Pharmacology for the 21st Century:The Successful Implementation of an Innovative, Integrative Pharmacotherapeutics Curriculum for Medical Students

Thomas Lynch, Pharm.D.Julie Bridges, PhD Candidate

Eastern Virginia Medical SchoolNorfolk, VA

EVMS Facts and Figures 2013

Located in Norfolk, VirginiaAnnual Budget 230.9 MillionState Appropriations 24.1 Million

Students in 2015 MD Class 145

Faculty, Residents and StaffResidents, Interns, Fellows 349

Foundational Science Faculty 46Clinical Faculty 365

EVMS Doctor of Medicine Program

EVMS M3 and M4 Years

Two semester curriculum starting later than other M2 courses

No synchronization with other courses Little emphasis on clinical use of drugs Out-of-date material Didactic presentations by multiple faculty

without standardized format Five small group sessions using 6

pharmacology faculty members Four exams using non-USMLE style questions

plus final shelf exam

Pharmacology Curriculum Pre-2012

2008 2009 2010 2011 20120

1

2

3

4

5

3.663.47

2.73 2.79

2.33

Satisfaction

Overall Course Satisfaction

Consistently poor student evaluations Low attendance (10-20%) Material taught not relevant to current clinical

practice Students in 3rd & 4th years not able to evaluate

and/or recommend medication regimens safely and effectively

Student prone to “hidden curriculum” Pharmaceutical marketing, inaccurate advice from

other students & residents

Concerns With Pharmacology Curriculum Pre-2012

Over 4 billion prescriptions dispensed with sales of $325 billion in U.S. in 2012 Five brand drugs accounted for over $26 billion! Nexium, Abilify, Crestor, Advair, Cymbalta

For every dollar spent on drugs, one dollar is spent on adverse events

Mortality secondary to drugs is unofficially estimated to be the 3rd leading cause of death in the U.S.

11% of hospital admissions of older adults are due to adverse drug reactions

42% of adults > 65 years old take more than 5 drugs 13% take more than 10 drugs

At least 50% of patients are nonadherent to medications

Some Drug Facts

Concern: Medical students are not

receiving sufficient education and

training in rational prescribing

Panel: Academic and industry

experts in drug therapy,

pharmacology education, and

pharmaceutical research and

developmentObjectives: Based on six core

competencies recommended by

ACGME

Developed, directed, & taught by Pharm.D. Board certified pharmacotherapy specialist 25 years experience in hospital and ambulatory

clinical practice 15 years experience teaching physicians, residents,

and students (medical, pharmacy, physician assistant, nursing)

Emphasis on preparation for Step 1 (20%) Emphasis on the applied use of pharmacology

principles (pharmacotherapeutics) to prepare medical students for clinical years (80% of content)

Integrative Pharmacotherapeutics Curriculum Starting August, 2012

Merging of basic pharmacology with principles of therapeutic use of drugs

Goal: ensuring the safe, appropriate, and economical use of drugs in patient care by students and physicians

Incorporates current therapeutic reviews and guidelines published in peer journals, Medical letter, Prescribers Letter, DynaMed, etc

Focuses on benefits and risks of most common drugs used and abused in clinical practice

Be able to select the most appropriate medication for a patient based on pharmacodynamics, pharmacokinetics, clinical efficacy data, and individual patient characteristics

Be able to recognize inappropriate and dangerous drug regimens Also incorporates pharmacoeconomics, marketing principles, print & TV

advertisements, personal student experiences, clinical trial evaluations, techniques for evaluating biased vs unbiased information sources

Integrative Pharmacotherapeutics – What Is It?

Lengthened course by 1 month New class schedule synchronized with topics in

other basic science courses New faculty New course objectives and content Standardized presentation format New exam and grading system Introduction of active learning methods

Integrative Pharmacotherapeutics Curriculum Changes

Nine modules each consisting of 5-7 topics, a modified team-based learning session, and exam

Modules synchronized with other courses Nine exams using USMLE-style questions plus

national Pharmacology Subject Exam for final Quiz at start of class based on assigned reading

and part of final grade Attendance not mandatory except for TBL

Course Structure

Two question quiz at start of most classes based on assigned reading in Brenner’s Pharmacology and part of final grade Use of personal response system (PRS) to capture answers Ensures attendance and familiarity with new terms and concepts

Use of clinical case examples during didactic USMLE questions during didactic with use of PRS to

evaluate answers, provide constructive feedback, and capture attendance

Modified team-based learning sessions

Active Learning Methods

Modified Team-Based Learning SessionsTwenty two teams of 6-7 students in one roomMentored by two Pharm.D. facultyTwo cases over 2 hour period based on module topics

Detailed history, presentation, physical exam, labs, and current medication list

Current therapeutic guidelines made available online for reference Teams expected to prepare and present a therapeutic plan without prior

knowledge of case within 1 hour Teams chosen at random to answer set of questions

Scheduled several days before examNo grading but attendance mandatoryLast TBL session of year is series of realistic polypharmacy cases and

teams must identify presumed drug indications, inappropriate dosing, contraindications, potential adverse effects, and drug interactions

Longitudinal Component of CurriculumDuring 3rd year by Pharm.D.Family Medicine clerkship

Review of drug treatment of diabetes, hypertension, heart failure, and hyperlipidemia

Journal club to review key clinical drug trials published in primary literature

Review of pharmaceutical marketing techniques – “the science of persuasion”

Inpatient rounds in hospitalGeriatric Medicine clerkship

In depth review of Polypharmacy

Results

Highest student evaluations of any of the basic sciences mid-year and end of year

Mean scores for Pharmacology Subject Exam and Step 1 higher than previous years

High attendance rates (80-95%) throughout year, although not mandatory

Positive feedback from 3rd year clinical preceptors regarding students’ clinical drug knowledge

Student Evaluations at End of Year 2013 96% Satisfaction Overall

Integrative Pharmacotherapeutics 2013 Student Satisfaction Summary Report

Year

Mean Score

2009 2010 2011 2012 2013*214

216

218

220

222

224

226

228

230

232

234

EVMS Mean Step 1All Mean Step 1

*Interim Results as of 10/28/2013

NOTE: Years 2011, 2012, 2013 EVMS scores were significantly higher than all test takers in the U.S. and Canada

EVMS Five Year Step 1 Exam: Mean Test Results

EVMS Mean Scores on Step 1

ConclusionsToday’s medical students must be able to manage a patient’s medications by the start of their 3 rd year A clinically focused pharmacotherapeutics curriculum replacing a traditional pharmacology curriculum for 2 nd year medical

students resulted in high evaluation scores and attendance rates without negatively impacting Step 1 scoresModified team-based learning sessions of 145 students can be successfully managed by two clinical faculty