Pharmacy Education
Students’ Perception of an Integrated Approach of Teaching Entire Sequence of Medicinal Chemistry, Pharmacology, and Pharmacotherapeutics Courses in PharmD Curriculum
Journal of Pharmacy Practice 2015, Vol. 28(2) 220-226 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014544821 jpp.sagepub.com
Mohammed A. Islam, PhD1,2, and Teresa A. Schweiger, PharmD2,3
Abstract Purpose: To develop an integrated approach of teaching medicinal chemistry, pharmacology, and pharmacotherapeutics and to evaluate students’ perceptions of integration as they progress through the PharmD curriculum. Methods: Instructors from each discipline jointly mapped the course contents and sequenced the course delivery based on organ systems/disease states. Medicinal chemistry and pharmacology contents were integrated and aligned with respective pharmacotherapeutics contents to deliver throughout second and third year of the curriculum. In addition to classroom lectures, active learning strategies such as recitation, case studies, online-discussion boards, open book quizzes, and writing patient progress notes were incorporated to enhance student learning. Student learning was assessed by examination scores, patient progress notes, and writing assignments. The impact of course integration was evaluated by a Web-based survey. Results: One hundred and sixty-nine students completed the survey. Students exhibited positive attitude toward the integrated approach of teaching medicinal chemistry, pharmacology, and therapeutics. The P3 and P4 students better appreciated the benefits of integration compared to P2 students (P < .05). Conclusion: Students perceived the course integration as an effective way of learning. This study supports course improvement and the viability of expanding the concept of integration to other courses in the curriculum. Keywords medicinal chemistry, pharmacology, pharmacotherapeutics, integration, pharmacy curriculum
Introduction Curricular integration in interdisciplinary teaching has become an important strategy in North American health care education.1-3 There is an increasing recognition that traditional instructional modes of separating basic and clinical sciences no longer conform with current demands for interdisciplinary learning and practice.1,4,5 Moreover, cognitive psychology theories of learning suggest that an integrated approach of teaching can promote contextual and applied learning.6,7 Harden8 developed ‘‘the integration ladder’’ that can be used as an effective strategy to teach basic and clinical sciences in medical or pharmacy school curricula. Recently, Muller et al9 described the integrated approach of teaching and learning of 2 or more academic disciplines as an important but a complex strategy. The accreditation standards and guidelines of the Accreditation Council for Pharmacy Education emphasize the need for an integrated curriculum in US Pharmacy schools: ‘‘The curriculum must define the expected outcomes and be developed, with attention to sequencing and integration of content and the selection of teaching and learning methods and assessments.’’10
Traditionally, pharmacology, medicinal chemistry, and pharmacotherapeutics courses are taught in silos making students responsible to connect the knowledge parts together to understand the interrelatedness of basic and clinical science principles. There are few reports on curricular integration of basic and clinical sciences in pharmacy programs in the literature.11-15 More than a decade ago, Alsharif et al12 introduced the concept of ‘‘structurally based therapeutic evaluation
1 Department of Pharmaceutical Sciences, West Coast University School of Pharmacy, Los Angeles, CA, USA 2 At the time of study, authors were affiliated with Lake Erie College of Osteopathic Medicine, School of Pharmacy, Bradenton, FL, USA 3 Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA, USA
Corresponding Author: Mohammed A. Islam, Department of Pharmaceutical Sciences, West Coast University School of Pharmacy, 590 N Vermont Ave, Los Angeles, CA 90004, USA. Email: [email protected]
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When the Lake Erie College of Osteopathic Medicine (LECOM) Bradenton, School of Pharmacy program began in 2007, the decision was made to fully integrate pharmacology, medicinal chemistry, and pharmacotherapeutics. The primary goals of course integration was to help students (1) develop an understanding as to how physicochemical properties of drug molecules influence their activity at its biological target, and, consequently, their therapeutic performance; (2) learn the mechanisms of action, pharmacokinetics, toxicity profiles, contraindications, and drug–drug interactions pertaining to drug classes used in a particular disease state in a conceptual framework; (3) integrate their knowledge about drug action from the level of an individual molecular or cellular target to the level of the human patient; and (4) develop a therapeutic plan to include the appropriate drug, dose, and monitoring parameters to effectively treat different disease conditions. The overarching goal of this integration was to help students to connect together the concepts of basic and clinical sciences related to drug action and utilization. Figure 1 represents the overview of the development process of integration. Medicinal chemistry and pharmacology were combined (Medicinal Chemistry/Pharmacology I, II, and III) and taught concurrently with pharmacotherapeutics (Pharmacotherapeutics I, II, and III) over 3 semesters starting in the spring of the second professional (P2) year and continuing until the spring of the third professional (P3) year of the traditional 4-year program.
Integrated Course: Medicinal Chemistry, Pharmacology, and Pharmacotherapeutics Credit hour allocation
Mapping of course contents
Sequencing of topics
Integration of contents
Commitment and collaboration between basic and clinical sciences faculty
Tues
Wed
Thur
Recitation–Diabetes: Problem solving and application of integrated knowledge
Mon
Therapeutics: Diabetes mellitus
Pharmacology: Endocrine pancreasDiabetes Therapeutics: Diabetes mellitus
Figure 1. The process of integration from baseline foundation to implementation and evaluation.
Pharmacology: Endocrine pancreasDiabetes
Methods Design and Implementation of the Integrated Course
Implementation and Evaluation of Integrated Course
Chemistry: Insulin and Oral hypoglycemic Drugs
(SBTE)’’ of drugs as an approach to teach medicinal chemistry in PharmD curriculum. In SBTE approach, 7 therapeutic areas were focused where concepts of chemical and structural aspects of drug molecules and the pharmacological and therapeutic principles of drug actions were integrated. Ives et al13 have reported that integration of content in medicinal chemistry and pharmacotherapeutics courses improved students’ learning and application of concepts. In a recent article, Marshall and Nykamp14 discussed an integrated active-learning strategy of teaching a pharmacotherapy module of musculoskeletal disorders by developing a patient case study incorporating problems from pathophysiology, medicinal chemistry, pharmacology, and pharmacotherapeutics. In addition, Kolluru et al15 discussed an integration of basic and clinical sciences in an active-learning exercise of depression module of a pharmacotherapy course. However, the instructional design and students’ evaluation of integrated entire sequences of medicinal chemistry, pharmacology, and therapeutics courses in PharmD curriculum have not been reported. This article will discuss (1) the development and instructional design of an integrated approach of teaching an entire sequence of medicinal chemistry, pharmacology, and pharmacotherapeutics over 3 consecutive semesters and (2) students’ perceptions of this teaching method as they progress through the curriculum.
Fri
Figure 2. Sequential and integrated class room teaching schedules for medicinal chemistry, pharmacology, and pharmacotherapeutics of diabetes.
Instructors in each of the disciplines met and sequenced the course topics based on what they felt was a logical progression through organ systems. The organ systems were further divided into specific disease states. Each discipline decided how much time would need to be allotted for each drug class/disease state and began to build a map of each semester including a list of drugs/drug classes to be discussed in an integrated fashion. Sharing of course materials and communication between course coordinators/course instructors were emphasized for the successful implementation of the team-taught approach. In order to fully integrate the courses, the classroom delivery for respective topics (eg, disease states/drug class) was scheduled and conducted in a collaborative fashion by instructors from each discipline. As an example, Figure 2 shows the sequential and integrated class room teaching schedules for medicinal chemistry, pharmacology, and pharmacotherapeutics aspects of diabetes mellitus. With this learning approach, concepts of different subject areas can be developed and connected in a cohesive fashion in students’ mind and they are able to integrate their knowledge about drug action from the molecular or cellular level to the level of patients (Figure 3). In the spring of P2 year (2009), the first sequences of integrated courses were taught. At the very beginning, the
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Therapeutics
Pharmacology
Pharmacology
Medicinal chemistry
Medicinal chemistry
Medicinal chemistry
Knowledge
Skills and abilities
Case-studies Problem solving: application of integrated knowledge & skills
Application (Practice)
Figure 3. Integrated approach of teaching/learning medicinal chemistry, pharmacology, and therapeutics which allow students gain knowledge and skills in basic and clinical sciences and apply that to clinical problems
concept of integration and the integrated approach of teaching 3 courses were explained to students. The integrated topics began with an introductory discussion about chemical, molecular, cellular, and physiological basis of drug action. Then various classes of drugs acting on the autonomic and central nervous systems and the pharmacotherapeutics of psychiatric and neurological conditions were discussed. In addition, the respiratory system, glaucoma, and dermatology were covered in this semester. In the second semester (fall P3 year), students were provided with an in-depth knowledge of the treatment of cardiovascular, renal, endocrine, and genitourinary diseases. In the third semester (spring P3 year), students gained an understanding of the treatment of patients with infectious diseases, cancer, immune disorders, gastroenterological disorders, and pain. Table 1 shows the sequencing of topics and respective classroom contact hours for each sequence of integrated courses. The entire integrated sequence of courses had been taught one time by spring 2010 and the first class graduated in June 2011. Course materials were delivered in lecture format. Several active learning strategies were embedded in each course, such as group discussion, online-discussion boards, and open book quizzes to enhance students’ learning experiences. Case discussions were scheduled within the lecture portion of the class and once a week students attended recitation which involved small group discussion of patient cases. In case studies, students were challenged with therapeutic problems where they applied integrated knowledge to develop a therapeutic plan including writing patient progress notes. We planned to evaluate students’ perception of the integration by conducting a Web-based survey. A 13-item survey instrument was developed with emphasis on the students’ perception of the purpose and importance of the integration, coordination of basic science and clinical science topics, the allotment of time for each component, redundancy of content, effectiveness of the integration on learning, and their ability
to apply integrated knowledge to solve therapeutic problems. This project was granted exempt status by the institutional review board of LECOM. In the spring of 2011, the survey was administered to students from P2 through P4 years to assess their perceptions of the integrated courses. At the time of survey administration, P2 students had completed one semester and both P3 and P4 students had completed three semesters of the integration sequence. In addition, P4 students were completing their Advanced Pharmacy Practice Experiences (APPEs). The P4 students received the same survey as P2 and P3 students, but with one additional question addressing the integration’s impact on APPEs. The respondents were asked to indicate their degree of agreement with individual statements using a 5-point Likert-type scale (ranged from 1 ¼ strongly disagree to 5 ¼ strongly agree). At the end of the survey items, students were asked to provide overall comments about the course integration. The mean score, median, and interquartile range (IQR, 25%-75%) for each question were calculated. Statistical analysis was performed using the Kruskal-Wallis nonparametric one-way analysis of variance to determine any differences among the three groups of respondents. Mann-Whitney Rank Sum test was used to measure the differences in students’ perceptions between paired groups (P2 vs P3 and P2 vs P4).
Results Evaluation and Assessment Strategies for both formative and summative assessment of students’ learning were employed for medicinal chemistry/ pharmacology and therapeutics courses. In each semester, students’ gained knowledge was evaluated by in-class quizzes, examinations, and a comprehensive and cumulative final examination. All examinations included multiplechoice, true/false statements, and matching questions. Examination questions for student learning assessments focused on knowledge covering each course objective. In addition, students were also directly assessed by patient progress notes and writing assignments. A total of 169 students from P2 through P4 years completed and returned the 13-item survey. As shown in Table 2, we gathered aggregated as well as class-wise response rates on each survey items. The students’ average rating for each statement in the survey was positive. The response indicating degree of agreement with individual statements ranged from 3.7 to 4.3. Among the total respondents, 90% of them agreed or highly agreed that they clearly understand the purpose of course integration. Students’ rating of the design and implementation of the integration was highly satisfactory. Students’ responses were positive (mean response rate ranged from 3.8-4.2) in regard to the lecture time committed to each component of integrated courses. Eighty percent of students agreed or strongly agreed with the statement that the coordination of basic and clinical science topics was done effectively. When the responses to this survey item were compared between student
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Table 1. Sequencing of Topics and Respective Classroom Contact Hours for Each Sequence of Pharmacology/Medicinal Chemistry and Pharmacotherapeutics Courses. Semester 1: Pharmacology/Medicinal Chemistry I (3 credit hours ¼ 45 hours) Pharmacotherapeutics I w/lab (4 credit hours ¼ 45 hours didactic þ 45 hours lab) Contents
Course
Introduction þ psychiatry þ neurology
Pharmacology and Medicinal chemistry Therapeutics Pharmacology and Medicinal chemistry Therapeutics Pharmacology and Medicinal chemistry Therapeutics Therapeutics Therapeutics Therapeutics
Respiratory Antihistamines/Allergic rhinitis Glaucoma Nutrition þ vitamins Dermatology
Distribution of hours 37 24 6 7 2 1 1 8 4
Semester 2: Pharmacology/Medicinal Chemistry II (4 credit hours ¼ 60 hours) Pharmacotherapeutics II w/lab (5 credit hours ¼ 60 hours didactic þ 45 hours lab) Cardiovascular Renal Reproduction/gynocology/urology Endocrine
Pharmacology Therapeutics Pharmacology Therapeutics Pharmacology Therapeutics Pharmacology Therapeutics
and Medicinal chemistry and Medicinal chemistry and Medicinal chemistry and Medicinal chemistry
40 25 6 12 3 9 11 14
Semester 3: Pharmacology/Medicinal Chemistry III (4 credit hours ¼ 60 hours) Pharmacotherapeutics III w/lab (6 credit hours ¼ 75 hours didactic þ 45 hours lab) Gastroenterology Immunology/rheum/pain Hematology Oncology Infectious disease
Pharmacology Therapeutics Pharmacology Therapeutics Therapeutics Pharmacology Therapeutics Pharmacology Therapeutics
and Medicinal chemistry and Medicinal chemistry
and Medicinal chemistry and Medicinal chemistry
years, a statistically significant difference (P < .05) was found between the P2 and P3 years as well as the P2 and P4 years. The survey items assessed students’ perceptions of the effectiveness of the integration of basic and clinical sciences in their learning experiences as well as their application in clinical practice. Eighty-four percent of respondents agreed or strongly agreed that the integration teaching approach enhanced their learning experiences. Seventy-five percent of the respondents from P2 through P4 classes agreed or strongly agreed with the statement that they were able to effectively apply the integrated knowledge to develop rational therapeutic recommendations during pharmacotherapeutics recitations. When comparing P2 responses to P3 and P4 responses, an increase was seen between the P2 year and the other years. The difference was statistically significant (P < .05) between P2 and P4 years. The mean responses were 3.75 versus 4.05 for P2 and P4 years. Similarly, the respective medians (IQR 25%-75%) were 4 (3-4) and 4 (4-5).
4 12 6 17 6 13 10 24 30
Similarly, 78% of the students felt that the integrated courses prepared them with required knowledge to provide optimal patient care in the clinical setting. This observation is further supported by the positive response of P4 students who were on APPE rotations. Seventy-eight percent of P4 students agreed or strongly agreed that integration effectively prepared them to critically analyze, problem solve, and make decisions in a clinical setting during APPE rotations. A total of 81 open-ended comments were recorded from a total of 169 respondents and were subjected to thematic analysis (Table 3). The most common theme which emerged from students’ comments reflected upon positive outcomes of the integration process in regard to enhancement of learning experiences. Students commented that they liked the opportunity to see important information presented multiple times in the semester and felt it better enabled them to understand how each discipline is enmeshed with the others. There were few
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Table 2. Students’ Perceptions of an Integrated Approach of Teaching Medicinal Chemistry, Pharmacology, and Therapeutics Courses. P2 (n ¼ 56)
P3 (n ¼ 55)
P4 (n ¼ 58)
Survey items
Median Median Median (IQR) Mean (IQR) Mean (IQR) Mean
I understand the purpose of integrating the courses. The coordination of basic and clinical science topics was done effectively
5 (4-5) 4(3-4)
The integration of courses enhanced my learning experience 4 (3.3-5) Redundancy in the course content was minimized effectively 4 (3-4) There was consistency in information between medicinal chemistry, pharmacology, 4 (3-4) and pharmacotherapeutics Lecture time committed to medicinal chemistry was appropriate 4 (4-5) Lecture time committed to pharmacology was appropriate 4 (4-5) Lecture time committed to pharmacotherapeutics was appropriate 4 (4-5) Time commitment to pharmacotherapeutic recitations was appropriate 4 (4-5) Pharmacotherapeutic recitations contributed greatly to my learning 4 (3-5) 4 (3-4) I was able to effectively apply this integrated knowledge of medicinal chemistry, pharmacology, and pharmacotherapeutics to develop rational therapeutic recommendations during pharmacotherapeutics recitation The integration of courses prepared me to apply my knowledge to critically solve 4 (3.3-5) therapeutic problems to provide optimal patient care in the clinical setting The integration effectively prepared me to apply my knowledge and critically analyze, problem solve, and make decisions in a clinical setting during my APPE rotations (P4)
4.36 3.73
5 (4-5) 4 (4-5)
4.6 4.31
5 (5-5) 4 (4-5)
4.76 4.15
3.98 3.71 3.61
5 (4-5) 4 (4-5) 4 (3-5)
4.47 4.2 3.82
5 (4-5) 4 (3-5) 4 (4-5)
4.34 4.02 3.97
3.95 3.96 4.04 3.98 3.73 3.75
4 (4-5) 4 (4-5) 4 (4-5) 4 (4-5) 4 (4-5) 4 (4-5)
4.02 4.22 4.15 3.94 3.96 4.09
5 (3-5) 4 (4-5) 4 (3-5) 4 (2-5) 4 (2-5) 4 (4-5)
3.84 4.15 3.83 3.68 3.59 4.05
3.96
4 (4-5)
4.25
P .019a .004 .037b .012a .009a NS NS NS NS NS NS 0.03b
NS 4 (4-5)
4.05
Abbreviations: IQR, interquartile range (25%-75%); NS, not significant. a Significant difference P3 versus P2. b Significant difference P4 versus P2.
Table 3. Thematic Analysis of Students’ Open-ended Comments During Survey on Course Integration. Number of citations Theme
P2
P3
P4
Total
Liked the opportunity to see information multiple times and gives the opportunity to connect concepts together Devote more time to pharmacology and pharmacotherapeutics and less to medicinal chemistry Begin the course sequence in the Fall of P2 year to decrease the amount of material in 1 semester Organization of topics was not optimal Conflicting information between disciplines (adverse effects) Redundancy and overlapping information
9 3 0 9 3 2
18 2 5 1 1 1
14 8 2 1 1 1
41 13 7 11 5 4
open-ended comments pertained to redundancy between disciplines. Students stated that some redundancy was helpful because if the student could not understand the concept when discussed in one discipline, the instructor in the other discipline would explain concepts in a different way which sometimes made it easier to comprehend.
Discussion In the setting of pharmacy education, integration and merging the principles of basic and clinical sciences can form a framework for individualized and effective approaches to patient care. In addition, it enables students to acquire the knowledge, skills, and abilities with the hope that by better understanding how different disciplines are interconnected, students can make better decisions for their patients in a complex environment.
Although curricular integration is focused to foster students’ learning, the effort may be impeded by multiple barriers and challenges from institution, faculty, and student levels.3 These may include lack of interdepartmental harmony, lack of faculty interest and time, consistency and compliance on course content and distribution of contact hours, and inadequate level of interaction between basic and clinical science faculty. Moreover, students’ lack of understanding the core concept of integration or resistance to unfamiliar pedagogical learning strategies may also negatively affect the process of integration.16,17 In the beginning of the design process, faculty members from both basic science and practice consulted with each other to ensure appropriate distribution of contact hours for each component, sequencing of the contents, identification of overlaps, elimination of redundancies, and coherence and fluidity of the materials delivered. The open communication
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and teamwork were essential to the success of the integration and made the process easier than expected. Moreover, planning for continuous follow-up of the integration approach was also emphasized. Mechanisms are in place to review the syllabi, class schedules, and course materials at both the course coordinators and individual instructors level to maintain the consistency and themed arrangements of contents before each semester. The students’ average rating for the survey item regarding understanding of the purpose and a goal of the course integration was positive. Students in all 3 years of the program understood the purpose of the integration. The students highly rated the design, implementation, and outcomes of the integration approach of teaching and learning. An overwhelming percentage of students was in agreement that integration of medicinal chemistry, pharmacology, and pharmacotherapeutics enhanced their learning experiences. Moreover, they were able to effectively apply the integrated knowledge to develop rational therapeutic recommendations during therapeutics case recitations or in clinical settings during APPE rotations. Surveying students from P2 to P4 who had progressive exposure of integration allowed us to determine whether there is a change in perception over progression through the program. We found that as students progress to APPEs and graduation, they better appreciated the benefits of integration on their ability to make therapeutic decisions. There were significant differences in students’ perception (P2 vs P3 or P4) on the purpose of integration, coordination of respective course components, and outcomes of integration in terms of learning and applying the knowledge into clinical practice. The P2 students just had their first experience with the integrative approach of teaching. Therefore, an unfamiliar pedagogical learning strategy and lack of understanding of the integration process may explain their relatively lower degree of agreement. Several themes emerged from students’ open-ended comments that include allotment of more time in teaching pharmacology and pharmacotherapeutics and reduction of contact hours in medicinal chemistry. Students also suggested beginning the integrated course in P1 rather than P2 year so that the concepts can be introduced early and reintroduced throughout the span of 3 years. These comments were discussed in Curriculum Committee and were evaluated during curricular mapping. It was decided to not make any changes to the integration at that time as the comments appeared to be highly subjective. In regard to the suggestion for medicinal chemistry, the justification of reducing contact hours was not evident from students’ comments. Design and implementation of specific survey questions are required to flesh out whether the students were not challenged enough for chemistry content to justify its time allocation or students were not clear about the relevance of chemistry into therapeutic practice. Ideally, we would have liked to have surveyed students prior to integration of courses and after the integration was
complete; however, this was not possible because the program was new. In this study, the survey compared different years of students at one time point in the curriculum. In the future, we would like to survey the students in a class and follow them over the course of the integration sequence. This would better confirm our observation that perceived benefits and understanding occurs as the student moves further along the curriculum.
Conclusion Integration in the curriculum is often difficult to design and implement because of barriers to the process; however, a coordinated effort between disciplines is essential to its success. In addition, faculty must approach the process with an open mind and a sense of teamwork. Based on the survey of P2 to P4 students, they perceive that the integration of medicinal chemistry, pharmacology, and pharmacotherapeutics courses enhances student learning outcomes including understanding core concepts and ability to solve clinical problems. These data will be helpful to make recommendations for course improvements and the viability of expanding the concept of integration to other courses in the curriculum. We are currently planning to resurvey students to look more deeply into how perceptions change regarding the integration as students move through the course sequence and into experiential rotations. Acknowledgments The author would like to thank Dr Mark Best for helping with statistical analysis.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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7. Regehr G, Norman G. Issues in cognitive psychology: implications for professional education. Acad Med. 1996;96:988-1002. 8. Harden RM. The integration ladder: a tool for curriculum planning and evaluation. Med Educ. 2000;34(7):551-557. 9. Muller JH, Jain S, Loeser H, et al. Lessons learned about integrating a medical school curriculum: perceptions of students, faculty and curriculum leaders. Med Educ. 2008;42(8):778-785. 10. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree (2007). Guidelines version 2.0. Page 19. https://www.acpe-accredit.org/pdf/S2007Guidelines2.0_ ChangesIdentifiedInRed.pdf. Accessed November 6, 2013. 11. Alsharif NZ, Shara MA, Roche VF. The structurally-based therapeutic evaluation (SBTE) concept: An opportunity for curricular integration and interdisciplinary teaching. Am J Pharm Educ. 2001;65:314-324. 12. Alsharif NZ, Theesen KA, Roche VF. Structurally based therapeutic evaluation: a therapeutic and practical approach to
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Students’ Perception of an Integrated Approach of Teaching Entire Sequence of Medicinal Chemistry, Pharmacology, and Pharmacotherapeutics Courses in PharmD Curriculum
Journal of Pharmacy Practice 2015, Vol. 28(2) 220-226 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0897190014544821 jpp.sagepub.com
Mohammed A. Islam, PhD1,2, and Teresa A. Schweiger, PharmD2,3
Abstract Purpose: To develop an integrated approach of teaching medicinal chemistry, pharmacology, and pharmacotherapeutics and to evaluate students’ perceptions of integration as they progress through the PharmD curriculum. Methods: Instructors from each discipline jointly mapped the course contents and sequenced the course delivery based on organ systems/disease states. Medicinal chemistry and pharmacology contents were integrated and aligned with respective pharmacotherapeutics contents to deliver throughout second and third year of the curriculum. In addition to classroom lectures, active learning strategies such as recitation, case studies, online-discussion boards, open book quizzes, and writing patient progress notes were incorporated to enhance student learning. Student learning was assessed by examination scores, patient progress notes, and writing assignments. The impact of course integration was evaluated by a Web-based survey. Results: One hundred and sixty-nine students completed the survey. Students exhibited positive attitude toward the integrated approach of teaching medicinal chemistry, pharmacology, and therapeutics. The P3 and P4 students better appreciated the benefits of integration compared to P2 students (P < .05). Conclusion: Students perceived the course integration as an effective way of learning. This study supports course improvement and the viability of expanding the concept of integration to other courses in the curriculum. Keywords medicinal chemistry, pharmacology, pharmacotherapeutics, integration, pharmacy curriculum
Introduction Curricular integration in interdisciplinary teaching has become an important strategy in North American health care education.1-3 There is an increasing recognition that traditional instructional modes of separating basic and clinical sciences no longer conform with current demands for interdisciplinary learning and practice.1,4,5 Moreover, cognitive psychology theories of learning suggest that an integrated approach of teaching can promote contextual and applied learning.6,7 Harden8 developed ‘‘the integration ladder’’ that can be used as an effective strategy to teach basic and clinical sciences in medical or pharmacy school curricula. Recently, Muller et al9 described the integrated approach of teaching and learning of 2 or more academic disciplines as an important but a complex strategy. The accreditation standards and guidelines of the Accreditation Council for Pharmacy Education emphasize the need for an integrated curriculum in US Pharmacy schools: ‘‘The curriculum must define the expected outcomes and be developed, with attention to sequencing and integration of content and the selection of teaching and learning methods and assessments.’’10
Traditionally, pharmacology, medicinal chemistry, and pharmacotherapeutics courses are taught in silos making students responsible to connect the knowledge parts together to understand the interrelatedness of basic and clinical science principles. There are few reports on curricular integration of basic and clinical sciences in pharmacy programs in the literature.11-15 More than a decade ago, Alsharif et al12 introduced the concept of ‘‘structurally based therapeutic evaluation
1 Department of Pharmaceutical Sciences, West Coast University School of Pharmacy, Los Angeles, CA, USA 2 At the time of study, authors were affiliated with Lake Erie College of Osteopathic Medicine, School of Pharmacy, Bradenton, FL, USA 3 Bernard J. Dunn School of Pharmacy, Shenandoah University, Winchester, VA, USA
Corresponding Author: Mohammed A. Islam, Department of Pharmaceutical Sciences, West Coast University School of Pharmacy, 590 N Vermont Ave, Los Angeles, CA 90004, USA. Email: [email protected]
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When the Lake Erie College of Osteopathic Medicine (LECOM) Bradenton, School of Pharmacy program began in 2007, the decision was made to fully integrate pharmacology, medicinal chemistry, and pharmacotherapeutics. The primary goals of course integration was to help students (1) develop an understanding as to how physicochemical properties of drug molecules influence their activity at its biological target, and, consequently, their therapeutic performance; (2) learn the mechanisms of action, pharmacokinetics, toxicity profiles, contraindications, and drug–drug interactions pertaining to drug classes used in a particular disease state in a conceptual framework; (3) integrate their knowledge about drug action from the level of an individual molecular or cellular target to the level of the human patient; and (4) develop a therapeutic plan to include the appropriate drug, dose, and monitoring parameters to effectively treat different disease conditions. The overarching goal of this integration was to help students to connect together the concepts of basic and clinical sciences related to drug action and utilization. Figure 1 represents the overview of the development process of integration. Medicinal chemistry and pharmacology were combined (Medicinal Chemistry/Pharmacology I, II, and III) and taught concurrently with pharmacotherapeutics (Pharmacotherapeutics I, II, and III) over 3 semesters starting in the spring of the second professional (P2) year and continuing until the spring of the third professional (P3) year of the traditional 4-year program.
Integrated Course: Medicinal Chemistry, Pharmacology, and Pharmacotherapeutics Credit hour allocation
Mapping of course contents
Sequencing of topics
Integration of contents
Commitment and collaboration between basic and clinical sciences faculty
Tues
Wed
Thur
Recitation–Diabetes: Problem solving and application of integrated knowledge
Mon
Therapeutics: Diabetes mellitus
Pharmacology: Endocrine pancreasDiabetes Therapeutics: Diabetes mellitus
Figure 1. The process of integration from baseline foundation to implementation and evaluation.
Pharmacology: Endocrine pancreasDiabetes
Methods Design and Implementation of the Integrated Course
Implementation and Evaluation of Integrated Course
Chemistry: Insulin and Oral hypoglycemic Drugs
(SBTE)’’ of drugs as an approach to teach medicinal chemistry in PharmD curriculum. In SBTE approach, 7 therapeutic areas were focused where concepts of chemical and structural aspects of drug molecules and the pharmacological and therapeutic principles of drug actions were integrated. Ives et al13 have reported that integration of content in medicinal chemistry and pharmacotherapeutics courses improved students’ learning and application of concepts. In a recent article, Marshall and Nykamp14 discussed an integrated active-learning strategy of teaching a pharmacotherapy module of musculoskeletal disorders by developing a patient case study incorporating problems from pathophysiology, medicinal chemistry, pharmacology, and pharmacotherapeutics. In addition, Kolluru et al15 discussed an integration of basic and clinical sciences in an active-learning exercise of depression module of a pharmacotherapy course. However, the instructional design and students’ evaluation of integrated entire sequences of medicinal chemistry, pharmacology, and therapeutics courses in PharmD curriculum have not been reported. This article will discuss (1) the development and instructional design of an integrated approach of teaching an entire sequence of medicinal chemistry, pharmacology, and pharmacotherapeutics over 3 consecutive semesters and (2) students’ perceptions of this teaching method as they progress through the curriculum.
Fri
Figure 2. Sequential and integrated class room teaching schedules for medicinal chemistry, pharmacology, and pharmacotherapeutics of diabetes.
Instructors in each of the disciplines met and sequenced the course topics based on what they felt was a logical progression through organ systems. The organ systems were further divided into specific disease states. Each discipline decided how much time would need to be allotted for each drug class/disease state and began to build a map of each semester including a list of drugs/drug classes to be discussed in an integrated fashion. Sharing of course materials and communication between course coordinators/course instructors were emphasized for the successful implementation of the team-taught approach. In order to fully integrate the courses, the classroom delivery for respective topics (eg, disease states/drug class) was scheduled and conducted in a collaborative fashion by instructors from each discipline. As an example, Figure 2 shows the sequential and integrated class room teaching schedules for medicinal chemistry, pharmacology, and pharmacotherapeutics aspects of diabetes mellitus. With this learning approach, concepts of different subject areas can be developed and connected in a cohesive fashion in students’ mind and they are able to integrate their knowledge about drug action from the molecular or cellular level to the level of patients (Figure 3). In the spring of P2 year (2009), the first sequences of integrated courses were taught. At the very beginning, the
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Therapeutics
Pharmacology
Pharmacology
Medicinal chemistry
Medicinal chemistry
Medicinal chemistry
Knowledge
Skills and abilities
Case-studies Problem solving: application of integrated knowledge & skills
Application (Practice)
Figure 3. Integrated approach of teaching/learning medicinal chemistry, pharmacology, and therapeutics which allow students gain knowledge and skills in basic and clinical sciences and apply that to clinical problems
concept of integration and the integrated approach of teaching 3 courses were explained to students. The integrated topics began with an introductory discussion about chemical, molecular, cellular, and physiological basis of drug action. Then various classes of drugs acting on the autonomic and central nervous systems and the pharmacotherapeutics of psychiatric and neurological conditions were discussed. In addition, the respiratory system, glaucoma, and dermatology were covered in this semester. In the second semester (fall P3 year), students were provided with an in-depth knowledge of the treatment of cardiovascular, renal, endocrine, and genitourinary diseases. In the third semester (spring P3 year), students gained an understanding of the treatment of patients with infectious diseases, cancer, immune disorders, gastroenterological disorders, and pain. Table 1 shows the sequencing of topics and respective classroom contact hours for each sequence of integrated courses. The entire integrated sequence of courses had been taught one time by spring 2010 and the first class graduated in June 2011. Course materials were delivered in lecture format. Several active learning strategies were embedded in each course, such as group discussion, online-discussion boards, and open book quizzes to enhance students’ learning experiences. Case discussions were scheduled within the lecture portion of the class and once a week students attended recitation which involved small group discussion of patient cases. In case studies, students were challenged with therapeutic problems where they applied integrated knowledge to develop a therapeutic plan including writing patient progress notes. We planned to evaluate students’ perception of the integration by conducting a Web-based survey. A 13-item survey instrument was developed with emphasis on the students’ perception of the purpose and importance of the integration, coordination of basic science and clinical science topics, the allotment of time for each component, redundancy of content, effectiveness of the integration on learning, and their ability
to apply integrated knowledge to solve therapeutic problems. This project was granted exempt status by the institutional review board of LECOM. In the spring of 2011, the survey was administered to students from P2 through P4 years to assess their perceptions of the integrated courses. At the time of survey administration, P2 students had completed one semester and both P3 and P4 students had completed three semesters of the integration sequence. In addition, P4 students were completing their Advanced Pharmacy Practice Experiences (APPEs). The P4 students received the same survey as P2 and P3 students, but with one additional question addressing the integration’s impact on APPEs. The respondents were asked to indicate their degree of agreement with individual statements using a 5-point Likert-type scale (ranged from 1 ¼ strongly disagree to 5 ¼ strongly agree). At the end of the survey items, students were asked to provide overall comments about the course integration. The mean score, median, and interquartile range (IQR, 25%-75%) for each question were calculated. Statistical analysis was performed using the Kruskal-Wallis nonparametric one-way analysis of variance to determine any differences among the three groups of respondents. Mann-Whitney Rank Sum test was used to measure the differences in students’ perceptions between paired groups (P2 vs P3 and P2 vs P4).
Results Evaluation and Assessment Strategies for both formative and summative assessment of students’ learning were employed for medicinal chemistry/ pharmacology and therapeutics courses. In each semester, students’ gained knowledge was evaluated by in-class quizzes, examinations, and a comprehensive and cumulative final examination. All examinations included multiplechoice, true/false statements, and matching questions. Examination questions for student learning assessments focused on knowledge covering each course objective. In addition, students were also directly assessed by patient progress notes and writing assignments. A total of 169 students from P2 through P4 years completed and returned the 13-item survey. As shown in Table 2, we gathered aggregated as well as class-wise response rates on each survey items. The students’ average rating for each statement in the survey was positive. The response indicating degree of agreement with individual statements ranged from 3.7 to 4.3. Among the total respondents, 90% of them agreed or highly agreed that they clearly understand the purpose of course integration. Students’ rating of the design and implementation of the integration was highly satisfactory. Students’ responses were positive (mean response rate ranged from 3.8-4.2) in regard to the lecture time committed to each component of integrated courses. Eighty percent of students agreed or strongly agreed with the statement that the coordination of basic and clinical science topics was done effectively. When the responses to this survey item were compared between student
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Table 1. Sequencing of Topics and Respective Classroom Contact Hours for Each Sequence of Pharmacology/Medicinal Chemistry and Pharmacotherapeutics Courses. Semester 1: Pharmacology/Medicinal Chemistry I (3 credit hours ¼ 45 hours) Pharmacotherapeutics I w/lab (4 credit hours ¼ 45 hours didactic þ 45 hours lab) Contents
Course
Introduction þ psychiatry þ neurology
Pharmacology and Medicinal chemistry Therapeutics Pharmacology and Medicinal chemistry Therapeutics Pharmacology and Medicinal chemistry Therapeutics Therapeutics Therapeutics Therapeutics
Respiratory Antihistamines/Allergic rhinitis Glaucoma Nutrition þ vitamins Dermatology
Distribution of hours 37 24 6 7 2 1 1 8 4
Semester 2: Pharmacology/Medicinal Chemistry II (4 credit hours ¼ 60 hours) Pharmacotherapeutics II w/lab (5 credit hours ¼ 60 hours didactic þ 45 hours lab) Cardiovascular Renal Reproduction/gynocology/urology Endocrine
Pharmacology Therapeutics Pharmacology Therapeutics Pharmacology Therapeutics Pharmacology Therapeutics
and Medicinal chemistry and Medicinal chemistry and Medicinal chemistry and Medicinal chemistry
40 25 6 12 3 9 11 14
Semester 3: Pharmacology/Medicinal Chemistry III (4 credit hours ¼ 60 hours) Pharmacotherapeutics III w/lab (6 credit hours ¼ 75 hours didactic þ 45 hours lab) Gastroenterology Immunology/rheum/pain Hematology Oncology Infectious disease
Pharmacology Therapeutics Pharmacology Therapeutics Therapeutics Pharmacology Therapeutics Pharmacology Therapeutics
and Medicinal chemistry and Medicinal chemistry
and Medicinal chemistry and Medicinal chemistry
years, a statistically significant difference (P < .05) was found between the P2 and P3 years as well as the P2 and P4 years. The survey items assessed students’ perceptions of the effectiveness of the integration of basic and clinical sciences in their learning experiences as well as their application in clinical practice. Eighty-four percent of respondents agreed or strongly agreed that the integration teaching approach enhanced their learning experiences. Seventy-five percent of the respondents from P2 through P4 classes agreed or strongly agreed with the statement that they were able to effectively apply the integrated knowledge to develop rational therapeutic recommendations during pharmacotherapeutics recitations. When comparing P2 responses to P3 and P4 responses, an increase was seen between the P2 year and the other years. The difference was statistically significant (P < .05) between P2 and P4 years. The mean responses were 3.75 versus 4.05 for P2 and P4 years. Similarly, the respective medians (IQR 25%-75%) were 4 (3-4) and 4 (4-5).
4 12 6 17 6 13 10 24 30
Similarly, 78% of the students felt that the integrated courses prepared them with required knowledge to provide optimal patient care in the clinical setting. This observation is further supported by the positive response of P4 students who were on APPE rotations. Seventy-eight percent of P4 students agreed or strongly agreed that integration effectively prepared them to critically analyze, problem solve, and make decisions in a clinical setting during APPE rotations. A total of 81 open-ended comments were recorded from a total of 169 respondents and were subjected to thematic analysis (Table 3). The most common theme which emerged from students’ comments reflected upon positive outcomes of the integration process in regard to enhancement of learning experiences. Students commented that they liked the opportunity to see important information presented multiple times in the semester and felt it better enabled them to understand how each discipline is enmeshed with the others. There were few
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Table 2. Students’ Perceptions of an Integrated Approach of Teaching Medicinal Chemistry, Pharmacology, and Therapeutics Courses. P2 (n ¼ 56)
P3 (n ¼ 55)
P4 (n ¼ 58)
Survey items
Median Median Median (IQR) Mean (IQR) Mean (IQR) Mean
I understand the purpose of integrating the courses. The coordination of basic and clinical science topics was done effectively
5 (4-5) 4(3-4)
The integration of courses enhanced my learning experience 4 (3.3-5) Redundancy in the course content was minimized effectively 4 (3-4) There was consistency in information between medicinal chemistry, pharmacology, 4 (3-4) and pharmacotherapeutics Lecture time committed to medicinal chemistry was appropriate 4 (4-5) Lecture time committed to pharmacology was appropriate 4 (4-5) Lecture time committed to pharmacotherapeutics was appropriate 4 (4-5) Time commitment to pharmacotherapeutic recitations was appropriate 4 (4-5) Pharmacotherapeutic recitations contributed greatly to my learning 4 (3-5) 4 (3-4) I was able to effectively apply this integrated knowledge of medicinal chemistry, pharmacology, and pharmacotherapeutics to develop rational therapeutic recommendations during pharmacotherapeutics recitation The integration of courses prepared me to apply my knowledge to critically solve 4 (3.3-5) therapeutic problems to provide optimal patient care in the clinical setting The integration effectively prepared me to apply my knowledge and critically analyze, problem solve, and make decisions in a clinical setting during my APPE rotations (P4)
4.36 3.73
5 (4-5) 4 (4-5)
4.6 4.31
5 (5-5) 4 (4-5)
4.76 4.15
3.98 3.71 3.61
5 (4-5) 4 (4-5) 4 (3-5)
4.47 4.2 3.82
5 (4-5) 4 (3-5) 4 (4-5)
4.34 4.02 3.97
3.95 3.96 4.04 3.98 3.73 3.75
4 (4-5) 4 (4-5) 4 (4-5) 4 (4-5) 4 (4-5) 4 (4-5)
4.02 4.22 4.15 3.94 3.96 4.09
5 (3-5) 4 (4-5) 4 (3-5) 4 (2-5) 4 (2-5) 4 (4-5)
3.84 4.15 3.83 3.68 3.59 4.05
3.96
4 (4-5)
4.25
P .019a .004 .037b .012a .009a NS NS NS NS NS NS 0.03b
NS 4 (4-5)
4.05
Abbreviations: IQR, interquartile range (25%-75%); NS, not significant. a Significant difference P3 versus P2. b Significant difference P4 versus P2.
Table 3. Thematic Analysis of Students’ Open-ended Comments During Survey on Course Integration. Number of citations Theme
P2
P3
P4
Total
Liked the opportunity to see information multiple times and gives the opportunity to connect concepts together Devote more time to pharmacology and pharmacotherapeutics and less to medicinal chemistry Begin the course sequence in the Fall of P2 year to decrease the amount of material in 1 semester Organization of topics was not optimal Conflicting information between disciplines (adverse effects) Redundancy and overlapping information
9 3 0 9 3 2
18 2 5 1 1 1
14 8 2 1 1 1
41 13 7 11 5 4
open-ended comments pertained to redundancy between disciplines. Students stated that some redundancy was helpful because if the student could not understand the concept when discussed in one discipline, the instructor in the other discipline would explain concepts in a different way which sometimes made it easier to comprehend.
Discussion In the setting of pharmacy education, integration and merging the principles of basic and clinical sciences can form a framework for individualized and effective approaches to patient care. In addition, it enables students to acquire the knowledge, skills, and abilities with the hope that by better understanding how different disciplines are interconnected, students can make better decisions for their patients in a complex environment.
Although curricular integration is focused to foster students’ learning, the effort may be impeded by multiple barriers and challenges from institution, faculty, and student levels.3 These may include lack of interdepartmental harmony, lack of faculty interest and time, consistency and compliance on course content and distribution of contact hours, and inadequate level of interaction between basic and clinical science faculty. Moreover, students’ lack of understanding the core concept of integration or resistance to unfamiliar pedagogical learning strategies may also negatively affect the process of integration.16,17 In the beginning of the design process, faculty members from both basic science and practice consulted with each other to ensure appropriate distribution of contact hours for each component, sequencing of the contents, identification of overlaps, elimination of redundancies, and coherence and fluidity of the materials delivered. The open communication
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and teamwork were essential to the success of the integration and made the process easier than expected. Moreover, planning for continuous follow-up of the integration approach was also emphasized. Mechanisms are in place to review the syllabi, class schedules, and course materials at both the course coordinators and individual instructors level to maintain the consistency and themed arrangements of contents before each semester. The students’ average rating for the survey item regarding understanding of the purpose and a goal of the course integration was positive. Students in all 3 years of the program understood the purpose of the integration. The students highly rated the design, implementation, and outcomes of the integration approach of teaching and learning. An overwhelming percentage of students was in agreement that integration of medicinal chemistry, pharmacology, and pharmacotherapeutics enhanced their learning experiences. Moreover, they were able to effectively apply the integrated knowledge to develop rational therapeutic recommendations during therapeutics case recitations or in clinical settings during APPE rotations. Surveying students from P2 to P4 who had progressive exposure of integration allowed us to determine whether there is a change in perception over progression through the program. We found that as students progress to APPEs and graduation, they better appreciated the benefits of integration on their ability to make therapeutic decisions. There were significant differences in students’ perception (P2 vs P3 or P4) on the purpose of integration, coordination of respective course components, and outcomes of integration in terms of learning and applying the knowledge into clinical practice. The P2 students just had their first experience with the integrative approach of teaching. Therefore, an unfamiliar pedagogical learning strategy and lack of understanding of the integration process may explain their relatively lower degree of agreement. Several themes emerged from students’ open-ended comments that include allotment of more time in teaching pharmacology and pharmacotherapeutics and reduction of contact hours in medicinal chemistry. Students also suggested beginning the integrated course in P1 rather than P2 year so that the concepts can be introduced early and reintroduced throughout the span of 3 years. These comments were discussed in Curriculum Committee and were evaluated during curricular mapping. It was decided to not make any changes to the integration at that time as the comments appeared to be highly subjective. In regard to the suggestion for medicinal chemistry, the justification of reducing contact hours was not evident from students’ comments. Design and implementation of specific survey questions are required to flesh out whether the students were not challenged enough for chemistry content to justify its time allocation or students were not clear about the relevance of chemistry into therapeutic practice. Ideally, we would have liked to have surveyed students prior to integration of courses and after the integration was
complete; however, this was not possible because the program was new. In this study, the survey compared different years of students at one time point in the curriculum. In the future, we would like to survey the students in a class and follow them over the course of the integration sequence. This would better confirm our observation that perceived benefits and understanding occurs as the student moves further along the curriculum.
Conclusion Integration in the curriculum is often difficult to design and implement because of barriers to the process; however, a coordinated effort between disciplines is essential to its success. In addition, faculty must approach the process with an open mind and a sense of teamwork. Based on the survey of P2 to P4 students, they perceive that the integration of medicinal chemistry, pharmacology, and pharmacotherapeutics courses enhances student learning outcomes including understanding core concepts and ability to solve clinical problems. These data will be helpful to make recommendations for course improvements and the viability of expanding the concept of integration to other courses in the curriculum. We are currently planning to resurvey students to look more deeply into how perceptions change regarding the integration as students move through the course sequence and into experiential rotations. Acknowledgments The author would like to thank Dr Mark Best for helping with statistical analysis.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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