Commercial Question Banks Present a Limited Scope of Sickle Cell Disease

INTRODUCTION Question banks are the most widely used educational resource for medical students and graduate medical trainees studying for professional licensing exams and are the preferred platform both for learning new material and for review. Trainees who use question banks to prepare for these critical exams achieve higher scores on their United States Medical Licensing (USMLE) Steps 1-3, which in turn predict success in residency clinical performance and ultimately, board certification. The content of question banks can therefore be regarded as a strong predictor of the clinical knowledge medical trainees are expected to master. This foundational knowledge base plays an important role in the formation and reinforcement of "illness scripts” that unconsciously drive real-life clinical decision-making.

Sickle cell disease (SCD) is an underserved area of healthcare with large disparities between research-proven interventions and clinical practice. In particular, the growing population of adults with SCD suffer high morbidity and mortality due to insufficient access to SCD specialists and comprehensive SCD care. Most patients with SCD seek care from centers without important clinical expertise. Family physicians, internists, and ED physicians are primarily responsible for the treatment of many with SCD. When surveyed, these physicians report high levels of discomfort with SCD management due to lack of specialized knowledge and training.

Our study is the first to examine SCD content in commercial question banks and determine how the disease is portrayed to medical trainees. We hypothesize that the pathophysiologic and clinical scope of SCD portrayed by question banks does not reflect the true epidemiology or scope of this complex disease.

METHODS Nine of the most widely used commercial question banks for undergraduate and graduate medical trainees were accessed and searched for questions related to SCD. Inclusion criteria consisted of questions in which SCD was intended as the educational objective as featured in the question stem only. Questions were excluded if they featured SCD among the answer choices only, answer explanations only, or if sickle cell trait was intended as the primary educational objective. Questions that met all criteria were transcribed into RedCap software and three reviewers independently coded questions for content. Code book variables like sickle cell disease clinical complications were compiled using the 2014 NHLBI evidence-based guidelines for management of SCD. Questions coded with unique or discrepant entries were examined individually and final coding was determined by consensus.

RESULTS A total of 22,152 questions were screened for inclusion from question banks listed in Table 1. Seventy unique questions featured SCD as the primary educational objective and were included in the analysis. Children aged 10 and younger formed the largest proportion of patients presented in questions (n=32, 45.7%). In contrast, data from the CDC Sickle Cell Data Collection Program shows healthcare utilization is lowest in children younger than 10 and increases with age [Green line in Figure 1]. The oldest patient in our dataset was 37 years old and there were two questions in which no patient age was mentioned. Clinical complications presented in questions were almost always acute (89%). The most common complications were acute pain, acute infection, and acute anemia presented in 42%, 41%, and 23% of questions, respectively. Only 4 patients (5.9%) presented in questions were taking hydroxyurea (HU).

CONCLUSION Our novel study suggests that commercial question banks portray the patient with SCD as predominantly young and presenting with acute complaints. There is little focus on the multi-system organ dysfunction that ultimately drives the high morbidity and mortality associated with SCD. Disease-modifying treatments like hydroxyurea are rarely mentioned and evidence- based preventative care measures are not emphasized. Future research is needed to determine how this narrow portrayal of SCD risks reinforcing an overly simplistic "illness script” or narrative that may influence the clinical decision-making of practicing physicians.

Hsu:Aruvant: Consultancy, Honoraria; DisperSol: Consultancy; Hilton Publishing: Consultancy, Research Funding; NIH: Research Funding; Sickle Cell Disease Association of America: Membership on an entity's Board of Directors or advisory committees; Sickle Cell Disease Association of Illinois: Membership on an entity's Board of Directors or advisory committees; Westat: Consultancy.