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Teaching the Basics of Clinical Pharmaceutical Care:Innovative Pharmacy Workshops at the

University of Wisconsin and the University of Nebraska

Dean R. Keller, MD; David V. O’Dell, MD; Susan E. Skochelak, MD, MPH;Gary L. Cochran, PharmD; Sara J. Shull, PharmD; Craig L. Gjerde, PhD

Background: Safe and effective prescription writing, using drug formularies, and managing pharmaceu-tical care are skills medical students need to acquire. Spurred by the Undergraduate Medical Educationfor the 21st Century (UME-21) grants, the University of Wisconsin and the University of Nebraska inde-pendently developed educational workshops to address these competencies. Methods: The University ofWisconsin’s workshop is presented to medical students at the start of their third year. They receive infor-mation from pharmacists on medication errors, prescription writing, and drug formularies. A “ learnersguide” summary is discussed by a physician, which brings into focus the clinical application of the didac-tic sessi on. A small-group session follows with hands-on experience in writing prescriptions and usingformularies for three patient case scenarios. The workshop at the University of Nebraska consists of threesessions during the third-year internal medicine clerkship. In the first session, pharmacists discuss for-mularies, the Pharmacy and Therapeutics (P&T) committee, and the preparation of a drug monograph.During the second session, students develop an evidence-based drug monograph on a product or herbal.In the final session, the class functions as a mock P& T committee, and after listening to the drug mono-graphs, determines whether the product should be added to the formulary. We evaluated students’ satis-faction with the workshops using Likert scales and assessed students’ ability to correctly fill out a pre-scription form. Results: Both workshops were well received. The mean rating at University of Wisconsinwas 1.7 on a scale of 1 (satisfied) to 7 (dissatisfied), and at University of Nebraska it was 3.8 with 5(outstanding) to 1 (unacceptable). At the University of Wisconsin, on a year-end skills assessment involv-ing 148 students, 100% of the students properly filled out a prescription. Ninety-four percent received anexcellent grade, 6% a pass, and no marginal or failing grades were given out. Conclusions: The work-shop on pharmaceutical prescribing was rated favorably by students. After participating in the workshop,students acquired skills in prescription writing.

(Fam Med 2004;36(January suppl):S89-S92.)

From the Department of Internal Medicine (Dr Keller) and the Departmentof Family Medicine (Drs Skochelak and Gjerde), University of Wisconsin;the Department of Internal Medicine, University of Nebraska (Drs O’ Delland Cochran); and Nebraska Health Systems (Dr Shull)

The tremendous growth in the number of pharmaceu-ticals has had a signif icant effect on patient care. Medi-cations are integral to any patient care model, but withthe ever-increasing complexity of the medicationchoices, problems have arisen. The problems includemedication errors,1-4 drug interactions, the cost of themedications, the presence of multiple conflicting drugformularies, and the coordination of care. Traditionalmedical school curricula have not addressed these prob-lems, and there is scant literature regarding educating

medical students or physicians in managing pharma-ceutical care.5

This paper discusses two Undergraduate MedicalEducation for the 21st Century (UME-21)-supportedworkshops. One was from the University of Wisconsinand the other from the University of Nebraska. Theobjectives of the workshops were similar, but eachschool emphasized different skills. The objectives areshown in Table 1.

MethodsPharmacy Workshop at the University of Wisconsin

Prior to beginning clinical clerkships, all 140 third-year medical students participated in this 2-hour work-shop. During the f irst hour, basic information on medi-

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cation errors, legal requirements of a prescription, andcore elements of a safe prescription were reviewed bya pharmacist. The pharmacist also presented informa-tion on drug formularies, pharmacy and therapeuticscommittees, formulary decisi on-making, and what for-mularies mean to prescribers. To end the didactic com-ponent, a physician reviewed a learners guide (avail-able from the authors) to writing prescriptions and us-ing drug formularies. The learners guide gave pragmaticadvice in key areas such as the format of the prescrip-tion, supply of medication, refills, critical information,samples, and drug information sources. The learnersguide brought into focus the clinical application of thedidactic sessi on and was provided in a summary for-mat the students could carry with them on clinical ro-tations.

The second hour of the module consisted of small-group breakout sessions to give students hands-on ex-perience in writing prescriptions and using formular-ies. Three clinical case scenarios were given to the stu-dents—each involved reviewing a patient’s medicalproblem, then writing a prescription using our localmanaged care formulary. The first case involved an ACEinhibitor prescription for a diabetic patient with nephr-opathy and hypertension, the second involved a pre-scription for a proton pump inhibitor requiring a priorauthorization form, and the last case was of a pediatricpatient requiring an antibiotic suspension calculation.The students were required to select a covered medica-tion from the formulary, pick appropriate dosagestrengths, and properly write out a prescription includ-ing authorization of refills. They were encouraged tominimize Latin abbreviations, to omit a trailing zeroafter a decimal point, and to include a leading zero be-fore a decimal point. Physician and pharmacy facilita-tors led the small groups (10 small groups of 14 stu-dents each) and reviewed proper prescription writingtechniques and formulary usage with the students atthe conclusion of the small group.

Workshop at the University of NebraskaFifteen students participated in each workshop as a

component of their third-year internal medicine clerk-ship. The workshop was repeated six times throughoutthe year. In the initial session, a staff pharmacist pro-vided a lecture describing formularies, generic substi-tution, pharmaceutical information resources, cost-effective analysis, structure and function of the Phar-macy and Therapeutics (P& T) committee, and the cre-ation of drug monographs for presentation to the P& Tcommittee.

Following this session, the students were separatedinto three groups to develop an evidence-based mono-graph on a pharmaceutical product. The monographsaddressed indications, pharmacology, clinical trials,adverse effects and interactions, dosing and adminis-trations, economics, recommendation, and literaturesearch/bibliography. Each group was assigned a spe-cif ic pharmaceutical selected to illustrate a key con-cept that may influence formulary decision making.Concepts included “me too” drugs, novel products forniche indications, medications with rare but seriousadverse reactions, therapeutic substitution strategies,and contemporary herbal products. The students que-ried the literature independently and then reconvenedfor the second session to assemble the monograph. Astaff pharmacist facilitated this session.

In a f inal session, the class functioned as a P& T com-mittee. A representative from each group presented theirmonograph to the class. Fol lowing discussion, the classvoted to add the drug to the formulary, reject the drug,or add the drug with restrictions to its use. For the herbalproducts, the students developed a consensus statementon the use of the product that included critiquing avail-able evidence on safety and eff icacy. A physician fa-cilitator summarized the session by stressing the im-portance of making decisions using an evidence-basedapproach, stewardship of health care resources, work-ing with other members of the health care team, docu-menting and reporting adverse drug reactions, relevanceof formularies, and strategies for keeping current withpharmaceuticals. In total, the workshop required 3 hoursof student time and 4 hours of faculty time per 6-weekrotation.

ResultsUniversity of Wisconsin

At the University of Wisconsin, the workshop washighly rated by students. Ratings were based on a scaleof 1 (satisf ied) to 7 (dissatisf ied), and data were col-lected from 135 students. Overall satisfaction was ratedat 1.7 (SD=.9). Individual item ratings included effec-tiveness of the large-group presentations (mean=2),small-group sessions (mean=1.47), and teaching activi-ties consistent with stated objectives (mean=1.6). Indi-vidual student comments focused in particular on the

Table 1

Objectives of Pharmaceutical Care Workshops

Objective School

Wisconsin Nebraska• Introduce basic information on medication X X

errors, drug formularies, pharmacy andtherapeutic committees, economics, andwhat formularies mean to prescribers.

• Emphasize an interdisciplinary model X X• Teach beginning third-year medical X

students safe and effective prescriptionwriting.

• Evidence-based medicine skills X• Practice leadership and team skills X

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usefulness of the small-group hands-on experiencecombined with clinically useful material given in thelarge-group session. Some students felt the informa-tion was completely new, not covered elsewhere in thecurriculum, and they asked for more information and abit slower pace. Other comments found the formularymaterial to be less useful, and some were disappointedthat Latin abbreviations were not reviewed and werediscouraged.

At the end of the third year, all students were evalu-ated by a year-end professional skills assessment(YEPSA). The testing station required the students toprescribe an antibiotic for a young woman with com-munity-acquired pneumonia. They were given a drugmonograph on erythromycin and had to write a pre-scription including the patient name, date, drug name,strength, directions, and quantity of medication. Of the148 students tested, 94% received an excellent grade(all seven elements correct), 6% a pass (one elementnot correct). There were no marginal (two elementsincorrect) or failing grades.

University of NebraskaThe workshop at the University of Nebraska was

successful in producing quality drug monographs, lit-erature reviews, and presentations based on the con-sensus judgment of the faculty. In addition, the work-shop led to productive discussions and required the stu-dents to work within a team framework. After criticallyreviewing the monographs and literature during theirrole-play as members of the P&T committee, the stu-dents often voted to reject the product or place the prod-uct on the formulary with restrictions.

Student acceptance of the workshop was generallygood but suffered when compared with other compo-nents of the internal medicine clerkship. Using the scaleof 5 (outstanding) to 1 (unacceptable), 323 studentsevaluated the workshop immediately afterward and thensubsequently at the end of the clerkship. For the work-shop overall, the mean for the immediate evaluationwas 3.8, but the mean for the subsequent evaluationfell to 2.5. Subjective comments ranged from: “excel-lent way to learn” to “not as bad as I thought” to “tootime consuming” (and other less favorable comments)but were probably best summarized by the comment“good idea, wrong time.” The final wrap-up sessionroutinely was evaluated as the most valuable portionof the workshop (4.2) and the initial didactic sessionthe least (3.6).

DiscussionEven though the content of the two pharmacy work-

shops was different, common themes emerged fromboth schools’ experience.

The f irst theme was timing. Timing of the workshopwas very important to the students’ acceptance. The

University of Wisconsin’s workshop occurred imme-diately prior to the students beginning their clinicalclerkships and provided “ just in time” training for use-ful skills—basic prescription writing and using drugformularies. The University of Nebraska’s workshopoccurred during the clinical clerkship. The students atthe University of Nebraska viewed the workshop as anintrusion into clinical medicine and resulted in the Uni-versity of Nebraska subsequently moving the workshopto occur in a time slot similar to the University ofWisconsin’s workshop.

The second theme was relevance. Keeping the work-shops clinically relevant was imperative to the students’acceptance. Both schools emphasized that medicationerrors are responsible for many untoward events. TheUniversity of Wisconsin used examples of the resultsof poor prescription writing. The University of Ne-braska highlighted adverse drug events in patients andstressed the mechanism and the importance of report-ing them. Both schools used local commercial formu-laries and real-world clinical scenarios. Drug bulletins,pharmacy report cards from local insurance companies,and requests from managed pharmaceutical planshelped reinforce the relevance of the workshops.

The third theme was physician leadership, which wascritical at both schools to gaining student acceptanceof the workshops. It was important to have a physicianmodel the value of bringing pharmacists into discus-sions of patient care. The pharmacists proved to be ef-fective teachers and facilitators. A success of the work-shops was the medical students’ appreciation of phar-macists as potential future partners in patient care. Itwas key to have a physician conclude the f inal sessionby relating the issues directly to patient care.

The fourth theme was the students’ preference forinteractive sessions. The P&T committee at the Uni-versity of Nebraska provided a forum to cover specif ictopics. The reading of monographs required the stu-dents to critically review the supporting literature us-ing evidence-based medicine skills. The importance off inancial stewardship was addressed in the formularydiscussions. Once the data had been presented, the stu-dents were not hesitant, based on either the evidence orcost information, to limit a formulary or restrict andrecommend close monitoring of a given product. Anexample was the students’ unwillingness to placesibutramine on the formulary despite the FDA approvalof the product. Regarding the herbals (St John’s Wart,glucosamine, etc), most of the consensus statementsdeveloped by the small groups were neutral, primarilydue to the discussions of inconsistency in the manu-facturing of the product and lack of a proven benefitversus risk. The students enjoyed the review of the“battles worth f ighting,” ie, the discussion of when is itappropriate for a physician to reject or accept a requestfrom a managed pharmaceutical plan.

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ConclusionsThe results/analysis of the workshops included stu-

dent surveys at both schools as well as performancedata on a year-end skills assessment at the Universityof Wisconsin. As new teaching modules, the studentsurveys were initially helpful for formative evaluationand making constructive changes to the modules. Theexcellent grades on the YEPSA prescription-writingstation validated the course content and showed reten-tion of the material. The students received the educa-tional module at the beginning of the year, and the test-ing was done at year-end. During the third year, thestudents received further exposure to prescription writ-ing, but the experiences varied greatly, and the modulewas the only standardized and consistent instructionstudents received.

Corresponding Author: Address correspondence to Dr Keller, 600 High-land Avenue, Room J5/210 CSC, Madison, WI 53706. 608-263-4920.Fax: 608-262-2327. drkeller@wisc.edu.

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