Biol Blood Marrow Transplant 22 (2016) 1710–1716

Biology of Blood and

Marrow Transplantation
j o u r n a l h o m e p a g e : w w w. b b m t . o r g

Medical Students’ Knowledge, Familiarity, and Attitudes

towards Hematopoietic Stem Cell Donation
Stem Cell Donation Behaviors
Praveena Narayanan, Alexandra Wolanskyj, Shawna L. Ehlers, Mark R. Litzow,
Mrinal S. Patnaik, William J. Hogan, Shahrukh K. Hashmi *
Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota

Article history: A B S T R A C T
Received 24 February 2016 Hematopoietic stem cell transplantation (HSCT) is a potentially curative treatment for patients with blood
Accepted 15 June 2016 disorders and genetic diseases. Approximately 70% of the HSCTs currently performed in the United States use
stems cells from an unrelated donor who donated voluntarily. Medical students (MS) are a young, diverse,
Key Words: influential population whose willingness to engage in altruistic acts, such as donating stem cells, may be cor-
Bone marrow transplantation related with knowledge on the topic. A literature gap exists in MS perspectives towards HSCT and the bone
Registry marrow registry (BMR) and prior studies suggest that misconceptions about donation deter MS from partic-
Donor
ipation on the BMR, which may decrease opportunities to educate other potential donors. We performed a
Altruism
cross-sectional survey among the 4-year cohort of MS at Mayo Medical School in Rochester, Minnesota. The
questionnaire evaluated multiple areas including whether MS were current members of the BMR and/or prior
blood donors, MS current knowledge on donor eligibility (DE) and the donation process (DP), MS familiarity
with HSCT and the DP, and MS attitudes towards joining the BMR and towards donating stem cells. The re-
sponses were analyzed and assessed alongside a self-reported, standardized scale measuring students’ altruistic
behaviors. There were 99 out of 247 potential respondents (40%), with 45% (n = 44) of MS in preclinical years
1 or 2, 37% (n = 37) in clinical years 3 or 4, and 18% (n = 18) in research or alternative portions of their train-
ing, of which 43% (n = 41) in total were current BMR members. BMR status correlated positively with prior
blood donation (P = .015) and female sex (P = .014). Respondents had a 57.7% and 63.7% average correct re-
sponse rate regarding knowledge of DE and DP, respectively, with knowledge of DE not surprisingly higher
in BMR members (P < .0001). The majority of MS surveyed, 68% (n = 65), had learned about HSCT during medical
school. BMR status correlated with the following attitudes towards donating stem cells: lower concern with
all evaluated aspects of HSCT—time, cost, pain, and side effects (for all subsections, P < .05) but not with the
altruism score (P = .32). The mean altruism score for respondents was 59.9 ± 11.3 (of a possible 100 points)
with no significant difference in age, race, sex, level of training, or participation in the BMR. Altruism scores
did not directly correlate with lower concern with aspects of time, cost, and pain of HSCT but did with long-
term side effects (P = .021). This latter correlation was regardless of BMR status. Among MS, positive predictors
for participation in the BMR included prior blood donation and female sex. BMR status did not ensure knowl-
edge of all aspects of donating stem cells, but it correlated with less concern regarding the DP and was unrelated
to altruism score. Improving knowledge gaps regarding the BMR and HSCT for the next generation of physi-
cians and health care providers through expanded medical education curriculum may be beneficial to for the
recruitment and retention of donor populations to the BMR.
© 2016 American Society for Blood and Marrow Transplantation.

INTRODUCTION including leukemia, genetic diseases, and autoimmune dis-

Allogeneic hematopoietic stem cell transplantation (HSCT)
is the curative treatment for a number of blood disorders,
Financial disclosure: See Acknowledgments on page 1716.
* Correspondence and reprint requests: Shahrukh K. Hashmi MD, MPH,
Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester,
MN 55905.
E-mail address: Hashmi.shahrukh@mayo.edu (S.K. Hashmi).
orders [1]. Peripheral blood stem cell donation, a simpler and
less invasive alternative, has replaced bone marrow harvest
in 75% of cases [2]. Thus, the term bone marrow transplan-
tation has since become a misnomer and is more accurately
referred to as HSCT.
Of the > 8000 allogeneic transplantations performed yearly
in the United States, over one-half rely on the supply of he-
matopoietic stem cells (HSC) from unrelated donors [3]. The

http://dx.doi.org/10.1016/j.bbmt.2016.06.014
1083-8791/© 2016 American Society for Blood and Marrow Transplantation.
 P. Narayanan et al. / Biol Blood Marrow Transplant 22 (2016) 1710–1716
National Marrow Donor Program has created a network of
more than 12 million potential donors through Be The Match,
the national bone marrow registry (BMR), to connect pa-
tients with an HLA-matched donor [4]. However, the mixing
of genes in the population has resulted in a significant linkage
disequilibrium that may make the process of finding a full
donor match increasingly difficult in the future [5]. The current
make-up of the BMR is 60% Caucasian, leaving a limited pool
of potential donors for patients of ethnically and racially
diverse backgrounds [3]. Furthermore, current recruitment,
retention, and utilization rates of potential minority donors
are not sufficient to meet projected demands for HLA-
matched unrelated donors [6-8].
Many non-HLA factors contribute to the success of the
BMR. Young, healthy donors are preferred for their longer
eligibility on the BMR and have documented better trans-
plantation outcomes [9]. Because joining the BMR is not a
binding agreement to donate, it is imperative that donors are
well informed and willing to donate. Misconceptions of stem
cell donation as a painful, time-consuming, and costly process
may account for the substantial attrition rates on the BMR
[8,10]. Individuals’ intrinsic commitment to donate and the
establishment of realistic expectations at the time of joining
the BMR are attributed to lower attrition rates [10,11]. Thus,
educational efforts are a crucial component of the recruit-
ment and retention process for the BMR.
The drive to increase awareness and participation in the
BMR parallels similar efforts in blood [12,13] and organ do-
nation [14-18]. Research in the latter has revealed that an
individual’s attitudes and beliefs towards organ donation pos-
itively correlate with his or her willingness to register as organ
donors and follow through with donation [14-16]. These
studies have been conducted on both the general popula-
tion as well as within targeted populations, such as medical
students (MS). For MS, a correlation between willingness to
donate solid organs and years of medical education has been
documented [17,18].
MS are a unique and powerful study group to consider. They
represent an ideal donor demographic for stem cells as young,
diverse, and motivated individuals. As future health care leaders,
MS will be sources of information or misinformation and may
influence patient behavior via social norms [19]. Despite these
qualities, MS remain a particularly overlooked population in
the assessment of knowledge, attitudes, and behaviors re-
garding stem cell transplantation. Studies of university students
in Turkey and Poland have shown that even brief educa-
tional efforts can generate more interest and positive attitudes
towards the BMR [20,21]. Among MS as a study population,
there is evidence to suggest that the use of emotional appeal
and tailored health communications has a positive effect on
intentions to donate [22]. Overall, however, previous polling
of MS who are not on the BMR suggests they hold significant
misconceptions that deter them from participation [23]. Among
all newly recruited unrelated potential donors, an intrinsic com-
mitment to donate without external pressure or concerns about
donation risks has been found to be associated with less un-
certainty about carrying through with donation [14].
A question that remains unanswered is how MS’ behav-
iors are shaped by factors such as medical school curriculum
and inherent altruistic tendencies. To answer this, we spe-
cifically asked our cohort of MS about their exposure thus
far to HSCT and their willingness to register as bone marrow
or stem cell donors. We hoped to locate deficits in knowl-
edge of HSCT and identify motivators or barriers to
participation on the BMR. We anticipated that MS’ willingness
1711
to donate stem cells would increase in time and duration of
their medical studies.
METHODS
The study population was composed of 247 MS at Mayo Medical
School in Rochester, Minnesota. Participation in the study was voluntary and
careful consideration was taken in reporting findings to protect student
confidentiality.
A cross-sectional survey was created using Qualtrics Online Survey Soft-
ware and the resources of the Mayo Clinic Survey Research Center. A team
of HSCT experts (hematologists), a medical school educator, a psycholo-
gist, and a MS collaborated to design the study and the study questionnaire
(Figure 1). Approval by the Mayo Clinic institutional review board was ob-
tained for all components of the study. The final questionnaire, including a
statement of consent, was administered electronically via email between
November 2014 and December 2014. MS were given 30 days to partici-
pate in the study and provide their responses. A single email reminder was
sent halfway through the month. Participants received no compensation or
reward in return for completing the questionnaire.
Age, sex, race, and level of training were recorded for all respondents.
The questionnaire items were intentionally constructed to evaluate the knowl-
edge, experience, and attitudes of MS towards HSCT and the BMR. Knowledge
of the BMR was assessed in a series of 6 true/false questions. This included
3 items on current knowledge of donor eligibility (DE) and 3 items on current
knowledge of the donation process (DP). Students were asked about their
experience learning about HSCT before and during medical school (yes/
no). Attitudes towards the BMR were evaluated by a Likert scale (strongly
disagree [0] to strongly agree [5]), by which subjects rated responses re-
flecting views on the personal and public decision to join the BMR. An open-
ended question was added to the end of the survey: “Have you considered
being a donor, but have a condition (medical or other) that disqualifies you from
donating?” allowing respondents to provide a written explanation for their
reason(s) not to join the BMR.
Because the stem cell or bone marrow donors do not receive any com-
pensation for volunteer donation for unrelated patients, it is presumed that
the donation is being done purely for altruistic purposes. For this reason, a
20-item validated self-reported altruism scale (Altruistic Personality Scale,
Fetzer Institute) was included in which participants indicated the frequen-
cy in which they have engaged in everyday acts of altruism from never (0)
to very often (4) [24]. This scale has been used in a prior study of altruism
and stem cell donation [22].
Statistical Analysis
Chi-square testing was used to compare outcomes for categorical data
and continuous variables were assessed using a 2-sample t-test. A 2-sided
P value of less than .05 was considered statistically significant. To further
evaluate positive predictors of BMR status, multivariable analysis was con-
ducted using a logistic regression model with output of odds ratios, confidence
intervals, and P values.
RESULTS
Among 247 MS, 99 subjects completed the question-
naire (Figure 1) (response rate, 40%); however, the number
of responses to each individual component of the question-
naire varied (n = 94 to n = 99). Demographics, including sex,
age, race, and level of training, did not significantly differ
between the 99 respondents and 148 nonrespondents. The
majority of respondents were female (n = 54, 56%), between
the ages of 21 and 25 (n = 54, 56%), and Caucasian (n = 70,
73%). Forty-one respondents (n = 41, 43%) were already on the
BMR. Forty-five percent (n = 44) of students were in preclini-
cal years 1 or 2, 37% (n = 37) in clinical years 3 or 4, and 18%
(n = 18) in research or alternative portions of their training.
Level of training showed no significant correlation with BMR
status (Supplementary Table S1). Female sex (n = 29, 71%) was
a distinguishing factor between respondents on the BMR and
not on BMR (P = .014) (Table 1). Prior blood donation rates
were higher in those subjects on the BMR (P = .015) (Table 1)
but did not vary by sex alone (P = .702). On multivariable lo-
gistic regression analysis by BMR status (n = 91), both female
sex (odds ratio, 2.00; 95% confidence interval, .64 to 6.44;
P = .233) and prior blood donation (odds ratio, 2.97; 95% con-
fidence interval, .97 to 9.76; P = .057) were no longer of
1712 P. Narayanan et al. / Biol Blood Marrow Transplant 22 (2016) 1710–1716

a
Do any of the following apply to you? Yes No N/A
I am currently a registered member of the Be The Match.
I have been to a Donor Registry drive.
I have been an employee or volunteer of a Stem Cell Organization
(e.g., Be The Match).
I have donated marrow in the past.
I have donated peripheral blood stem cells in the past.
I have donated stem cells to a family member.
I have donated stem cells to an unrelated recipient.
I have donated blood products.
I have (or had) a blood cancer.
I have had a hematopoietic malignancy.
Someone in my immediate family has/had a hematopoietic malignancy.

b
Please answer the following questions based on your True False I don't N/A
current knowledge. know
Current knowledge of donor eligibility (DE)
If I am not able to donate blood, I cannot donate bone
marrow.
Joining the bone marrow registry requires a blood sample.
Most bone marrow transplants require harvesting bone
marrow from the donor's hip in an operation room.
Current knowledge of the donation process (DP)
Ethnicity and race are factors that determine finding a match
for transplant.
Donating stem cells requires in-patient hospitalization.
Serious side effects are common as a bone marrow donor.

c
Please answer the following questions based on your experience. True False N/A
Familiarity with HSCT and donation process (DP)
I learned about stem cell transplant in medical school.
I learned about the process of stem cell donation in medical school.
I learned about stem cell transplant before medical school.
I learned about the process of stem cell donation before medical school.
I have never heard of stem cell transplantation.
I am not aware of the process of stem cell donation.

Figure 1. Mayo-designed medical student (MS) questionnaire on the BMR and HSCT.

statistical significance; however, a trend to significance was

appreciated with prior blood donation.

Current Knowledge of DE and DP

Table 1 Three questions queried the students’ current knowl-
MS Respondent Demographics (n MS R to 99) and Correlation with BMR Status
edge of the DE and another 3 questions focused on the DP
Variable On Not on P Value (Figure 1B, Table 1). The average correct response rates among
Registry Registry all respondents (n = 94) were 57.7% and 63.7% for current
Total n = 95 41 (43%) 54 (57%) knowledge of DE and DP, respectively (Table 2). MS on the
Sex Male 12 (29%) 29 (71%)
BMR were more likely to respond correctly to DE questions
Female 29 (55%) 24 (45%) .014*
Incomplete 1
concerning requirements for joining the BMR (P ≤ .0001)
Race Caucasian 27 (45%) 33 (55%) .720 (Table 3), as anticipated. Compared with those not regis-
Other 14 (41%) 20 (59%) tered, BMR members responded to questions about serious
Incomplete 1 side effects (P = .017) with more correct answers. There was
Age, yr 21 to 25 26 (48%) 28 (52%)
no difference between the 2 groups in responses to whether
26 to 30 13 (41%) 19 (59%)
>30 2 (24%) 7 (76%) .320 donating stem cells often requires harvesting marrow from
Level of Preclinical (yr 1-2) 18 (41%) 26 (59%) the hip (P = .30) or in-patient hospitalization (P = .26). Level
training Clinical (yr 3-4) 17 (47%) 19 (53%) of training did not affect responses to these questions
Other (MD/PhD, 6 (40%) 9 (60%) .840
(Supplementary Table S1).
off year)
Altruism score 61.2 ± 10.7 58.9 ± 11.7 .320
Prior blood Yes 27 (56%) 21 (44%) Timing and Level of Familiarity with HSCT
donation No 14 (31%) 31 (69%) .015* MS were asked about if and when they became familiar
Incomplete 2 with HSCT and/or HSCT DP (Table 4). The results indicate that
* Indicates statistical significance. 68% (n = 65) of MS who responded had learned about HSCT
 P. Narayanan et al. / Biol Blood Marrow Transplant 22 (2016) 1710–1716 1713

d
Please rate your agreement or disagreement Strongly Agree Neither Disagree Strongly
with the following statements. agree disagree
Attitudes towards joining BMR
If there was a Donor Registry drive in my area,
I would join.

Health professionals and students who haven’t

registered to be a stem cell donor should be
required to do so.

People over the age of 18 years old in the

United States should automatically be swabbed
and added to the national marrow donor
registry unless they indicate that they want
otherwise (opt-out system).

Attitudes towards donating SC

If a family member of mine needed a bone
marrow transplant and I was a match, I would
be willing to donate my stem cells to them.

I am willing to donate stem cells to any patient

I may match.

If called during medical school, I would donate

stem cells to an unrelated recipient in need of a
transplant.

I am concerned about the time commitment of

stem cell donation.

I am concerned about the financial cost of stem

cell donation.

I am concerned that stem cell donation will be

painful.

I am concerned about the long term side effects

of stem cell donation.
BMR bone marrow registry SC stem cells

e
Please answer the following question. Yes No Other
Have you considered being a donor, but have a condition
(medical or other) that disqualifies you from donating?

Figure 1. (continued).

Table 2 during medical school, 35% (n = 34) before medical school,

MS Current Knowledge of DE and DP (n = 94)
Knowledge Assessment Correct Correct
Answer Responses (%)
Current knowledge of DE
If I am not able to donate blood, False
I cannot donate bone marrow.
Joining the bone marrow registry False
requires a blood sample.
Ethnicity and race are factors True
that determine finding a
match for transplant.
Current knowledge of DP
Most bone marrow transplants False
require harvesting bone
marrow from the donor’s hip
in an operation room.
Donating stem cells requires False
in-patient hospitalization.
Serious side effects are common False
as a bone marrow donor.
and 7% (n = 7) reported never having learned about HSCT. Re-
spondents had an overall greater familiarity with HSCT
compared with the HSCT DP, regardless of whether they ac-
quired this information before or during medical school
37 (39%) (P ≤ .0001). Level of training correlated positively with having
learned about HSCT during medical school (P = .035) but
65 (68%)
without significant differences in HSCT-DP (P = .391).
63 (66%) Avg. DE
57.7 ± 16%
Attitudes Towards Joining the BMR and Donating HSC
Eleven questions queried MS’ attitudes towards joining the
39 (41%) BMR and donating stem cells (Figure 1D). MS in clinical years
3 or 4 were more likely respond that they would join the reg-
istry if there were a drive in their area (P = .005); however,
65 (68%) level of training had no significant correlation with con-
cerns regarding HSCT (Supplementary Table S1). Of all those
79 (82%) Avg. DP who responded to questions in this section (n = 93), concern
63.7 ± 21%
was highest for potential pain of stem cell donation (56%)
1714 P. Narayanan et al. / Biol Blood Marrow Transplant 22 (2016) 1710–1716

Table 3
MS Current Knowledge of DE and DP and Correlation with BMR Status

On Registry (n = 41) Not on Registry (n = 53) P Value

DE Correct Responses Correct Responses
If I am not able to donate blood, I cannot donate bone marrow. n = 26 (63%) n = 11 (21%) <.0001*
Joining the bone marrow registry requires a blood sample n = 40 (98%) n = 24 (45%) <.0001*
Ethnicity and race are factors that determine finding a match for transplant n = 29 (71%) n = 33 (62%) .390
DP
Most bone marrow transplants require harvesting bone marrow from the n = 19 (46%) n = 19 (36%) .300
donor’s hip in an operation room.
Donating stem cells requires in-patient hospitalization. n = 30 (73%) n = 33 (62%) .260
Serious side effects are common as a bone marrow donor. n = 38 (93%) n = 39 (74%) .017*

* Indicates statistical significance.

followed by time commitment (52%), long-term side effects

Table 4
(39%), and financial cost (25%). When correlated with BMR
MS Familiarity with HSCT and HSC DP (n = 96)
status, MS already on the BMR (n = 41) had fewer concerns
Familiarity Level and Timing HSCT HSC DP P Value
about the potential negative consequences of donation, such
N = 96 N = 96
as the time commitment (P = .004), cost (P = .019), pain
Ever Yes n = 7 (7%) n = 26 (27%)
(P = .042), and long-term side effects (P = .016) (Table 5). Ms
No n = 89 (93%) n = 70 (73%) .0003*
Before medical school Yes n = 34 (35%) n = 19 (20%) on the BMR also had significantly stronger positive atti-
No n = 62 (65%) n = 76 (80%) <.0001* tudes towards joining the BMR from a personal (P < 0.0001,
During medical school Yes n = 65 (68%) n = 46 (49%) P = 0.0004) and public standpoint (P = 0.026, P = 0.031), as well
No n = 31 (32%) n = 49 (51%) <.0001* as a stronger positive attitude towards donating stem cells
* Indicates statistical significance. to any patient they may match (P < 0.0001) (Table 6).

Table 5 Altruism Scores

Correlation of MS BMR Status and Attitudes towards Donating Stem Cells The mean altruism score for respondents was 59.9 ± 11.3
(n = 93)
of a possible 100 points (α = .88). Altruism tendencies were
Concern Agree Neutral Disagree P Value not significantly different by age (P = .291), sex (P = .431), level
On BMR Registry n = 41 n (%) of training (P = .623), or race (P = .722). There was no signif-
Time commitment 17 (35%) 5 (28%) 19 (68%) .004* icant difference in altruism score by those MS currently on
Financial costs 7 (29%) 4 (25%) 30 (57%) .019* the BMR (n = 41, 61.2 ± 10.7) and those not on the BMR (n = 54,
Pain of procedure 21 (40%) 2 (18%) 18 (44%) .042* 58.9 ± 11.7, P = .32) (Table 1). Comparison of altruism scores
Long-term side effects 11 (31%) 6 (33%) 24 (62%) .016*
and concerns about donation (Table 7) reveal MS with higher
* Indicates statistical significance. altruism scores have less concerns about long-term side effects

Table 6
MS Attitudes towards Joining the BMR and Donating Stem Cells

Attitude Assessment Yes (Strongly Agree or Agree)

Total On Registry P Value

n = 95 n = 41
Attitudes towards joining BMR
If there was a Donor Registry drive in my area, I would join. 59 (64%) 37 (93%) <.0001*
If called during medical school, I would donate stem cells to an unrelated recipient in need of a transplant. 70 (75%) 39 (95%) .0004*
Health professionals and students who haven’t registered to be a stem cell donor should be required to do so. 5 (5%) 4 (10%) .026*
People over the age of 18 years old in the United States should automatically be swabbed and added to the 28 (29%) 14 (34%) .031*
national marrow donor registry unless they indicate that they want otherwise (opt-out system).
Attitudes towards donating stem cells
I am willing to donate stem cells to any patient I may match. 67 (72%) 40 (98%) <.0001*
If a family member of mine needed a bone marrow transplant and I was a match, I would be willing to donate 93 (98%) 41 (100%) .204
my stem cells to them.

Data presented are n (%), unless otherwise indicated.

* Indicates statistical significance.

Table 7
Correlation of MS Altruism Score and Attitudes towards Donating SC (n = 95)

Concern Agree Neutral Disagree P Value

Altruism score n (score ± SD)
Time commitment 49 (58.0 ± 10.7) 18 (58.7 ± 10.6) 28 (64.2 ± 11.4) .066
Financial costs 24 (56.5 ± 12.6) 16 (58.3 ± 10.0) 55 (62.0 ± 11.1) .119
Pain of procedure 53 (58.4 ± 11.3) 11 (65.5 ± 11.9) 31 (60.7 ± 11.4) .165
Long-term side effects 37 (56.1 ± 10.8) 18 (63.5 ± 12.0) 40 (62.0 ± 11.1) .021*

* Indicates statistical significance.

 P. Narayanan et al. / Biol Blood Marrow Transplant 22 (2016) 1710–1716
of HSCT (P = .021). Although not significant, there was a trend
seen between higher altruism scores and less concern about
the time commitment of donation (P = .066).
Write-in Response
MS write-in responses to the question “Have you consid-
ered being a donor, but have a medical condition that disqualifies
you from donating” (n = 17) revealed that 12% (n = 2) had a
condition that truly made them ineligible to join the BMR (eg,
Legg-Calve-Perthes, previous spinal surgery). Another 3 re-
spondents had hesitations that prevented them from joining
the BMR, including the following: “low iron levels,” a phobia
towards needles, and belief that their homosexuality may
prevent them from being an eligible donor.
DISCUSSION
Health care providers are great sources of information, but
they sometimes can inadvertently provide misinformation.
Moreover, physicians are seen as behavioral role models in
society especially when it comes to healthy habits, lifestyle,
and altruistic choices. Medical school is the ideal period in
medical training to address these misconceptions and em-
phasize these behaviors. To our knowledge, this study is the
first of its kind to be conducted at a medical school affili-
ated within a large transplantation center such as the Mayo
Clinic, which currently performs > 500 HSCTs (including both
autologous and allogeneic) annually. It is also the first study
to capture data on HSCT knowledge and attitudes from all
levels of MS, both in preclinical years and clinical years, before
and after taking hematology courses. In this study, we ob-
served that the future physicians (MS) held incorrect beliefs
about donation, including requirements to become a donor
and the most common route of donation. In our cohort, MS
were found to have the most significant concern about long-
term side effects of stem cell donation (P = .021). This
overwhelming belief is in contradiction with the actual rates
of long-term and short-term adverse events (eg, cancer, au-
toimmune illness, and thrombosis) for both bone marrow and
stem cell donation, which occur at the rates of .99% and .31%,
respectively [25], thus indicating an area for improvement
by knowledge provision. Currently more than 18,000 MS grad-
uate annually in the United States, with anticipated expansions
in enrollment [26]; it is imperative to correct MS’ knowl-
edge deficiencies as they may adversely affect donation rates
if left uncorrected.
A comparison of our study subjects to the reported de-
mographics of all United States allopathic MS reveals a similar
distribution. A recent study evaluating the racial demograph-
ics of US MS showed that disproportionate amounts of MS
are Asian compared with the general population census [27].
The distribution across our 4-year cohort of MS was both
similar in age, sex, race, and level of training to the national
MS breakdown as well as an appropriate representation of
Mayo Medical School. Although response rate was not optimal
in our study, the demographics, sex, age, race, and level of
training were not found to be significantly different between
responders and nonresponders.
We found that of the respondents who were already on
the BMR, the overwhelming majority was female (n = 29, 55%,
P = .014) (Table 1). This subgroup is representative of the Be
The Match (the largest BMR in the United States) donor pool,
which currently is 58% female [5]. We also found that BMR
status did not translate to more knowledge about donation
practices. This calls for better education and follow-up both
before and at the time of joining the BMR.
1715
We allowed MS to acknowledge unalterable conditions for
which they cannot join the BMR including but not limited
to health conditions, phobias, or a personal history of cancer.
In our sample cohort, 17% (n = 17) submitted reasons for
which they cannot or choose not to join the BMR. Partici-
pant write-in responses highlighted the importance of
educating potential donors on exclusion criteria, especially
related to differences from blood donation requirements in-
cluding concerns about the issue of sexual orientation and
the BMR. Negative past experiences with blood donation may
also factor into one’s decision to join the BMR [28]. We should
consider alternative outreach approaches for those students/
clinicians ineligible to donate to still advocate for and be
involved with the BMR.
Our study is congruent with a prior study that found al-
truism is not independently predictive of ones’ decision to
register as a stem cell donor of any sort [22]. In contrast,
studies regarding the association of being a solid-organ
donor show varying results, with some indicating a posi-
tive correlation between altruism and donating organs [29],
and some indicating that altruism is the not the most im-
portant determinant for organ donations, and the behavior
varies a lot depending on laws, culture, religion, and aware-
ness [30-32].
Compared with previously published data [23], our cohort
of MS had over 10% more registrants on the BMR (n = 41, 43%).
The favorable gap may be attributed to a cohort effect, the
presence of a large transplantation center at the Mayo Clinic,
and many campus-wide drives held in the past 3 years. Min-
nesota is a unique state with respect to HSCT, as 2 of the large
transplantation centers globally are located within 150 miles
of each other (Mayo Clinic and the University of Minneso-
ta). Additionally, the Be The Match/National Marrow Donor
Program registry (the largest BMR filtering into Bone Marrow
Donors Worldwide) is headquartered in Minnesota. Because
of the increased visibility of the BMR and HSCT in Minne-
sota, it is possible that our results are skewed towards a better
knowledge of DE and DP compared with those of MS in other
states. A nationwide study will be helpful with regards to the
outcomes assessed in our trial from the general makeup of
current MS nationally.
MS at Mayo Medical School have a 5-week course in
hematology during their preclinical training that includes
multiple visits from patients who share their stories about
diagnosis and treatment of various blood disorders. Al-
though not specifically assessed in our study, it is possible
that personal patient encounters motivated MS who had not
considered joining the BMR to do so. This reflects a previ-
ously studied notion that emotional appeals can be more
powerful than other efforts in encouraging students to
join the BMR [22]. Enhancing medical education to incor-
porate more exposure to HSCT could have positive conse-
quences outside of increasing BMR participation. Educating
MS early in their careers could give them more exposure to
the field of hematology and oncology. It is anticipated that
there will be shortage of over 1000 transplantation physi-
cians by the year 2020 [33]. Thus, advancements in medical
student curriculum could benefit the field of hematology as
a whole.
We recognize that our study does present several limi-
tations. The main questionnaire for our study was created by
a team of hematologists, medical educators, and a psychol-
ogist. It was drawn based on previous instruments used to
assess similar parameters regarding bone marrow transplan-
tation in the general public as well as regarding organ
1716 P. Narayanan et al. / Biol Blood Marrow Transplant 22 (2016) 1710–1716
transplantation in the medical student population. However,
the questionnaire has not been validated. As we hope to
expand the study to a greater cohort of medical and health
professional students, we will be able to use this study as a
pilot from which to validate our tool. Because the study was
conducted electronically, we cannot exclude the potential for
selection bias, with MS potentially opting to answer the survey
because they were already familiar with the topic. Perhaps
the largest limitation of a cross-sectional study such as this
is that we are limited to respondents’ beliefs at 1 point in time.
We cannot extrapolate from their responses when they de-
veloped certain attitudes and how this may correlate with
when and if they decided to join the BMR. The voluntary
nature of the study, with the absence of reward or other form
of compensation may also have deterred MS from partici-
pation. Finally, the duration of the study at 30 days was short
and it is possible more time to complete the questionnaire
would have yielded a higher response rate.
CONCLUSION
Joining the BMR does not imply that an individual is mo-
tivated and will carry through to donate stem cells to any
patient in need. The results of our study revealed that MS’
status on the BMR may correlate with knowledge on DE but
does not correlate with knowledge on the DP. Factors that play
a role in translating knowledge to action include sex and al-
truism. Many knowledge gaps are identified among MS with
regards to the HSC donation process and BMR, which may
be overcome by educating them during their medical school
years and may translate into expanded potential donor popu-
lations. Given that health care providers are a common source
of health information and advice, a multicenter and
multisubject (eg, other health professionals such as physi-
cian assistants, nurses, psychologists, dieticians, social
workers) study is warranted to evaluate differences in be-
haviors and attitudes of health care professionals and inform
needed changes to medical education curricula regarding the
BMR and HSCT across the country.
ACKNOWLEDGMENTS
Financial disclosure: None.
Conflicts of interest statement: None.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
online at doi:10.1016/j.bbmt.2016.06.014.
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