|Year : 2018 | Volume
| Issue : 2 | Page : 127-131
Postgraduate residents' awareness of organ transplantation protocols – Survey at a teaching hospital
Sujan Pudippedi1, Biju K Varghese1, CS Naidu2
1 Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India
2 INHS Sanjivani, Kochi, Kerala, India
|Date of Submission||28-Sep-2018|
|Date of Acceptance||06-Dec-2018|
|Date of Web Publication||10-Jan-2019|
Gp Capt Biju K Varghese
Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Introduction: Much as the techniques have progressed to make organ transplantations safe and effective, the legal and ethical tangle surrounding the process has necessitated strict regulations and protocols to be followed. This paper studies a cross-sectional survey conducted on 198 postgraduate residents from various specialties with the aim of determining awareness of (a) legal and ethical requirements, (b) organ donation possibilities, and (c) technical details including brain-death criteria. Methods: A cross-sectional survey was conducted among postgraduate residents of all specialties in a tertiary care teaching institution. The survey instrument was a questionnaire with multiple choice questions aimed at evaluating awareness of the residents in the three knowledge domains. The mean scores of residents from each specialty and groups of specialties with similar work exposure were calculated and compared, with statistical significance tested using the ANOVA. Results: There was no statistically significant difference between the year-wise mean scores between residents of 1st, 2nd, and 3rd years. No significant difference in scores was obtained between groups of residents from similar specialties. Scores obtained by residents of specialties routinely managing patients in intensive care unit did not show any statistically significant difference with year of training. There was significantly lesser score obtained by anesthesiology residents in the domain concerning the possibility of donation of specific organs compared with surgery residents. There were significantly high mean scores in the knowledge domain related to brain death criteria and transplant techniques for medicine and surgery residents, respectively. Conclusion: The low levels of scientific knowledge regarding organ donation protocols and associated legalities among resident doctors are a matter of concern. These findings may merit consideration to include these protocols as part of teaching curriculum.
Keywords: Awareness, brain death, curriculum, organ procurement, transplantation
|How to cite this article:|
Pudippedi S, Varghese BK, Naidu C S. Postgraduate residents' awareness of organ transplantation protocols – Survey at a teaching hospital. J Mar Med Soc 2018;20:127-31
| Introduction|| |
Organ transplantation is one of the most important medical inventions of modern times which have offered hope to millions of patients of end-stage organ failure. Much as the techniques have progressed to make it safer and more effective, the legal and ethical tangle surrounding the process has necessitated strict regulations and protocols to be followed to ensure acceptable overall outcomes. With the large population of India, the number of patients requiring organs is ever increasing. The early start and commendable progress made in the 1970s was tarnished by rampant unethical “commercial” living donor practices which ensued due to financial poverty of a large proportion of our country. The Transplantation of Human Organs Act first passed by the Government of India in 1994 made transplants from an unrelated living donor illegal and laid down the legalized deceased organ donation and acceptability of brain death.
Deceased organ donations, however, hardly met the massive requirement of organs globally due to cultural and religious beliefs, lack of awareness among public as well as health-care providers, technical difficulties in harvest, transport, and transplantation within the specified time frame to allow optimal organ function. Illegal organ trade has continued to flourish, drawing reactions from international bodies and causing further modifications of the national legislation.
With the information technology revolution, public education has become relatively easier. It is evident from various organ donation drives and public declaration of pledging organ donation after death by celebrities and religious leaders that an era of improved deceased organ donor availability may be unfolding. In a large teaching hospital, the backbone of round the clock patient care is the residents and fellows in various specialties. They form part of the interface between a potential deceased donor's relatives and the transplant team. Effective communication depends on sound knowledge of protocols, and it is necessary to assess the knowledge levels of this vital group of people who actually have the potential to convert the “interest” in donation to a lifesaving deceased organ transplant.
This paper studies a cross-sectional survey conducted on 198 postgraduate residents from various specialties with the aim of determining awareness of (a) organ donation possibilities, (b) legal and ethical requirements, and (c) technical details including brain death criteria. The objectives included comparison of knowledge between specialties and between the 3 years of residency program to examine if organ transplant awareness was related to specialty or duration of training.
| Methods|| |
This was a cross-sectional questionnaire-based survey. The study was approved by the institutional ethical committee.
The survey instrument was a questionnaire designed by focus group discussion with a senior transplant surgeon with more than a decade of experience in organ transplantation. Objective (multiple choices) questions were designed with one or more possible answers. The content was validated by three consultants having experience in organ transplantation. Items meeting acceptable content validity index were included. No negative marking was used. The questions were grouped under three knowledge domains as follows: Domain A – awareness of consent, social, legal, and ethical aspects; Domain B – awareness of possibility of donation of specific organs; and Domain C – awareness of brain death criteria and technical feasibility.
All postgraduate residents of all 3 years of training from various specialties in a medical college were approached for the study.
The survey was administered during May 2017, during the month, the fresh postgraduate residents join for training. Thus, the 1st-year residents were in the very beginning of their training and 3rd-year residents were in the beginning of their final year of residency. Participation was voluntary. The survey was conducted by handing out printed questionnaires during scheduled departmental academic sessions and collected after completion during the same session. Verbal permission was taken from the respective heads of departments for administering the questionnaire during their individual training schedules. Time allowed to complete the questionnaire was 30 min and the process was supervised by the first author. The survey was administered in all the departments within a period of 1 week.
Scoring and statistical analysis
Mean scores in each of the three knowledge domains and total scores were tabulated for (a) each specialty; (b) each year of training; (c) groups of similar specialties, namely, medicine and allied clinical specialties, surgery and allied clinical specialties, health and hospital management, preclinical and paraclinical specialties; and (d) specialties dealing routinely with intensive care unit (ICU) patients (medicine, surgery, anesthesiology, and critical care).
Comparison of mean scores in the three knowledge domains as well as combined scores obtained by each specialty and specialty group was done. In addition, scores achieved by residents in Medicine, Surgery, and Anesthesiology which are the major specialties dealing with ICU patients were compared with all other specialties taken together. Statistical analysis was done using ANOVA to find out the significance of difference between mean scores.
| Results|| |
Of a total of 379 postgraduate residents who were administered the test, completed questionnaires were obtainable from 198 residents. The response rate was thus 52%. The maximum response was from General Surgery, General Medicine, Community Medicine and Obstetrics and Gynecology which was roughly indicative of the larger number of residents in these specialties.
Mean scores of residents of each specialty, year of training, and specialty subgroups were tabulated as shown in [Table 1]. For the entire population, the mean knowledge domain score was 8.39/12 (69.9%) for awareness of possibility of donation of specific organs, 3.26/10 (32.6%) for awareness of consent, social, legal, and ethical aspects, 2.53/8 (31.62%) for awareness of brain death criteria, and transplant techniques. The mean total score was 14.16/30 (47.2%).
|Table 1: Mean scores and comparison of residents from various specialties|
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There was no statistically significant difference between the year-wise mean scores between all residents of 1st, 2nd, and 3rd year of training. No significant difference in scores was obtained between residents of similar specialties grouped together. Comparison of training year-wise scores obtained by residents of specialties routinely managing patients in ICU did not show any statistically significant difference.
When mean scores obtained by medicine and surgery residents were compared with all other specialties taken together, there were significantly high mean scores in the knowledge domain related to brain death criteria and transplant techniques (P = 0.0466 for surgery and P = 0.009 for medicine). There was significantly lesser score obtained by anesthesiology residents in the domain concerning the possibility of donation of specific organs (P = 0.042) compared with surgery residents.
| Discussion|| |
It has been documented that increasing availability of donated organs from deceased donors is the most viable way to improve the supply of organs to patients with end-stage organ dysfunction and to reduce the menace of commercial organ donation. However, in spite of coordinated and collaborative efforts, the donation rates have been found to be grossly deficient to meet the rising demand even in Western countries. The unique exception to this situation achieved by Spain with a continuous decade-long improvement in cadaveric organ donation has been clearly attributed to a proactive organ donor detection program. As observed by Matesanz and Miranda, the problem is not the deficiency of donors but the inability to convert potential donors into actual donation.
Low level of knowledge about legal and technical aspects of organ transplantation among health-care professionals has been voiced as a concern by several studies. The role of the health-care professionals who may not be directly a part of the transplant team is very important in influencing the decision of the families of potential deceased donors. This is true, especially in case of fellows and residents who are in contact with the patients and their relatives for maximum duration of time in teaching institutions.
We could get responses from 52% of postgraduate residents in a teaching institution having postgraduate courses in all basic specialties. The survey was conducted by direct administration of the questionnaire during departmental academic sessions over during 1 week. Response rates were affected by residents not willing to complete the questionnaire and some being on leave during the survey period. Repeat administration of survey for the absentees was not done since that could affect the outcome, due to possible discussions between the residents.
Our study revealed a low mean total score of 47.2% among postgraduate residents of all specialties. The mean scores were lower in the vital knowledge domains of Consent, Social, Legal, and Ethical Aspects (32.6%) as well as of brain death criteria and transplant techniques (31.62%). This is commensurate with the observation by several authors that there is a general lack of adequacy in the awareness among health-care professionals about this vital subject.,, Even though mean score for awareness of the possibility of donation of specific organs was high (69.9%), it is only of significance as “general knowledge” when it comes to a postgraduate resident and may not contribute to actual application in the professional scenario unless combined with knowledge in the other domains.
The present curriculum of training did not appear have any change in the knowledge levels as the resident's training progressed, as evidenced by no significant change in the mean domain scores or total scores between 1st-, 2nd-, and 3rd-year residents. Thus, postgraduate training did not seem to have any influence on improving transplant awareness as a specific learning objective. This lack of formal inclusion of transplant protocols as part of medical school curriculum has been pointed out as a lacuna in the implementation of deceased organ transplants. Ironically, certain authors have even observed surprisingly high transplant awareness among 1st-year medical students and even high school students,,, possibly due to inclusion of this topic in premedical courses or due to higher enthusiasm. The basic awareness and positive attitudes toward transplantation at the beginning of medical education were not found to effectively develop into practically useful knowledge.
Our findings were similar when residents of specialties with common workplace exposures were grouped together. The mean scores remained comparable between health management group, medicine group, surgery group, and pre/paraclinical groups. This further points to the fact that even workplace experiences did not add significantly to the knowledge base regarding transplant protocols.
Health-care professionals who manage critically ill patients are key persons in improving the chances of deceased organ donations., The value of a trained intensivist has been well recognized, but often in teaching hospitals, it is the residents from the specialties of surgery, medicine, and anesthesiology who man the ICU round the clock. Our evaluation of scores among the residents of these three specialties which routinely deal with ICU patients did not reveal any significant difference between them and the rest of the specialties. Furthermore, there was no improvement in scores within this group as training progressed from 1st to 3rd year, reflecting no specific learning which took place regarding transplant awareness.
However, when individual specialties of medicine and surgery were compared with the rest, the mean scores of Domain C (Brain Death criteria and Transplant Techniques) were found to be significantly higher. It is possible that these better scores reflect learning which occurred as part of routine curriculum of these participants and not specifically targeted at the objective of transplant awareness. The residents of Anesthesiology and Critical Care who were routinely on round the clock duties in the ICU did not share this higher scoring. In fact, their awareness of the Domain B (possibility of donation of specific organs) was found to be significantly lower than that of their surgical colleagues.
The findings of the study were limited by the comparatively poorer response rates from residents in senior years as compared to the 1st year. It is possible that the results would have been different with higher number of responses, especially from residents in the senior years. However, the differences would not significantly alter the overall finding that knowledge about organ transplantation protocols is deficient among postgraduate residents in the present situation and curriculum.
| Conclusion|| |
Public awareness drives powered by information technology revolution are rapidly changing the perception of the general population toward organ donation. However, the conversion of brain death to organ donation has been very low even in apex trauma care centers which have a high potential for this life-saving process.
It is vital that sufficient knowledge exists in health-care workers, especially postgraduate residents who spend considerable time in close contact with patients and relatives in a tertiary care center. The low level of knowledge regarding organ donation protocols and associated legalities among resident doctors is a matter of concern. These findings may merit consideration in including these protocols as part of teaching curriculum.
Further studies are required to determine the appropriate interventions in training postgraduates in organ transplant protocols and applications of the same.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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