Context.—Given the number of controversial issues in transfusion medicine, an understanding of biostatistics and evidence-based medicine is invaluable. No detailed curricula that address teaching critical appraisal of the transfusion medicine literature have been published or evaluated.

Objective.—To design, implement, and evaluate an evidence-based transfusion medicine curriculum.

Design.—Four hour-long training sessions in journal club format were designed for a 2-month transfusion medicine rotation for clinical pathology residents. A previously validated survey was administered precurriculum and postcurriculum to gauge changes in resident self-reported attitudes and confidence regarding biostatistics methods and critical appraisal of the medical literature. Residents were also asked to evaluate the course regarding content, execution, and utility.

Results.—Seven second-year residents participated in the sessions. Following the curriculum there were statistically significant increases in the residents’ self-reported ability to appraise critically and search the medical literature (P  =  .05). Resident confidence interpreting an article's statistical results also significantly improved (P  =  .01). There was also a significant change in the residents' desire to learn more about statistics (P  =  .02). Resident reviews of the curriculum were overall extremely positive.

Conclusion.—A 4-session curriculum can have a significant effect on resident self-reported ability to appraise critically and understand the medical literature and help foster interest in biostatistics. Although based on small numbers, this study represents one of the first efforts to evaluate the efficacy of a transfusion medicine curriculum and can potentially serve as a starting point to better integrate and evaluate knowledge of evidence-based transfusion medicine during residency training.

There are many controversial areas in transfusion medicine. Recent examples include the current debate regarding the appropriate ratio of plasma to red cell units in massive transfusion and the potential benefits of “young” blood for patients.14 If we are to provide the best care for patients, an evidence-based medicine (EBM) approach is needed to allow us to incorporate the available data and apply it to clinical practice. To achieve this goal, some knowledge of biostatistics as well as the ability to read the literature critically is necessary for blood bank professionals to reach sound conclusions.5 

A recent study of internal medical residents suggests medical schools are not adequately teaching basic biostatistics or critical appraisal skills. Windish et al6 developed and then administered a biostatistics assessment tool to 277 internal medicine residents. Only 11.9% were able to correctly interpret a 95% confidence interval and only 10.5% could correctly interpret Kaplan-Meier analysis results. Even more surprising, statistical knowledge actually decreased with more advanced years of training.

Given these results, it is likely many clinical pathology (CP) residents are also not learning these important skills. Clinical pathology training encompasses all the clinical laboratories including the blood bank. Published curricula for CP residents include the goals of demonstrating “knowledge of evidence-based medicine” and more specifically “ability to evaluate literature for therapeutic apheresis” but they provide no guidance as to how to teach these skills.7,8 Furthermore, no studies have directly assessed pathology resident abilities or attitudes regarding biostatistics or EBM.

This article describes the development of a curriculum for CP residents in evidence-based transfusion medicine. During 4 sessions with prespecified teaching goals, articles on important clinical issues were discussed in a journal club format. Resident attitudes and confidence regarding biostatistics and critical appraisal of the medical literature were measured precurriculum and postcurriculum.

Study Population

Second-year anatomic pathology/CP residents were asked to participate in the study. The first year of training is entirely anatomic pathology and the second year is entirely CP. During the second year, each resident does a 2-month initial rotation in transfusion medicine followed by a third month later in the year. The residents were recruited during the initial 2-month rotation. The protocol was approved for exempt status by the Beth Israel Deaconess Medical Center Institutional Review Board (Boston, Massachusetts).

Curriculum

During the first 4 to 6 weeks of the initial transfusion medicine 2-month rotation, there were 4 EBM sessions facilitated by a single individual (R.L.H.). For each session, the residents were first given a brief narrative (described later) with a clinical question and then asked to find articles to help answer the question. After I received the lists of articles from the residents, I gave out 2 articles regarding the clinical questions for the residents to review prior to a 1-hour discussion session. The 2 articles selected for each session reached different conclusions regarding the same clinical question. At the beginning of each session, the different article search strategies (eg, Medline queries) would be reviewed with suggestions for improvement. All sessions were in a journal club format and the key aspects of reviewing a research article were discussed including goals of the trial, type of trial, intervention, blinding, inclusion/exclusion criteria, outcomes measured, statistical methods, validity of authors' conclusions, and application to patient care. Session-specific articles and curricular goals are listed in Table 1.

Table 1

Evidence-Based Transfusion Medicine Curriculum

Evidence-Based Transfusion Medicine Curriculum
Evidence-Based Transfusion Medicine Curriculum

Narrative 1/Randomized Controlled Trials A9,10 

The chief of transplant surgery calls you to discuss the possibility of using recombinant factor VIIa prior to liver transplant surgery. She says that recent data suggest a benefit in reducing blood loss. What literature can you find for and/or against use of prophylactic recombinant factor VIIa in this setting? Are there any randomized controlled trials?

Narrative 2/Randomized Controlled Trials B11,12 

You are paged by the renal fellow requesting plasma exchange for a patient with multiple myeloma. The patient presented with an elevated creatinine that has failed to respond to hydration. The fellow states that the Scientific Advisors of the International Myeloma Foundation and American Society for Apheresis both endorse plasma exchange for “myeloma kidney.” Are there any randomized trials testing the efficacy of plasma exchange for acute renal failure in the setting of myeloma?

Narrative 3/Observational Studies13,14 

You are in the midst of a platelet shortage and triaging all requests for platelets. You receive a call from a resident requesting platelets prior to a lumbar puncture. The patient is a 5-year-old girl with acute leukemia and a platelet count of 38 000/µL. The lumbar puncture is needed to administer intrathecal chemotherapy. Is there information in the medical literature that can help determine the need for a platelet transfusion in this setting? Would it matter if the tap was for diagnostic purposes and the resident was concerned about a “bloody tap”?

Narrative 4/Direct Comparison of a Randomized Controlled Trial and an Observational Study15,16 

A bone marrow transplant physician calls you regarding “cytomegalovirus–reduced risk” blood products. The practice at your hospital is to provide leukoreduced and not cytomegalovirus-seronegative blood products to prevent infection. The physician is concerned because he read recently that seronegative blood products are “better” than leukoreduced for prevention of cytomegalovirus.16 What other data can you find regarding this clinical question? Are there any randomized controlled trials?

Survey Tool

Immediately prior to the first EBM session, the residents completed a precurriculum survey tool. Part A of the survey determined prior biostatistics training and resources used for solving clinical problems. Parts B and C of the survey were based on a previously validated survey to determine medicine resident attitudes and self-reported confidence regarding biostatistics.6 Questions were added to identify self-reported ability to appraise critically and search the medical literature and question B4 was modified to better reflect the experience of pathology residents. The survey was piloted on 3 third-year pathology residents to ensure instructions and questions were clear. Following the final EBM session, the residents completed a postcurriculum survey, which consisted of parts B and C of the precurriculum survey as well as a standard course evaluation form (with some modifications) used at Beth Israel Deaconess Medical Center. A summary of the surveys is included in the  Appendix.

All surveys were anonymous and only reviewed after all residents had completed all sessions.

Statistical Analyses

Descriptive statistics (mean, standard error of the mean) were calculated for all rankings. For part B of the precurriculum survey and part A of the postcurriculum survey, a response of 1 or 2 was considered agreeing with the statement. For the confidence questions, a “total confidence score” was used to help assess changes (maximum score, 20).6 Because the surveys were anonymous and because the a priori hypothesis was for only an improvement in resident attitudes regarding biostatistics, a 1-sided unpaired Student t test was used to compare precurriculum and postcurriculum surveys. A P value .05 or less was considered statistically significant. Statistical results were calculated using Microsoft Excel 2003 (Microsoft Corp, Redmond, Washington).

Baseline Characteristics

Seven second-year residents, 4 women and 3 men, completed their initial 2-month transfusion medicine rotation in the 2008 academic year. All were in the anatomic pathology/CP program at Beth Israel Deaconess Medical Center and all agreed to take part in the study.

Only one resident reported having biostatistics training in college (1 quarter). All the residents reported having taken a biostatistics/epidemiology course in the first or second year of medical school. Five of the students reported a course duration (30 hours, 2 weeks, 4–6 weeks, 1 semester). The other two residents described the course as either “brief” or “minimal.” One resident also reported taking an 8-hour fourth-year medical school elective but none of the participants reported any exposure during residency.

The self-reported resident exposure to EBM occurred only in medical school and was more diverse. Only one student reported a specific course (longitudinal during 2 years) while another noted integration into “rotations/curriculum.” Three other residents noted informal, minimal, or sporadic exposure, with one specifically stating there was an approximate total of 16 hours during 4 years. Two students actually reported that there was no specific curriculum.

Regarding resources used to answer clinical questions that arise on service, the most highly ranked was faculty followed by UpToDate (www.uptodate.com; Waltham, Massachusetts) and the Internet (Table 2). The primary literature was ranked last with no residents ranking this resource as first and 3 residents responding that they do not use this resource at all.

Table 2

Ranking of Resources Used to Answer Clinical Questions

Ranking of Resources Used to Answer Clinical Questions
Ranking of Resources Used to Answer Clinical Questions

Attitudes and Confidence Regarding Biostatistics

Results for the precurriculum and postcurriculum surveys are shown in Table 3 and in the Figure. Regarding questions on attitudes, all residents strongly agreed (a response of 1 on a scale of 1 to 5) both precurriculum and postcurriculum that “to be an intelligent reader of the literature, it is necessary to know something about statistics.” All other postcurriculum survey responses show movement toward agreeing with the statements in the survey (ie, the hoped for result). Even with the small number of participants, several of these changes reached a P value of .05 or less including the desire to learn more about biostatistics and the perceived ability to both appraise critically and search the medical literature.

Precurriculum and postcurriculum resident confidence regarding biostatistics and evidence-based medicine. The mean scores ± standard error of the mean for questions in part C of the precurriculum survey and part B of the postcurriculum survey were compared (1, none; 5, complete confidence). *P  =  .05; **P  =  .04; ***P  =  .01.

Precurriculum and postcurriculum resident confidence regarding biostatistics and evidence-based medicine. The mean scores ± standard error of the mean for questions in part C of the precurriculum survey and part B of the postcurriculum survey were compared (1, none; 5, complete confidence). *P  =  .05; **P  =  .04; ***P  =  .01.

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Table 3

Resident Attitudes Precurriculum and Postcurriculum

Resident Attitudes Precurriculum and Postcurriculum
Resident Attitudes Precurriculum and Postcurriculum

Self-reported confidence in biostatistics concepts also improved following the sessions (Figure). For 3 of the 4 areas queried (power calculations, interpreting statistical results, and assessing the appropriateness of a statistical test), there was a significant improvement in confidence. For the other area, confidence interpreting P values, there was also an improvement (P  =  .10). Overall confidence scores were 10.3 before the curriculum and 13 afterward (P  =  .01).

Curriculum Evaluation

Regarding opinions of the sessions, all except one resident rated each question a 4 or 5 (of a maximum of 5) demonstrating positive reviews of the course. One resident rated each question a 1 or 2. It appears, however, that this reflects a misreading of the scale of the question because this same resident made the comment that he or she “enjoyed the course.” For the purposes of full reporting, the results with and without the outlying review are presented in Table 4.

Table 4

Resident Evaluation of the Curriculum

Resident Evaluation of the Curriculum
Resident Evaluation of the Curriculum

Three residents had specific comments. One wrote “this was a valuable exercise…I had no confidence in this prior to this course, but now I feel a bit more comfortable with it. It's extremely important to have the ability to evaluate medical journal articles. I hope there will be more opportunities for this sort of activity/evaluation later in residency training.” Another wrote “very well done. I learned a lot, feel more comfortable with the literature.” The final resident wrote “I enjoyed the EBM sessions” and provided the suggestion that “I think perhaps a general overview of statistical variables and studies and techniques would be useful; we did some of this, but I would've liked a more formal didactic and organized format as an intro.”

Transfusion medicine specialists must be able to appraise the medical literature critically. How do we teach future blood bankers this important skill? Although methods for teaching EBM to residents in a various specialties have been described, to my knowledge this article represents the first effort to create and evaluate a detailed curriculum in evidence-based transfusion medicine and biostatistics for pathology residents.17 The journal club, a well-established method for teaching critical appraisal of the medical literature, was adapted to teach EBM concepts in relation to important topics in transfusion medicine.18 

Although based on small numbers, the group studied is similar to a previously studied large group of internal medicine residents in that most had biostatistics training and this training mainly occurred in medical school.6 In addition, baseline confidence in biostatistics was also similar (total confidence scores of 10.3 vs 11.4). One surprising finding is that the lowest ranked resource for finding answers to clinical questions was the primary literature. It would be interesting to determine whether residents at other institutions also infrequently use research articles to direct their daily practice.

All postsurvey answers showed positive changes in attitudes and confidence regarding biostatistics and critically appraising the medical literature. Remarkably, although only 7 residents participated, many of these changes reached statistical significance including residents wanting to learn more biostatistics as well as feeling more comfortable searching and critically evaluating the medical literature. There was also greater confidence interpreting statistical tests. Overall, reviews of the curriculum were extremely positive. There was one suggestion for a more formal introduction to basic statistical concepts and this may be incorporated in future iterations of the curriculum.

This study has several weaknesses, especially the small numbers. As noted previously, however, statistically significant differences were still obtained. Given possible differences in residency program characteristics, the results also may not apply to other institutions. Another potential weakness is that all sessions were conducted by a single individual and the effect of instructor variability on curriculum efficacy remains to be determined. The residents' responses may also have been biased as they all knew the instructor (ie, R.L.H.) as one of their attendings. To mitigate this weakness, the surveys were anonymous and not reviewed until all residents had completed the sessions. It is also unlikely that residents remembered their responses to the precurriculum survey because the postcurriculum survey was administered 4 to 6 weeks later. Lastly, because the postcurriculum survey was administered shortly after completion of the teaching sessions, the results may only reflect short-term changes in resident confidence in appraising the medical literature. Future studies should address the durability of any positive effects of the curriculum.

Regardless of potential deficiencies, this study represents the first attempt to design a curriculum for CP residents in evidence-based transfusion medicine. Given the promising results, it is hoped other institutions may try to adapt similar curricula to train their transfusion medicine residents and fellows. This study also represents one of the first attempts to evaluate the efficacy of any curriculum in transfusion medicine. Recent articles have documented the need for greater “methodological rigor” in medical education research with a focus on measuring outcomes.19 There are few articles in the transfusion medicine literature that have taken this approach. As such, the results from this article can potentially be a starting point for evidence-based development, implementation, and evaluation of other transfusion medicine curricula.

I thank Lynne Uhl, MD, for her critical review of the manuscript.

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Appendix

Precurriculum and Postcurriculum Surveys

Precurriculum and Postcurriculum Surveys
Precurriculum and Postcurriculum Surveys

The Blood Banking Evidence-Based Medicine Course

The Blood Banking Evidence-Based Medicine Course
The Blood Banking Evidence-Based Medicine Course

Author notes

From the Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

The author has no relevant financial interest in the products or companies described in this article.