A Capstone Course with a Comprehensive and Integrated Review of the Pharmacy Curriculum and Student Assessment as a Preparation for Advanced Pharmacy Practice Experiences

This study received exemption from the Institutional Review Board.

A 3-pronged strategy integrated in the capstone course design sought to review significant topics from the curriculum, instill confidence in students by evaluating individual student skills, and assess student readiness for APPEs. It was a 4-credit hour course offered in the same term as a 1-credit hour case studies course. A case study course in the PCOM SOP curriculum was offered in each term of the second and third didactic years. Students were divided into groups and presented with a clinical case. Each group worked independently, in breakout rooms, for about 2 hours to assess the case and then wrote and submitted a subjective, objective, assessment, and plan (SOAP) note. At the end of the group work, all students reconvened in the classroom and groups were called on to verbally present parts of the case to the entire class in the presence of a faculty member. The faculty member then addressed the entire class to review the take-home points of the case and to provide feedback. During the spring term of the third year, the case studies course was modified so students only submitted the SOAP note. The cases presented in the case studies course were then used in the capstone course for in-depth discussion and further evaluation.

The capstone course design can be summarized as weekly pattern that repeated 8 times (Table 1). On Mondays, students were presented with a “mega-case” in the case studies course. Students were allotted 3 hours to work on the case with their respective groups. The faculty member in charge of the weekly case was available during this time to answer questions. On Wednesdays and Thursdays, the cases were reviewed, and student groups presented their SOAP notes and clinical findings to the class. In addition to mega-cases, several topics for review were selected by the curriculum committee and course coordinator. Every Tuesday was “Topic Tuesday,” during which a faculty member presented a review of key concepts related to the topic of the week. To supplement these instructional components, certain Fridays were designated as optional “Open-Lab Fridays,” during which students could practice compounding and sterile product skills and accompanying calculations at the pharmaceutical compounding and pharmacy practice laboratories. Student assessment in the course consisted of 4 multiple-choice examinations, one comprehensive examination, a comprehensive 2-day OSCE, and 8 mega-case presentation evaluations.

Due to the complexity of the course, variety of topics discussed, and skills practiced, this course was team-taught. Various faculty members from the pharmaceutical sciences and pharmacy practice departments collaborated, which reduced strain on one particular department and allowed faculty members to assist in the area of their expertise. This also gave students the opportunity to experience different approaches to patient care and different teaching styles, which would help them when transitioning to APPEs.

The capstone course was predominantly case-based, with 8 mega-cases presented by different faculty members throughout the trimester. The term “mega-case” was coined to indicate the cases were comprehensive and included many disease states and drug therapy problems to simulate real-life complex clinical situations that the students would likely encounter in APPEs. Usually, the clinical cases revolved around 1 or 2 major (or primary) disease states and various comorbidities. The cases were designed to incorporate evidence-based medicine by referring to current practice guidelines and relevant clinical trials. Usually there were 1 or 2 major disease states discussed (primary disorder(s)) and the comorbidities. The major disease states covered throughout the course included endocrine, cardiovascular, infectious diseases, gastrointestinal, pulmonary, neurological and psychiatric, and renal and musculoskeletal disorders. Other considerations included in the cases were obesity, use of dietary supplements and nonprescription medications, and pharmacoeconomic and socioeconomic aspects. Faculty members selected disease states that students would most likely encounter on APPE rotations. Major disease states were generally covered more than once during the course in order to reinforce key concepts and therapeutic management. For example, 1 case focused on newly diagnosed type 2 diabetes in a patient self-medicating with numerous dietary supplements who presented to the emergency department with diabetic ketoacidosis. However, the patient had several comorbidities including hypertension, hyperlipidemia, renal failure, osteopenia, and obesity. In working up the case and developing their SOAP note, students were required to address all of the disease states and to conduct a thorough review of each dietary supplement the patient was taking.

Faculty members were encouraged to design their cases per their discretion; however, they were asked to incorporate certain disease states or conditions if the course coordinators felt that specific disease states or conditions were not adequately covered in other cases. Mega-cases often had more than one section, with subsequent sections including either a complication from the initial diagnosis or a readmission. In addition to the disease states covered, faculty members were encouraged to include socioeconomic issues, pharmaco-economic issues such as formulary concerns, and compliance issues into their cases in order to simulate scenarios typically seen in clinical practice. One specific requirement for the cases was that primary literature as well as commonly used guidelines be incorporated into the cases to ensure the student’s ability to practice evidence-based medicine.

The mega-case review, evaluation, and presentation section of the course was team-based; students were divided into 10 groups of 7-8. Mega-cases were posted on Blackboard (Blackboard, Inc. Washington, DC) the Wednesday before the student group meeting to give students time to prepare for discussion with their assigned groups. As part of the case studies course, student groups met for a 3-hour period on Mondays, collaborated on the written assignment and submitted 1 assignment (typically in SOAP note format). Students were usually given 6 days from the time the mega-case was posted on Blackboard to complete the case. The faculty member(s) who assigned the case also graded the cases.

A discussion section led by the faculty member assigned to that particular case was part of the capstone course. During this 2-3-hour session, student groups presented their case to the entire class. Prior to the course, student groups were randomized to verbally present 3 cases throughout the course. These group assignments were not publicized to the students so each student group would adequately prepare for every case. The faculty member selected 2-5 student groups to present each case and then assessed student knowledge and understanding of the topic by asking specific questions regarding the disease states and medications covered in the case. During the final lecture hour dedicated to the mega-case, the faculty member(s) provided a wrap-up of the case, underscoring important take-home points for the students.

Grading rubrics for the written and verbal presentations were provided to students and faculty members and were included in the course syllabus. In addition, students were required to submit a peer evaluation form to help ensure that all members of the groups participated adequately in the preparation of the cases.

In addition to mega-cases, select faculty members presented a 2-hour didactic lecture on a variety of topics on “Topic Tuesdays.” Topics included pharmaceutical calculations, pharmacokinetics, pharmaceutical compounding (4 hours), and fluids and electrolytes. These topics were selected based on the assessment of the curriculum and student evaluations in various courses and were seen as beneficial in preparing students for the APPEs and for the final OSCE and comprehensive examination at the end of the capstone course. Topic Tuesdays were also used to review skills included in the final OSCE.

To enable students to practice their compounding skills, we instituted a voluntary “Open-Lab Friday” several times throughout the term. Each of these Fridays was dedicated to a specific compounding skill, such as sterile products, topical preparations, and oral preparations (solutions, suspensions, and capsules). Students were given several compounding problems at each laboratory and an answer key was provided. Faculty members were present in order to facilitate and to answer questions. Although attendance at the open laboratories was optional, approximately 80% of the students took advantage of the experience. One laboratory was dedicated to a practice standardized patient encounter (SPE) and attendance was mandatory because the encounter was part of the mega-OSCE and was required to successfully pass the capstone course. Five standardized patients (SPs) were brought in to simulate patients who were receiving a new prescription. Patients were debriefed on their prescription and were also given information regarding drug interactions with their other medications and disease states. Each student was allotted 10 minutes with the SP to conduct a patient interview. The SP encounter was videotaped for review by the student and faculty member. Standardized patients gave immediate feedback to students after the patient counseling session.

The capstone course required participation from many faculty members, but the course was designed so faculty members facilitating mega-cases only devoted 1 week to the course (Monday, Wednesday and Thursday for each mega-case) and an additional 2 days for the mega-OSCE. Faculty members who gave Topic Tuesday discussions generally did not facilitate mega-cases and were only required to give their 2-hour lecture and to help facilitate the open laboratory if applicable to their topic. For example, the faculty member who gave the pharmaceutical compounding review also helped out with the compounding open lab that same week. The first day of the mega-OSCE required 12 faculty members from pharmacy practice and 4 administrative assistants to help with proctoring. The second day required 7 pharmacy practice faculty members for the sterile product portion and 4 pharmaceutical sciences faculty members for the pharmaceutical compounding portion. Administrative assistants and other faculty members were also required to help with proctoring of the short answer calculations examination.

Assessments for the capstone course included written and verbal case presentations of the 8 mega-cases, 4 examinations based on topics discussed during the cases and the didactic portion of the course (Topic Tuesdays), a comprehensive examination, and a cumulative OSCE (the mega-OSCE), described in detail below. With the exception of the examinations (including the comprehensive examination), all assessments were graded pass/no-pass with rubrics included in the course syllabus. Examinations, including the comprehensive and the Errors and Omissions examinations, were in multiple-choice format. The calculations and pharmacokinetics examination in the final OSCE was in short-answer format, and faculty members could give partial credit for incomplete answers. The standardized patient experience, verbal clinical case, and compounding exercises of the final OSCE were graded on a pass/no-pass basis. Each scored assessment in the capstone course required a minimum score of 70% to pass.

Capstone course assessments were developed so student readiness for APPEs could be determined. Also, each part of the course or assessment was given equal importance, hence students were required to pass every component of the course in order to pass the capstone course. The mega-OSCE and comprehensive examination were designed to assess APPE readiness. If students failed any part of the course or any part of the mega-OSCE, including the comprehensive examination, they received a no-pass grade for the entire capstone course and had to remediate the course in the following summer I term, or first APPE rotation block following the capstone course. The breakdown of assessments for the capstone course is provided in Table 2.

The written assignments, including SOAP notes, were submitted by student groups and were graded by faculty members based on a rubric that focused on the inclusion of relevant and valid information and appropriate, patient-specific assessment and plan based on the disease states and medication problems identified. Verbal presentations were graded by faculty members based on a rubric that focused on delivery style as well as clinical content. Each student within the group was required to verbally present part of the Mega-Case when his or her group was called upon to present. These rubrics assigned numerical points for various components; however, the written and verbal assessments were graded as pass/no-pass. A minimum score of 70% was required to pass the assignment. If written presentations were inadequate, student groups were given 1 opportunity to revise and resubmit the presentation for credit. Although students submitted their written assignments as a group, each student in the group was assessed individually based on peer evaluation, presentation skills, and attendance. Because each student group submitted only 1 SOAP note, individual assessment of written assignments by faculty members was not possible. However, since each student in the group was required to present part of the case, faculty members were able to assess each student individually on verbal presentation. Any specific student within a group who failed any pass/no-pass assignment was afforded 1 make-up assignment at faculty members’ discretion.

The culmination of the capstone course was the mega-OSCE conducted over 2 days. The mega-OSCE included the following assessments: a standardized patient encounter, presentation of a clinical case to 2 faculty members, and an Errors and Omissions examination in Georgia State Board of Pharmacy Practical Examination format; the following day, a 90-minute, 20 question short answer calculations and pharmacokinetics exam, and a wet laboratory that included both sterile and pharmaceutical compounding and calculations.

The SPE was described earlier in this article. Students were given 5 minutes to review a new prescription including patient history and current medications. Each student then provided counseling to the standardized patient utilizing the Indian Health counseling method. Students were given 10 minutes to counsel their patient. The standardized patients graded the students based on a provided rubric, and the SPE was videotaped for review by faculty members to ensure accuracy of grading by the SPs.

Students were then given 15 minutes to review and prepare a clinical case. The clinical case was designed to focus on more than one of the following common disease states that students were likely to encounter frequently during their APPEs: hyperlipidemia, hypertension, diabetes mellitus, and asthma/COPD (chronic obstructive pulmonary disease). Students were given a worksheet to help prepare their case. After the 15 minute preparation, each student was given an additional 15 minutes to present the clinical case to 2 faculty members, who had been debriefed on the case prior to the OSCE and were also given a key with major points regarding the case. The verbal presentation was graded based on delivery, organization and content including a rationale for recommended interventions. Two faculty members assessed each student in order to minimize inter-rater variability and bias.

The Errors and Omissions (E&O) portion of the OSCE was designed to mimic the Georgia State Board of Pharmacy Errors and Omissions exam. Students were given 15 prescriptions and prescription labels in PowerPoint format. They were given 2 minutes to review each prescription to assess it for accuracy and completion. There was 1 error or omission per prescription. Answer choices for the E&O were as follows: (A) contact physician because of an error or omission in the written prescription; (B) prescription filled with the wrong drug or the wrong strength of the correct drug; (C) error or omission by pharmacist on the computer generated label; (D) controlled substance prescription does not meet federal or state requirements; (E) improper substitution based on Georgia law; (F) no error or omission exists. Students filled in Scantron forms (Scantron Corporation, Eagan, MN) for this exam. Because the Scantron forms only had 5 options (A through E), for the “F” choice (no error or omission), students filled in both A and B.

On day 2 of the OSCE, students first completed the short-answer calculations and pharmacokinetics exam. They then received 2 prescriptions for compounding: a prescription for a sterile product and a prescription for a pharmaceutical compounded product (ointment, cream, capsule or suspension). Students were given 30 minutes to review the prescriptions and perform the required calculations. They were then brought into the compounding labs in groups of 15 students to compound their products. Eight faculty members monitored and evaluated the sterile compounding and 4 faculty members monitored and evaluated the pharmaceutical compounding. Evaluation was based on both calculation and technique based on provided grading rubrics.

Students who did not pass all portions of the capstone course, including the mega-OSCE and comprehensive exam, were not able to start their APPE during the Summer I rotation, and instead were afforded the opportunity to remediate during that 5-week period. The fourth professional year of the PharmD curriculum consists of nine 5-week APPE sessions. Students are required to complete 8 APPEs with 1 off-session. Since students are scheduled to begin their APPEs in the summer I term, the first APPE block, remediation students would not be able to start their APPE during that block and would have to complete all 8 APPEs in the remaining 8 sessions. In case of unsuccessful remediation of the capstone course, students met with the Academic Performance and Standards Committee for action on academic future including dismissal from the program. Hence, these were high-stakes assessments. Since the capstone course was so complex with so many components, remediation was done as follows: students who did not pass 1 or more mega-cases were given 1 opportunity to remediate the case during the spring term. If students did not pass upon remediation, they were required to remediate the mega-case(s) during the summer I APPE term. The course coordinator divided the mega-OSCE in the following 3 sections: Errors and Omissions and short answer calculations examination, pharmaceutical and sterile compounding and verbal clinical case, and standardized patient encounter. Students who did not pass 1section were required to remediate both sections of the different “sections” in order to successfully remediate the course. For example, a student who did not pass the verbal clinical case had to retake that case and the standardized patient encounter. Students who did not pass the comprehensive examiantion were given the opportunity to retake it during the summer I APPE term.