Teaching pharmacotherapeutics to family medicine residents

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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Figure 1

Medication prescribing framework

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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Figure 2

Format for pharmacotherapeutic sessions

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.