline for our students.

We plan to repeat our course for subsequent groups of graduating medical students. The positive student reactions were highly encouraging, particularly since many attempts to teach laboratory medicine to medical students are met with poor feedback. However, increased attention will be given to the previously mentioned topics for which students performed most poorly on the exam. In addition, we plan to immediately create and include an informational handout, which some students requested. We did not initially provide a student handout because participants were offered the post-course BEST exam. That is, there were concerns that it may have provided a source of information that would have artifactually increased post-course scores. However, other institutions that intend to adopt this course may consider providing a handout to students for reference in their future practices.

Future studies assessing longer-term retention of the material covered in this course have already been planned. We also plan to adapt this course for use in a required online training module for all new residents. This will reach a broader audience, thereby improving the blood ordering practices at our institution. In addition, we intend to implement this novel course among several resident groups at various training levels, including those related to internal medicine, surgery, pediatrics, and both adult and pediatric hematology/oncology and nephrology fellows. We anticipate that periodic exposure to this course will be necessary to continually reinforce core TM objectives for physicians who will care for patients with blood product needs.