Teaching Student Pharmacists to Apply Drug Literature to Patient Cases

INTRODUCTION

The Pharmacists’ Patient Care Process (PPCP), published in May 2014 by the Joint Commission of Pharmacy Practitioners, describes a patient-centered approach to pharmacist-provided clinical care centered on five steps: collecting patient information, assessing patient information, developing an evidence-based care plan, implementing the care plan, and following up to ensure the plan is effective.¹ The ability to interpret and evaluate medical literature, and then to directly apply findings to a patient is essential for the third step. A key element of the 2016 Accreditation Council for Pharmacy Education (ACPE) Standard 10 is that doctor of pharmacy (PharmD) program curricula are designed to prepare student pharmacists to use the PPCP in practice.² Similarly, ensuring each student can apply information from the medical literature to patient care is a key element supporting ACPE Standard 2, Educational Outcome 2.1 (Patient-Centered Care).

Journal club, which is a group discussion and evaluation of a piece of medical literature, is a common learning tool used in the education of student pharmacists, as well as other health care professionals, with the goals of improving evidence-based practice skills and bringing emerging drug information to the attention of practice site personnel.³ Journal club discussions commonly focus on the primary article being evaluated, as well as potentially related pharmacology, general drug information, relevant clinical practice guidelines, and key prior studies; however, traditional journal clubs may not involve applying the article to the care of an actual or simulated patient. There is a paucity of published information describing learning activities designed to integrate drug literature evaluation and patient-centered care-related skills in pharmacy education. Specifically, published articles do not describe activities implemented in the curriculum prior to advanced pharmacy practice experiences (APPEs).^4,5

Critical evaluation of the available information about a treatment for a specific patient is a vital role the pharmacist plays on the health care team. To be practice ready, student pharmacists need to demonstrate a competence in this critical evaluation skill. The objectives of this paper are to describe a series of activities designed to longitudinally build drug literature evaluation skills and assess the impact of the activities on students’ ability to apply results from primary drug literature to patient cases.

DESIGN

The Manchester University PharmD program has adopted a spiral model of integration where related topics are integrated with previously encountered related coursework (ie, vertical integration) and among disciplines (ie, horizontal integration).^6-8 This curricular approach consists of intentional reinforcement, increasing depth and breadth with higher level objectives, logical sequencing, and flexibility to course aims. Drug literature-related skills are integrated throughout the curriculum in this fashion. Foundational principles of evidence-based medicine are taught in two courses: a required, fall first professional (P1) year course focused on gathering and interpreting information from tertiary drug information resources, and a required spring second professional (P2) year course focused on summarizing, interpreting, and evaluating primary drug literature. To continue developing student pharmacists’ drug literature evaluation skills, the pharmacy practice laboratory (PPL) and drug information faculty collaborated to develop skill-based activities in the third professional (P3) year that reinforce and build on concepts already incorporated in the didactic curriculum.

In addition to efforts aimed at enhancing spiral integration, Manchester University has transitioned from an ability-based outcomes (ABOs) model to an entrustable professional activities (EPA) model.⁹ The longitudinal assessment of drug literature evaluation skills fits naturally into the EPA model and the drug literature evaluation activities serve as the milestone assessments of the relevant program-specific EPAs. Both didactic courses introduce the application of information to patient-specific and population health scenarios in order for students to meet two EPAs: use drug literature to inform and support patient-care decisions, and make a recommendation impacting populations. Subsequent PPL activities reinforce these skills. These EPAs support a program-defined graduate attribute that graduates will be known as critical thinkers who use literature and other resources to evaluate and inform effective decisions. They were mapped to the following Center for the Advancement of Pharmacy Education (CAPE) Outcomes for programmatic assessment purposes: 1.1 (Learner), 2.1 (Caregiver), 3.1 (Problem Solver), and 3.2 (Educator) for EPA 1; 1.1, 2.2 (Manager), 2.4 (Provider), and 3.1 (Problem Solver) for EPA 2.² The focus of the described activities, assessment, and evaluation is on preparing students to meet EPA 1.

Both didactic courses incorporate significant active-learning, including use of problem-based learning, project-based learning, flipped classroom, and discussion guided by a constructivist approach to pedagogy.¹⁰ These courses contain outcomes and associated learning objectives geared toward developing students to provide drug information that addresses population and patient-specific pharmacy care. In particular, the P2 drug literature evaluation course is completely taught using a flipped classroom approach. Although traditional examinations are employed as assessment strategies, these approaches only account for approximately 40% of course points. Other assessment strategies include general and patient-specific drug information questions, article evaluations, journal club handouts, and a drug formulary monograph.

In order to further guide students toward achieving EPA 1, a 2-hour, case-based article discussion was introduced into the P2 drug literature evaluation course as an additional patient-specific assessment strategy. Students prepared for class by reading two provided articles focusing on heart failure interventions.^11,12 During class, students engaged in small-group discussion-based activities where they focused on applying these studies to a patient case. The primary class objectives were for students to determine (1) whether the study would apply to the patient as determined by inclusion criteria, exclusion criteria, and baseline characteristics, and (2) whether results were of sufficient statistical and clinical significance to warrant use for the patient. These objectives were also used to inform design of all subsequent described activities.

To continue development of evidence-based medicine skills prior to beginning APPEs in the fourth professional (P4) year, students engaged in a journal club series during their P3 year that spanned the fall and spring PPL sequence. The purpose of the journal club activities were for students to continue to practice summarizing, interpreting, and evaluating primary literature, but also to integrate use of tertiary resources (eg, drug information databases, clinical practice guidelines) and ultimately, apply findings to a patient case. The most important learning objectives of this activity, as previously described, were deemed to be of special importance because of their relevance in preparing students to practice within the PPCP, and the need to reinforce this skill set introduced during the P2 year.

Students were provided with directions, rubrics, and a journal club handout template in advance of each journal club activity (materials available from the corresponding author). Directions described the roles for journal club leader(s) (ie, student[s] responsible for preparing a handout, presenting the article, and generating discussion) and participants (ie, students who have read the article and are prepared to discuss it). Rubrics, based on a published, validated rubric,¹³ contained 20 items that focused on content (50% of points), presentation (25% of points), and handout (25% of points); students who did not earn at least 70% (fall P3) or 75% (spring P3) of content points were required to repeat the assignment. The journal club template, used throughout the curriculum, described suggested content for each section of the handout and correlating discussion, as well as provided question-based prompts to help students form their critique of the article. Articles were selected by instructors to ensure they integrated with and complemented concurrent therapeutics topics. Three core faculty instructors (two PPL-focused and one drug information-focused) served as journal club facilitators, whose roles included supporting the journal club leader, posing questions to the leader and participants in order to generate discussion, ensuring the article was accurately interpreted and applied to the case, and evaluating the leader. The drug information instructor prepared an “at a glance” document that noted key information from the methods and results, highlighted potential strengths and limitations of the article, and suggested questions to pose to the students. The facilitators were not bound to this document, but it was available as a reference.

In the P3 fall semester, preformed student learning teams (consisting of four to six students and used across the curriculum) were responsible for collaboratively leading a traditional journal club. Teams were provided a peer-reviewed, scientific article and collaborated to prepare a journal club handout and lead the discussion during PPL. Teams leading journal club were allotted 30 minutes to summarize, interpret, and evaluate the study. Individual students were selected at random by the instructor to lead different portions of the discussion. Each student also participated in another team’s journal club discussion, so that there were four to six student participants in each journal club, and assessed the other team’s performance using an open-ended evaluation form.

In the P3 spring semester, each student was responsible for individually leading a case-based journal club presentation. Students were provided with a brief patient case, associated with a patient- or caregiver-initiated drug information question, and a peer-reviewed scientific article. Students were responsible for preparing a journal club handout and leading a discussion with four to six peer participants and an instructor. During a 30-minute discussion in PPL, the student leader was required to summarize, interpret, and evaluate the study, and also responsible for describing how they would apply the results of the study to address the patient case and patient-specific drug information question.

During the spring semester, students also participated in five peer journal club discussions. Active participation was promoted in several ways. The leader was required to phrase at least three critique points as questions to the audience, in order to gather input from the participants prior to forming their final opinion about the point. The leader also rated their peers’ participation using a defined five-point scale, where the highest score (ie, “actively participates and meaningfully contributes to the discussion”) could be awarded to no more than two participants per journal club. Finally, participants were required to ask at least three thoughtful questions during journal club throughout the semester. In order to count, questions had to demonstrate knowledge of the article and critical thinking (eg, “Did you think the observed effect size was clinically significant given the patient’s therapeutic goals?”). Basic questions (eg, “Was the result for the primary endpoint statistically significant?”) were welcomed, but did not count toward this requirement. Faculty facilitators evaluated and kept track of questions throughout the semester.

DISCUSSION

This article describes a longitudinally integrated series of activities designed to build student pharmacists’ drug literature evaluation skills, and the results of an assessment of student pharmacists’ ability to apply results from primary drug literature to patient cases. Students’ ability to determine whether the study would apply to the patient, considering inclusion criteria, exclusion criteria, and baseline characteristics improved over the course of the longitudinal drug literature evaluation activities. Students’ ability to determine whether the results were of statistical and clinical significance to warrant use for the patient likewise improved.

The most significant finding of this assessment was the substantial improvement in pass rate from the objective literature evaluation activity from the beginning of the fall P3 semester to the end of the spring P3 semester; student performance improved on each item and overall the first-time pass rate approximately doubled from 45% to 89%. This is particularly notable given that the primary activity in the P3 year specifically designed to develop students in evidence-based practice skills was the journal club sequence in the PPL course. We also found that students highly valued all related activities (eg, activities from the P2 drug literature evaluation course, journal club sequence) in developing them as evidence-based clinicians. Improvement in self-confidence was observed across all assessed items from the fall P3 to spring P3 semesters, but with substantial improvement noted for student confidence in leading and participating in a journal club discussion in both the quasi-experimental and the retrospective pre- and post-intervention assessments. Students agreed that this coursework had relevance to their future practice. Finally, strengths of this sequence of activities included purposeful integration and scaffolding, increasing difficulty and student independence, and integration of patient case and drug literature skills in a pre-APPE setting. Informally, students expressed an increase in their comfort and confidence levels in completing and presenting a journal club meeting, and this was reflected in the P4 year through both informal and formal feedback from APPE preceptors.

The ultimate purpose of cultivating journal club skills is building students’ ability to apply knowledge learned from a journal club discussion to a given patient case. Few PharmD programs contain formal activities where drug literature is directly applied to a patient case or describe student confidence in this skill.^18,19 A review of the literature identified two reports of drug literature activities in which students applied literature evaluation skills to a patient scenario: an application activity conducted during APPEs, and a pharmacy practice resident journal club that incorporated a patient case.^4,5 However, no similar activities conducted with student pharmacists prior to starting their APPEs were found. The study with APPE students used literature application for patient evaluation in a primary care setting and reported improved student performance on an examination. The study with pharmacy residents reported positive resident perceptions of drug literature activities, which began as discussions relating articles to disease states and guidelines, and progressed to application of literature to patient cases. These articles could suggest that such activities may benefit student pharmacists. Our report is unique because it is the first to describe a case-based, literature evaluation activity systemically applied in an entire pre-APPE cohort. Our assessment demonstrated substantial improvement in student performance and highly positive perceptions.

There were several limitations to this study that could have affected the results. First, an advanced elective focused on application of drug literature in the neuropsychiatry setting was offered concurrent to the P3 journal club sequence. This spring semester elective course could have been partially responsible for improvements in performance on the objective assessment. Students enrolled in the elective performed better on both structured assessments, with similar improvement noted compared to the overall cohort. Each student enrolled in the elective (n=13) passed the spring P3 assessment, and eight (61.5%) students passed the fall P3 assessment. Additionally, we received anecdotal feedback that faculty facilitators each had a different style and degree of active involvement in the journal club discussion, which could have decreased consistency in grading. However, we believe there is value in students observing different journal club facilitation styles prior to APPEs, and purposefully rotated so that student groups interacted with each of the three faculty members at different points.

Although a higher response rate would have made generalization of the results from this project more applicable, this response rate was considered appropriate because participation incentives were minimized to avoid coercion. Savvy students may have been unmotivated to respond by the low bonus point value when the total points available in the courses were considered. Likewise, since the first review of the journal club was not associated with a grade, students may not have been as diligent in completing the assessment. The timing of the first review at the beginning of the fall semester, immediately following an academic break, may have resulted in students being less efficient at reviewing literature and guidelines. However, it was conducted in a style consistent with the high stakes OSCE. Student reporting of their self-confidence and perceptions of the assessed activities could be falsely elevated as surveys were distributed by a faculty member commonly associated with drug literature-related activities; however, participation was confidential and surveys were electronically administered. Recall bias could prompt students to report falsely elevated self-confidence at the end of the P3 year; however, we controlled for this effect by conducting both the retrospective pre-/post-intervention (to examine perceived changes in self-confidence), as well as the quasi-experimental comparison (to increase objectivity). Similarly, using the same journal article for both assessments may have resulted in improved performance due to learner effect. While the authors acknowledge this as a potential bias, the fact that students reviewed the article at the beginning and end of the academic year (eight months apart) and considering that multiple journal club activities occurred throughout the didactic curriculum, learner effect is likely of minimal concern. Anecdotally, few students recalled having completed the original P3 orientation activity by the time the P3 OSCE was conducted.

As literature evaluation activities continue to evolve within the pharmacy curriculum, potential future directions include incorporating additional elements to increase individual student participation during the P3 journal club sessions and increasing the time dedicated to journal club sessions in the PPL course. Additional time could provide enhanced student participation and discussion, and allow for more immediate feedback from facilitators. These activities could also be enriched by requiring student self-assessment of journal club performance and comparing that to the instructor evaluation, an approach students may encounter on APPEs. Future directions also may include formal evaluation of performance in these key EPAs during APPEs. Similarly, student performance and perceptions of their abilities as participators could be assessed in a future project. Although not formally assessed, these learning interventions were relatively simple to implement and not resource intensive. Based on the ease of implementation of the journal club sessions and the significant improvements in student performance on the OSCE, we conclude that this is a curricular effort worth continuing and perhaps a model to use for teaching and/or improving other skills.