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Vol. 54, No. 4, April 2008, pp.549 - 549.e6
Copyright © 2008 by The College of Family Physicians of Canada
Print Short, Web long* |
Teaching pharmacotherapeutics to family medicine residents
A curriculum
Jana Bajcar, MScPhm EdDHealthcare Educator and an Associate Professor in the Leslie Dan Faculty of Pharmacy and the Department of Family and Community Medicine in the Faculty of Medicine at the University of Toronto in Ontario
Natalie Kennie, PharmD
Primary care pharmacist affiliated with the Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont, and an Assistant Professor in the Leslie Dan Faculty of Pharmacy at the University of Toronto
Karl Iglar, MD CCFP FCFP
Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. He is a staff physician and, at the time of writing this article, he was the Residency Program director in the Department of Family and Community Medicine at St Michael’s Hospital
Correspondence to: Dr Jana Bajcar, University of Toronto, Leslie Dan Faculty of Pharmacy, 144 College St, Toronto, ON M5S 2S2; telephone 416 978-4241; fax 416 978-8511; e-mailjana.bajcar{at}utoronto.ca
Medication prescribing is more complex than ever before, posing a challenge for both clinicians and medical educators. Rational prescribing refers to the "selection of the most appropriate therapeutic regimen for a specific patient."1 There is a need to teach principles of rational prescribing; one study found that 25% of medical students and residents do not always check for drug allergies and 70% do not always assess potential drug-drug interactions before prescribing.2 Furthermore, prescribing or prescription errors have been discovered in as many as 11% of all prescriptions in primary care.3
Adcock et al suggest "at least some adverse drug reactions occur because no comprehensive pharmacotherapy review is provided during the third and fourth years of most medical curricula and during residency training."4 A survey of accredited American family medicine programs in 2000 found that only 38.5% offered a formal pharmacotherapy curriculum.5 In 2005, the Society of Teachers of Family Medicine Group on Pharmacotherapy published guidelines for a pharmacotherapy curriculum, which stated that one of the suggested outcomes of such a curriculum should be the ability to "make informed pharmacotherapy decisions that are patient focused, evidence based, cost effective, and clinically sound."6 Prescribing habits are developed during residency training; therefore, formal education regarding rational drug use should be an integral part of the residency curricula.6 Formalized curricula in pharmacotherapeutics and rational prescribing in family practice residency programs have been previously described.7–9
The Department of Family and Community Medicine at St Michael’s Hospital in Toronto, Ont, an institution fully affiliated with the University of Toronto, is the training division for 24 to 30 residents annually, consisting of graduates from medical schools across Canada as well as international medical graduates. In 2001, a potential need for a formal pharmacotherapeutics curriculum was identified, and a needs assessment was conducted through 3 focus-group interviews (first- and second-year residents, and clinical teachers) and through direct assessment of residents’ therapeutic knowledge, using written tests. The results of the needs assessment supported the need for a formalized curriculum to enhance pharmacotherapeutic knowledge, drug information skills, and the residents’ ability to select, individualize, and monitor medications for patients with medical conditions commonly encountered in family practice. Areas of highest priority included drug classes with multiple therapeutic alternatives, new products, and clinical problems lacking evidence-based medicine or consensus guidelines. Furthermore, the needs assessment also supported the need for a medication prescribing tool to assist residents in applying a systematic process to navigate available pharmacotherapeutic information and select the most appropriate medication for a patient in a given situation.
The main objective of the formalized pharmacotherapeutics curriculum was to support the further development of family practice residents’ pharmacotherapeutic knowledge and medication prescribing skills required for rational prescribing.
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Program description |
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The 4 main components of the curriculum are as follows: 1) a medication prescribing framework, 2) selected pharmacotherapeutic topics, 3) the process for session design, and 4) the roles of facilitators involved in delivering the curriculum.
Medication prescribing framework
Based on the findings of the needs assessment, a medication prescribing framework composed of 3 main parts was developed (Figure 1). The first part is a macro frame based on 6 key sequential medication prescribing decisions made by the clinician. The second part includes specific questions attached to each subcomponent, used to prompt the pharmacotherapeutic information that needs to be applied to a patient’s case. The third part of the framework contains 7 specific pharmacotherapy subcomponents organized as a mnemonic (I Can PresCribE A Drug) according to the sequence of tasks.10
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Pharmacotherapeutic topics
The curriculum comprises a series of 12 2.5-hour sessions conducted every 2 months over the 2-year residency program. Topics include drug information and Helicobacter pylori management, osteoporosis, hypertension, antibiotics, diabetes, warfarin, pain, migraine, hyperlipidemia, asthma, depression, and anticonvulsants.
Process for session design
A 5-step design process was used to develop each session: 1) a medical condition was selected based on the topics identified in the needs assessment; 2) specific pharmacotherapeutic content for discussion was decided, based on the main prescribing tasks of the medical condition, as well as common and routine medication management issues, based on physician and pharmacist observation in daily practice and common gaps in care identified in the literature; 3) an authentic case scenario was developed to illustrate the common medication prescribing issues that occur in the context of daily practice; 4) the medication prescribing framework was used to sequence pharmacotherapeutic content for each session as illustrated in Figure 2; and 5) principles of adult education and the Kolb’s Learning Cycle11 were usedto sequencethe session,which included large group discussion, mini-lectures, and small group work.
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During the education session, the residents work through the case collaboratively in large and small groups and answer the questions posed by the medication prescribing framework, making decisions in response to the 6 outlined tasks. Mini-lectures are interwoven throughout the session, focusing on pharmacotherapeutic alternatives, clinical evidence, and prescribing issues. The learning experience is not only guided and structured, but also interactive and flexible, encouraging discussion and debate. Potential drug information resources are also introduced and utilized during the sessions. Through these steps, residents have an opportunity to identify all the pharmacotherapeutic possibilities available to treat a particular patient, then use a rational and systematic approach to decision making that combines best practices with patient-centred care.
Roles of facilitators
A clinical pharmacist and a staff physician co-facilitate each session. The physician’s role is to focus on the diagnostic knowledge and skills required for the case scenario, provide role modeling and coaching for the use of the framework, identify common issues from daily practice, and share real-life pearls. The clinical pharmacist’s role is to coordinate the sessions, identify common drug-related issues for discussion, identify relevant clinical resources, and teach pharmacotherapeutic concepts such as therapeutic alternatives, relevant clinical evidence and practice guidelines, dosing, educating, and monitoring.
Formative evaluation
Formal focus groups with first- and second-year residents were conducted at the end of the first 2 years of the program to evaluate the usefulness of the medication prescribing framework. The study was approved by the institution’s Research Ethics Review Board. The focus groups were run by an expert external facilitator and were attended by 45% of the residents. Two main themes relating to the utility of the framework emerged. First, the residents acknowledged the benefit and utility of a systematic medication prescribing framework with which to learn pharmacotherapeutics. In principle, they valued the systematic approach and felt that it improved their prescribing skills. Second, despite the considerable assistance the framework provided, many residents remained overwhelmed by the amount of pharmacotherapeutic knowledge they needed to command in order to use it. Specifically, they recognized that a vast amount of pharmacotherapeutic and diagnostic information was required to tailor the selection of the therapy of a specific patient. Therefore, some residents stated that they, at the outset, found the framework too time-consuming for daily use in patient encounters. This feedback guided a reorganization and revision of the original prescribing framework to make the tasks and questions easier to follow; these revisions are a part of the final version (Figure 1). In addition, the medication prescribing tasks and specific mnemonic triggers were incorporated more explicitly into session handout materials to further stress the use of the framework (Figure 2). Residents continue to rate the sessions highly in informal reaction evaluations.
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Discussion |
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The curriculum was designed to address the need for formal instruction in pharmacotherapeutics in a family medicine residency program. The specific components of the curriculum were created to support the development of the medication prescribing skills needed in the current complex environment of medication management. In addition, the learning environment was designed based on principles of adult education and provided the context of application in relation to daily primary care practice.
Three formalized curricula in pharmacotherapeutics and rational prescribing in family medicine residency programs, which described a variety of teaching strategies, were identified in the literature.7–9 In their pharmacotherapy curriculum, Bucci and Frey7 described the use of several teaching strategies: monthly noon conferences, a printed formulary and pharmacotherapy handbook, policy statements for drug representatives and the use of samples, a quarterly newsletter, and pharmacy consultation. In 1995, Gaspar described a curriculum that emphasized choosing prescription drug treatments for conditions where many options existed and developing skills in evaluating medical and commercial sources of drug information.8 Instructional strategies included lectures on drug treatments for common conditions seen in the outpatient setting and commercial promotion strategies by pharmaceutical manufacturers. The curriculum also included problem solving in clinical cases, writing simulated prescriptions, analyzing drug company promotional material, and a compiled drug therapy handbook. Cheng and Umland9 described a patient drug education curriculum, consisting of bimonthly 45-minute sessions that focused on core pharmacology concepts. Lectures, patient case studies, 1- to 2-page summaries, and quizzes were used to teach relevant content and reinforce key learning points. High rates of satisfaction and improvements in knowledge were observed with these programs.
These 3 programs describe many components similar to our program, including the focus on pharmacotherapeutic content most relevant to the setting and the use of lectures and patient cases. However, the main difference in our approach is the use of a systematic process for medication prescribing, which is the backbone of the design and delivery of our curriculum. With this approach, the curriculum fosters the identification of multiple pharmacotherapeutic alternatives and the selection of a specific choice that is best for the patient. This kind of patient-centred decision making is proposed as a key skill required by students, residents, and practising physicians.12
The use of another rational process for medication prescribing as part of a problem-based training course in pharmacotherapy for undergraduate medical students has been described and robustly evaluated.13 The World Health Organization manual on the principles of rational prescribing was used in a short course and evaluated in a multicentre randomized controlled trial. Results demonstrated that students in the study group performed significantly better than controls on patient problem-based tests and were able to apply their skills to new patient problems. Both the retention of learning and transfer of skills were retained 6 months after the training session. This suggests that the use of a structured medication prescribing process is useful for building both knowledge and skills, which extend to new patient encounters.
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Limitations |
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There are a few limitations to our program. First, the curriculum does not extend the teaching and application of the medication prescribing framework into residents’ daily clinical encounters, including structured feedback with staff physician supervisors. In addition, due to the time requirements of delivering the curriculum, it is a challenge to cover all potentially relevant pharmacotherapeutic topics that are desired by the residents; this is a comment frequently seen on residents’ evaluations. We hope that the use of our program’s systematic process to build medication prescribing skills will allow residents to identify and expand their own pharmacotherapeutic knowledge independently in day-to-day practice. Another factor to consider when addressing relevant knowledge and skills is whether this type of pharmacotherapy education, which focuses on rational medication prescribing, could be introduced earlier in medical training, as described by De Vries et al.13
Future research is planned to formally evaluate the curriculum’s impact on residents’ pharmacotherapeutic knowledge and medication prescribing skills, and to determine whether this program can be effectively delivered by other academic residency teaching programs.
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Conclusion |
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TOPProgram descriptionDiscussionLimitationsConclusionFootnotesAcknowledgmentReferences |
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A formalized pharmacotherapeutic curriculum, which focuses on building pharmacotherapeutic knowledge in the context of effective medication prescribing, was created. The use of a medication prescribing framework, authentic case scenarios, and adult learning principles help support the development of knowledge and skills needed in the current environment of complex patient care and medication management.
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Acknowledgment |
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The qualitative component of this study was funded through the Professional Development Fund of the Department of Family and Community Medicine at the University of Toronto in Ontario.
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Footnotes |
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Competing interests
None declared
*Full text is available in English at www.cfp.ca.
This article has been peer reviewed.
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References |
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- Knollmann BC, Smyth BJ, Garnett CE, Salesiotis AN, Gvozdjan DM, Berry NS, et al. Personal digital assistant-based drug reference software as tools to improve rational prescribing: benchmark criteria and performance. Clin Pharmacol Ther 2005;78(1):7-18.[Medline]
- Garbutt JM, Highstein G, Jeffe DB, Dunagan WC, Fraser VJ. Safe medication prescribing: training and experience of medical students and housestaff at a large teaching hospital. Acad Med 2005;80(6):594-9.[Medline]
- Sanders J, Esmail A. The frequency and nature of medical error in primary care: understanding the diversity across studies. Fam Pract 2003;20(3):231-6.
[Abstract/Free Full Text] - Adcock BB, Byrd DC, O’Neal MR. Evaluation of primary care residents’ knowledge of pharmacotherapy. South Med J 1999;92(9):882-5.[Medline]
- Dickerson LM, Denham AM, Lynch T. The state of clinical pharmacy practice in family practice residency programs. Fam Med 2002;34(9):653-7.[Medline]
- Bazaldua O, Ables AZ, Dickerson LM, Hansen L, Harris I, Hoehns J, et al. Suggested guidelines for pharmacotherapy curricula in family medicine residency training: recommendations from the Society of Teachers of Family Medicine Group on Pharmacotherapy. Fam Med 2005;37(2):99-104.[Medline]
- Bucci KK, Frey KA. A description of a pharmacotherapy curriculum in a university-based family medicine program. Ann Pharmacother 1992;26(7–8):991-4.[Abstract]
- Gaspar DL. Choosing prescription drugs rationally: a curriculum for a family practice residency program. Acad Med 1995;70(5):454-5.[Medline]
- Cheng C, Umland E. Practical therapeutics: an innovative residency drug education curriculum. Fam Med 2004;36(4):236-8.[Medline]
- Iglar K, Kennie N, Bajcar J. I Can PresCribE A Drug: mnemonic-based teaching of rational prescribing. Fam Med 2007;39(4):236-40.[Medline]
- Kolb DA. Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice Hall Inc; 1984.
- Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching information management instead? Acad Med 2005;80(7):685-9.[Medline]
- De Vries TP, Henning RH, Hogerzeil HV, Bapna JS, Bero L, Kafle KK, et al. Impact of a short course in pharmacotherapy for undergraduate medical students: an international randomized controlled study. Lancet 1995;346(8988):1454-7.[Medline]
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