福岡大学病院薬学部実習生に対する移植医療への意識調査

抄録

日本では1997年10月より臓器移植法が施行されて以来，2021年12月までに約800例の脳死下臓器提供が行われている．しかし，欧米諸国に比べて本邦での脳死下臓器提供は少なく，その要因の1つとして，移植医療について学ぶ機会が少なく，現状が把握できないことが推察される．2018年5月1日から2019年2月28日までの期間に，福岡大学病院薬剤部の実務実習カリキュラムを行った福岡大学薬学部5年生（77名）を対象に，臓器移植をテーマとした半日研修の前後で，移植医療の知識や理解度について無記名の質問紙調査を実施した．結果より，講義を行うことで，移植医療に関する知識が向上し，移植医療への関心が高まったことが示唆された，このことから，講義を通じての啓発や情報発信は知識習得機会の提供になると共に，移植医療を普及させる一助になると考えられる．

Abstract

After the Organ Transplantation Law came into effect in October 1997, there were approximately 800 organ donations from brain-dead patients reported in Japan by December 2021. This number was much lower than in Western countries because of the fewer opportunities for healthcare workers to learn about organ transplantation. The Department of Pharmacy at Fukuoka University Hospital conducted lectures on transplantation treatment during the fifth year of student practical training. It surveyed changes in student knowledge and attitudes toward brain death and organ donation. Between May 2018 and February 2019, 77 students completed an anonymous survey before and after a half-day training on the topic. Many students showed increased interest in transplantation treatment with the increased knowledge. Therefore, the improved education and information transmission through these lectures allowed students to gain knowledge about and awareness regarding organ transplantation treatment.

Purpose

In Japan, approximately 800 cases of organ donation from brain-dead individuals were reported from October 1997, which was when the Organ Transplantation Law was enacted, to December 2021. Numerous drugs have been developed for managing organ transplantation. However, in comparison to Western countries, Japan has fewer cases of organ donation from brain-dead individuals. Furthermore, students who may be involved in organ transplantation in the future do not have a high awareness of organ transplantation. Awareness of transplantation treatment is not high even among students in Japanese medical schools¹⁾. The reasons behind this are believed to include differences in religious beliefs, views on life and death, no social consensus on the topic, and few opportunities to learn about transplantation treatment. Thus, activities and education to familiarize people with transplantation have been emphasized on for a long time; however, awareness remains low. Moreover, we believe that understanding of and education about transplantation is needed. In transplant education for students in Japan, there have been reports targeting medical and nursing students, but few reports targeting pharmacy students. Fukuoka University Hospital (hereinafter referred to as our hospital) is a hospital where transplant medicine, including lung transplantation, is performed, and there are many opportunities to learn about transplant medicine. In addition, during a long-term education program, students are required to learn about team medicine and participate in transplant medicine as a member of the team. At the Department of Pharmacy, our hospital, we have incorporated a long-term practical education program regarding transplantation for fifth-year pharmacy students with the aim of improving their knowledge of this topic. We investigated whether conducting lectures about transplantation improved our students’ recognition of transplantation treatment and the usefulness of these lectures.

Method

The study population included 77 fifth-year students from the Department of Pharmacy who underwent long-term practical training at our hospital between May 1, 2018, and February 28, 2019. Pharmacy students completed an anonymous survey regarding their awareness and understanding of organ transplantation before and after training (Table 1). Moreover, a pretraining survey was conducted on the first day of the entire placement with the aim of preventing bias due to the possibility of being in charge of transplant patients in the placement before this lecture and training to avoid disclosure of the questionnaire content. Pharmacy students were asked to respond to items relevant to transplantation, possession of a donor card, presence of a description on the donor card, their perception of transplantation, consent when a family member wanted to donate their organs, training in transplantation and need for training, and an evaluation of their training content in a multiple-choice or open-ended manner. Regarding the questionnaire survey items, the items were set with reference to the Cabinet Office’s public opinion poll table on transplantation medicine. Overall practical training schedule encompassed 53 days, and SGDs were held during the practical training time slot (Fig. 1). The training period on transplantation was half a day, and the number of trainees was limited to a maximum of eight students per day. Lectures were provided using content from materials published by the Japan Organ Transplant Network and actual cases (electronic medical records) (Fig. 2). Lectures were set up as knowledge and SGDs as interest generation. To determine changes in the level of understanding for each item, pre- and post-training responses were compared using Fisher’s exact test with statistical significance set at p < 0.05. Furthermore, Excel Statistics (Social Information Services, Ltd, Tokyo, Japan) was used to perform all statistical analyses.

Table 1

Survey regarding transplantation treatment

Item	Pre-training (n = 77)			Post-training (n = 73)			p-value
	Yes	No	Not sure	Yes	No	Not sure
1) Are you interested in organ donation?	33 (43%)	44 (57%)	—	64 (88%)	9 (12%)	—	<0.001
2) To date, have you had opportunities to learn in detail about organ donation?	10 (13%)	67 (87%)	—	70 (96%)	3 (4%)	—	<0.001
3) Do you know about organ donor cards?	74 (96%)	3 (4%)	—	73 (100%)	0 (0%)	—	0.246
4) Do you have/would you like an organ donor card?	9 (12%)	68 (88%)	—	53 (73%)	20 (27%)	—	<0.001
5) Do you have a driver’s license, individual number card, and/or health insurance card?	76 (99%)	1 (1%)	—
6) Do you know that you can record your organ donation intentions on the back of your driver’s license, individual number card, and health insurance card, as well as on the internet?	56 (73%)	21 (27%)	—	73 (100%)	0 (0%)	—	<0.001
7) Circle the items on which you know that you can record your organ donation intentions among: the back of your driver’s license, individual number card, health insurance card, and on the internet. (Multiple answers are permitted)	Driver’s license 51 (66%) Internet 3 (4%)	Individual number card 10 (13%)	Health insurance card 33 (43%)
8) Do you think you will record your organ donation intentions on an organ donation card, the back of a driver’s license, individual number card, health insurance card, or on the internet? (Answer “Yes” if you have already done so)	9 (12%)	68 (88%)	—	60 (82%)	13 (18%)	—	<0.001
9) Circle the items on which you have recorded your organ donation intentions: organ donor card, back of your driver’s license, individual number card, health insurance card, and the internet. (Multiple answers are permitted)	Organ donor card 6 Health insurance card 3	Driver’s license 6 Internet 0	Individual number card 8
10) Do you know that organs can be donated if the family consents, even when there are no written intentions regarding organ donation?	40 (52%)	37 (48%)	—	73 (100%)	0 (0%)	—	<0.001
11) Do you agree with organ donation after brain death has been determined if the family member concerned has noted their consent to organ donation after brain death on a donor card?	43 (56%)	6 (8%)	28 (36%)	48 (66%)	2 (3%)	23 (31%)	0.244
12) Do you have a good impression of organ donation?	41 (53%)	0 (0%)	36 (47%)	51 (70%)	0 (0%)	22 (30%)	0.066
13) Do you think that organ donation should be promoted more?				56 (77%)	1 (1%)	16 (22%)
14) At the time of brain death, which organs do you think can generally be donated? (Multiple answers are permitted)	Heart 58 Lungs 46 Liver 53 Pancreas 34 Spleen 30 Kidneys 61 Stomach 31 Brain 3 Small intestine 20 Large intestine 20 Eyes 30
15) How was the lecture content?				Very good 34 (46%) Bad 0 (0%)	Good 37 (51%) Very bad 0 (0%)	Neither good nor bad 2 (3%)
16) Would you like to know more about organ donation?				55 (75%)	2 (3%)	16 (22%)
17) When do you think is a good time to start learning about transplantation treatment?				Infancy 0 (0%) High school 22 (30%)	Primary school 22 (30%) University 4 (6%)	Middle school 24 (33%) Adulthood 1 (1%)

Numerical value = n (%) and expressed as “n”; p < 0.05，Fisher’s exact test

Fig. 1

2018 Department of Pharmaceutics long-term practical training schedule. Practical training period, 53 days (excluding Saturdays, Sundays, and public holidays); 1 course, 13 days. SGD, small group discussion; TPN, total parenteral nutrition.

Fig. 2

Transplantation treatment SGD time schedule. Training duration, 0.5 days; Facilitator, 1-to-2 individuals; Number of students, 8 (2 groups of 4 students each). SGD, small group discussion.

Although this questionnaire is not subject to review by the Fukuoka University Medical Ethics Review Board, before subjects completed the questionnaire, items that were subject to ethical review were clarified verbally and in writing, and then the questionnaire was administered. In addition, we ensured that students had the opportunity to refuse to participate in this survey.

Results

The questionnaire was completed by 77 students (65% female), and the response rate was 100% before training and 94% after. Responses to the survey are presented in Table 1.

1.  Interest in organ donation

A total of 43% of the students were interested in organ donation before training and 88% after training, which was a significant increase (p < 0.001).

2.  Opportunities to learn about organ donation

While only 13% of the students responded that they have had opportunities to learn about transplantation treatment in detail before their training, 96% responded that they learned more about transplantation treatment after (p < 0.001).

3.  Organ donor card status

Although 96% of the students were aware of organ donor cards, only a relatively small number (12%) possessed these cards. However, after training, the number of students who thought they would like an organ donor card increased to 73% (p < 0.001). Furthermore, in comparison to organ donor cards, 99% of the students had a driver’s license, an individual number card, or a health insurance card, and 73% declared their organ donation intentions on the back of these cards. Furthermore, the declaration of one’s intentions, other than on an organ donor card, was most commonly made on the driver’s license (66%). Prior to training, only 12% of the students had noted or thought of noting their organ donation intentions on one of these cards, whereas after training, the number of students who wished to note their intentions significantly increased to 82% (p < 0.001). Moreover, the most common card expressing organ donation intentions was the individual identification card (n = 8), followed by the organ donor card (n = 6), and driver’s license (n = 6).

4.  Family approval and consent for organ donation

Fifty-two percent of the students knew that organ donation was possible if their family consented. There was no significant difference after training (pretraining vs. post-training: 56% vs. 66%, p = 0.159, respectively) regarding knowledge about the need for family consent for organ donation.

5.  Impression and promotion of transplantation treatment

Fifty-three percent of the students had a positive impression of organ donation before training which increased to 70% after. Furthermore, after training, 77% of the students responded that organ donation should be promoted.

6.  Organs that can be donated

When asked which organs could be donated at the time of brain death, the most common response was kidneys, followed by heart, liver, and lungs. Students also responded that the brain, spleen, and stomach could be donated, among which responses were greatest for the stomach (40%).

7.  Degree of satisfaction with the training contents

A total of 97% of the students answered “very good” or “good” when asked about satisfaction with the training. Furthermore, 75% responded that they wanted to learn more about organ donation.

8.  Timing to learn transplantation treatment

The appropriate time to start learning about organ donation was when they were in middle school, at 33%, followed by when they were in primary school, and when they were in high school, at 30% each.

Conclusion

Japanese students have few opportunities to learn about transplant medicine. There are also few reports on education in transplant medicine with regard to pharmacy students. In comparison, a study of nursing students in Spain reported that they had more opportunities to learn about and had a higher awareness regarding transplantation treatment compared to Japanese students²⁾. Therefore, we incorporated training in transplantation treatment into the long-term practical training of the Department of Pharmacy and provided the opportunity for our students to learn about this. Before training, 43% of the students reported that they were interested in transplantation. After training, this rate significantly increased to 88%. Furthermore, 96% of the students responded that they had learned about transplantation treatment. Thus, it appears that interest in and learning about transplantation treatment improved through the formation of a learning community.

Although 96% of the students were aware of organ donor cards, only 12% possessed one. There are several ways that an individual’s organ donation intentions can be recorded including on one’s driver’s license. After including such methods, 99% of the students had the ability to record their intentions. Furthermore, while 73% of the students were aware that they could record their intentions (e.g., on the back of their driver’s license), only 12% actually had noted their intentions. Based on these results, it was suggested that, despite understanding that one’s organ donation wishes could be recorded, students did not feel the need to do so and did not record their specific intentions.

The results of this study found that the rate of students who considered recording their intentions increased to 82% after the lectures. This indicates that the training changed students’ awareness and increased their interest in transplantation treatment, leading to an understanding of the need to record their intentions.

In 2010, the Organ Transplantation Law was revised to make organ donation possible if family members consented even when the individual concerned did not record their organ donation intentions. A total of 70% of organ donations were performed with family consent after the revised Organ Transplantation Law came into effect. In the training that occurred with this study, lectures on donation with family consent were held; however, results regarding family consent did not change after the training. In SGDs ‘What is the reason for the poor number of transplantation cases in Japan? And, what should be done to improve it?’, some students voiced the opinion that they were amenable to transplantation if the organ was donated by them. However, when it came to one’s family and the need to consider the thoughts and feelings of the family member concerned, that it would be difficult to make a decision for someone other than oneself. Thus, as a potential solution, the students argued that it would be important to regularly communicate with the family about organ donation. Liu et al. reported that it is important to encourage family discussions before making decisions about organ donation and to handle discussions amicably³⁾. As it relates to our current long-term practical training, we believe that lectures and SGDs about organ donation can serve as an opportunity for students to provide their family members with information that might increase interest in transplantation treatment.

In the present study, many of the students who received long-term practical training had little exposure to explanations of, or the issues associated with, transplantation treatment. Therefore, it is highly likely that a significant difference would be found in many items after practical training. Furthermore, Terunuma et al. reported that for Japanese individuals, body and mind are inseparable⁴⁾, and Japanese people have difficulty distinguishing between the body and mind with regard to a person’s death. Regardless of other bodily functions, the fact that brain death cannot be accepted as equivalent to a person’s death leads to be believed to a poor awareness of transplantation treatment. Moreover, most educational institutions in Japan do not directly include learning about organ donation and transplantation for pharmacy students. In the present survey, only 13% of pharmacy students responded that they had previously had the opportunity to learn about transplantation treatment; most students had not had opportunities to learn about, and were unaware of transplantation treatment. The opinion of pharmacy students within the SGDs was also that they wear not interested in it because they had not had the opportunity to know about it. Therefore, some of them commented that awareness of transplantation medicine is low. We believe that other reasons underlying this lack of interest include ethical concerns, and that no educational curriculum has been implemented to improve knowledge about organ transplantation. The Japanese educational system consists of a compulsory nine years of primary and middle school, and it is conceivable that many students could be taught about transplantation treatment during this period. Herein, 33% of the students responded that they considered the junior high school period to be suitable for learning about transplantation treatment, whereas followed by considered primary school and high school 30%.

It was suggested that the provision of learning opportunities during the stage of compulsory education is important to trigger interest in transplantation at the right time. Ríos et al. reported that even in Spain, where the number of organ donors is high, it is thought that increasing awareness through appropriate education will lead to increased student interest in organ donation. Furthermore, continued provision of such education is considered important⁵⁾. The pharmacy students in the SGDs also commented that the opportunity to learn about transplant medicine, even as part of their practical training, would help to promote transplant medicine. Based on the results of this study, which showed that 87% of students had never learned about transplant medicine, it is likely that not much time is devoted to transplant medicine at university. Alternatively, it is possible that university lectures alone do not give a real sense of the subject and that the impression is so weak that it is not retained as a memory. Sugiyama et al. also report that while lectures at universities have increased interest in transplant medicine, lack of course experience remains a problem⁶⁾. From the above, it is considered that university lectures alone cannot significantly improve students’ interest in transplantation. Therefore, we believe that incorporating the study of transplantation medicine into long-term practical training at the Faculty of Pharmacy, where practical training at medical institutions is part of the curriculum, would be useful for improving interest in transplantation. Furthermore, our hospital is involved in a lot of transplant medicine, including living lung transplants, and the pharmacy department is involved as part of the treatment system. By listening to the voices of pharmacists who are actually involved in the field, and by having lectures and discussions while looking at the drugs required for transplant medicine and actual cases, it is thought that, as well as improving their knowledge, they will also gain a realistic experience of the involvement of those providing medical care, in other words pharmacists, in transplant medicine, and deepen their learning. In addition, the pharmacy students participating in the practical training are fifth-year students and have already acquired a certain level of knowledge about health care at the university, so it is meaningful for the development of future pharmacists to learn the image of the actual field at that stage. The number of donors in Japan is currently low in comparison to other countries⁷⁾. The introduction of an opt-out system, such as that used in Spain⁸⁾ or the national organ and body donation system used in Korea⁹⁾, is needed at the government level, and educational lectures can be implemented on a small scale. In view of this situation, although limited to 0.5 days, more opportunities to learn about transplant medicine in actual clinical practice could lead to a correct understanding of transplant medicine, increase interest in transplant medicine and promote its spread, as well as provide an opportunity to learn the role of pharmacists in actual clinical practice. We believe that this is a good idea. Furthermore, in perceptions of transplant medicine, Almela-Baeza et al. reported that awareness is gained through the provision of information such as the use of the media; however, they also noted that decision-making is affected by information from reliable individuals such as family members¹⁰⁾. Some students are interested in transplant treatment, but at present they only receive general information and knowledge through mass media such as television and SNS, which may or may not be accurate.

Therefore, we believe that introducing training and lectures, such as those described in the present report, would serve as an excellent opportunity to recognize that a student’s knowledge and perception of transplantation treatment before practical training is only based on fragmented information. The students will need to obtain accurate information on transplantation treatment to be medical professionals in the future. If the preprofessional educational environment could proactively prepare them with discussions regarding brain death and organ transplantation, then interest in and knowledge of organ donation could be increased through lectures. This might lead to an improvement in the rate oforgan donation. We believe that education regarding transplantation treatment should be conducted on an ongoing basis by incorporating it into the curriculum. As personal values are also important in transplant medicine, the inclusion of SGDs provides an opportunity for pharmacy students to exchange views and learn about the concept of death. Furthermore, understanding and information provided through practical training provide opportunities to acquire knowledge, and we believe that it will serve to improve the view of transplantation treatment. The present study was associated with several limitations. First, the questionnaire was conducted at a single institution which makes it difficult to generalize the survey results. Second, after practical training, we were unable to determine whether the training was actually linked to the students’ recording their intentions regarding organ donation. We discovered that practical training increased interest in and knowledge of transplantation treatment. However, further examination of methods to deepen knowledge after practical training and investigation of the implementation of practical training on transplantation treatment is needed.

In the present study, we incorporated lectures about transplantation treatment into the practical training curriculum of students at the Department of Pharmacy and surveyed changes in knowledge and awareness regarding brain death and organ donation before and after practical training. The survey on interest in and awareness regarding transplantation treatment before and after practical training demonstrated a significant improvement in student interest following the training. Several students responding that they had understood transplantation treatment better after the training suggested that even short-term practical training utilizing SGD, could increase students’ interest and knowledge. We believe that improving understanding and providing information through training provides opportunities to acquire knowledge and increase understanding of transplantation treatment.

Conflict of Interest

There is no conflict of interest to be disclosed in relation to the contents of this paper.

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