TEACHING

CLINICAL

PHARMACOLOGY

Workshop

on Problem-Based Learning Method for Teaching Clinical Pharmacology and Therapeutics in Medical School

Robert

E. Vestal,

MD,

Chairman,

and

INTRODUCTION

Robert

E. Vestal,

MD

On March 5 through 6, 1989, the Council for Medical Student Education in Clinical Pharmacology,’ which was at that time composed of representatives from the American College of Clinical Pharmacology, the American Society for Clinical Pharmacology and Therapeutics, the American Society for Pharmacology and Experimental Therapeutics, and the Association for Medical School Pharmacology, sponsored a workshop entitled “Strategies for Implementing Clinical Pharmacology and Therapeutics Teaching in Medical Schools” held in Nashville, Tennessee. This workshop brought together more than 40 faculty members from various institutions to discuss obstacles encountered by efforts to change medical From Vestal),

the

Clinical

Veterans

Pharmacology Affairs

Medical

and Center,

Gerontology Boise,

Research Idaho,

and

Unit the

(Dr.

Depart-

of Medicine and Pharmacology (Dr. Vestal), University of Washington, Seattle, Washington; the Departments of Medicine, Psychiatry, and Pharmacy (Dr. Benowitz), and the Division of Clinical Pharmacology and Experimental Therapeutics (Dr. Benowitz), University of Calif ornia San Francisco, San Francisco, California. Contributors include Jean Gray, MD, Departments of Medicine and ments

Pharmacology,

Dalhousie

University,

Halifax,

Nova

Scotia,

Canada;

Stuart M. MacLeod, MD, PhD, Departments of Medicine and Pediatrics, McMaster University, Hamilton, Ontario, Canada; and David Robertson, MD, Departments of Medicine, Pharmacology, and Neurology, Clinical Research Center, Vanderbilt University, Nashville, Tennessee. Presented at , San Francisco, California, March 24, 1990. Sponsored by Council for Medical Student Education in Clinical Pharmacology, the American College of Clinical Pharmacology. American Society for Clinical Pharmacology and Therapeutics, and American Society for Pharmacology and Experimental Therapeutics. Supported by the American College of Clinical Pharmacology, the American Society for Clinical Pharmacology and Therapeutics, and The Burroughs Welcome Fund. Address for reprints: Robert E. Vestal, MD, Research Service (151), VA Medical Center, 500 W. Fort St., Boise, ID 83702.

J CIIn Pharmacol

1992;32:779-797

Neal

L. Benowitz,

MD,

as a

Co-Chairman

school curricula, and to develop consensus for a core curriculum for medical school instruction in clinical pharmacology. The Council approved a consensus document in June 1990.2 The success of this first workshop and the need to explore methods to enhance the teaching of clinical pharmacology in medical schools led to sponsorship by the Council of a second workshop entitled “Problem-Based Learning as a Method for Teaching Clinical Pharmacology and Therapeutics in Medical School,” which was held on March 24, 1990, in San Francisco. This workshop was attended by more than 80 pharmacologists, clinical pharmacologists, and clinical pharmacists who are involved in teaching pharmacology and clinical pharmacology to medical students. What follows are the edited proceedings of that workshop. In view of the success of the previous workshop, the format for this workshop also included plenary sessions with formal presentations by one or more speakers. The keynote speaker was Dr. Stuart MacLeod, Professor of Medicine and Pediatrics and Dean of the Faculty of Health Sciences at McMaster University in Hamilton, Ontario. The title of Dr. MacLeod’s address was “Problem-Based Learning in Pharmacology: Salvation or Subversion?” This was followed by descriptions of two fourth-year elective courses in clinical pharmacology and therapeutics. It must be emphasized that these courses are not examples of problem-based learning, but they offer two different and contrasting approaches to teaching clinical pharmacology in the fourth year. The presentations were made by Dr. Neal Benowitz, Professor of Medicine, Psychiatry, and Pharmacy and Chief of Clinical Pharmacology and Therapeutics at the University of California, San Francisco, and Dr. David Robertson, Professor of Medicine and Pharmacology and Neurology and Director of the Clinical Research Center at Vanderbilt University in Nashville. In the afternoon, Dr. Jean Gray, Professor of Medicine and Pharmacology and

779

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AND

Associate Dean for Postgraduate Medical Education at Dalhousie University in Halifax, Nova Scotia, Canada, spoke on “Criteria for Selection and Evaluation of Good Teaching Cases.” These formal lectures were followed by two informal small group sessions, one in the morning and one in the afternoon. Groups of 20 to 25 attendees were asked to discuss in the first session the “ideal” course in clinical pharmacology in terms of content and teaching methods. The second session was devoted to a discussion of the use of resource materials and the selection of topics and teaching cases for an ideal course in clinical pharmacology. Open questions and discussion followed the lectures and reports from the small groups. In addition syllabus material was provided to each of the attendees. Copies of this material are available on request from the executive directors of the sponsoring societies. A brief summary of the deliberations of this workshop has been published in the Pharmacologist.3 REFERENCES 1. Nierenberg pharmacology

DW: for

Consensus medical

for a core curriculum in clinical students. Clin Pharmacol Ther

1990;48:603-604. 2. Nierenberg DW, Council Clinical Pharmacology and medical students in clinical Pharmacol Ther 1990;48:606-610.

3. Williams

PB, Rangachari

Duckles

SP:

Preparing

based

learning.

your

Pharmacologist

for Medical Therapeutics: pharmacology

PK, Voile students

Student Education A core curriculum and therapeutics.

RL, Brody for

the

90’s:

TM, Use

in for

CIin

Vestai

RE,

of problem-

1991;33:28-30.

PROBLEM-BASED LEARNING IN PHARMACOLOGY: SALVATION OR SUBVERSION? Stuart

M. MacLeod,

MD, PhD

As the Dean of the Faculty of Health Sciences at McMaster University and a practicing clinical pharmacologist for 20 years, I feel uniquely qualified to discuss the subject of problem-based learning and its application to the teaching of optimal drug therapy. Our faculty has been committed to innovation in medical education from its founding in 1965, and we have employed problem-based learning from the outset in an experiment that has attracted the widespread interest of medical educators.”2 I will approach the present topic in a philosophical vein because time and space do not permit many specifics about problem-based learning. One might commence with a recitation of some home truths. First of all is the thought that good students will do well in any system; I believe that to be fundamen-

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BENOWITZ

tally true. It may be that the biggest trick in medical education is simply to select the students who will fit the learning style in your particular institution. When an institution like ours is committed to problem-based learning as the foundation for its entire educational program, it becomes of paramount importance that we select students who will be comfortable with the chosen learning environment. In the end, however, good students prosper in almost any system. My second home truth is one that has been gaining increasing prominence in American medical literature; and that is the dictum that medical schools should abide by a social covenant that obligates them to promote an evolving socially responsive medical practice.3’4 This concept is particularly relevant to clinical pharmacology, a discipline in which most of us have become involved because we accept the notion of a social obligation to promote optimal teaching about drug therapy and about drug toxicity. I wish I could say that all medical educators are meeting that challenge, but it is, unfortunately, my feeling, and not entirely from my perspective as a medical school dean, that we are currently abrogating that responsibility in large measure. The final home truth comes from Senator Hightower, I believe, and that’s the statement that “there ain’t nothin’ in the middle of the road ‘cept yellow lines and dead skunks.” Should you question the relevance of that quotation to problem-based learning in pharmacology, I would suggest that a real interest in problem-based learning requires that you adopt the approach with enthusiasm and extensive commitment, rather than on a piecemeal basis. The argument could be made that all of us in clinical pharmacology are using problem-based learning routinely; most of us relate much of our teaching to case studies and proceed from there. However, an earnest wish to promote problem-based learning requires a great deal of thought, a great deal of preparation, and a great deal of formalization that goes well beyond traditional case-study approach to therapeutics. The text that follows reflects some personal biases about problem-based learning, about innovation in medical education, and about the teaching of clinical pharmacology. McMaster’s medical school is now 20 years old, operating with a total commitment to problem-based learning. The entire undergraduate medical school program is based on this system, and this involvement has extended to the development of a different kind of evaluation that blends harmoniously with the problem-based learning approach. We have totally eschewed formal written examinations at McMaster, with the exception of the final licensing examination that is offered on the

WORKSHOP

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completion of medical school and is, of course, a requirement for licensure in Ontario and other provinces in Canada. Other than that final hurdle, objective evaluation as students progress through the system consists of structured clinical examinations, and something that is peculiar to McMaster, a “triplejump” exercise. Here, the student is presented with a problem and, after a preliminary analysis with the examiner, is sent away to the library or some similar venue for 3 to 4 hours to do appropriate research. The student then returns to the final “jump,” which is a presentation of the case and the therapeutic management to the examiner. These techniques, and a variety of others, allow us to evaluate students as they progress; however, we have no formal examinations, and that, of course, very much changes the culture of the medical school. The other thing that is particularly unusual about McMaster, and certainly would distinguish us from the new pathway program at Harvard, is that our tutorial groups are usually led by non-expert tutors. Although Harvard promotes small group, problem-based learning, an expert tutor is still in attendance even if not always participating as an “expert” in the discussion. Theoretically, at least in the McMaster system, any tutorial problem can be handled by any faculty member. We are quite comfortable in having basic scientists managing later-stage clinical tutorial groups. The tutor in our system is present mainly as a guide to see that the students keep to a reasonable framework as they approach a case problem. Does this system produce distinctive graduates? There is, in fact, quite a bit of evidence that graduates over the last twenty years from the McMaster program are different. For instance, they have a greater interest than normal in academic medicine. Approximately 40% of all our graduates have appointments in a medical school; mostly in Canada, but certainly in other parts of the world as well, including the United States. There is also some evidence that there is a different pattern of practice among McMaster graduates. Those in primary care, who have been most studied, appear to spend about 15% longer with an individual patient than do their counterparts graduating in the same era from other medical schools. There has been an interesting comparison done in the last two years between senior MD students at Southern Illinois University, a problem-based school committed to self-directed learning, and the senior medical students at the University of Manitoba in Winnipeg, which is a relatively traditional Canadian medical school. The test instrument was an objective, structured clinical examination with twenty stations, and it is interesting that the senior medical

TEACHING

CLINICAL

PHARMACOLOGY

AND

THERAPEUTICS

students in the two programs proved to be indistinguishable, so there is at least a suggestion that a selfdirected program does produce senior medical students who have similar capabilities, and similar attitudes and skills, to those found in the products of a more traditional school. Our graduates have been shown to do as well, or better than, their Canadian counterparts on specialty and subspecialty examinations. Certainly, at the end of their postgraduate training, they are very similar to, or better than, other Canadian graduates; however, to be candid, on a knowledge-based examination at the end of medical school, the national licensing examination in Canada, their first-time pass rate is not as good as that observed among graduates of most Canadian medical schools. This may reflect, in part, the fact that we have a highly condensed three-year program, which, in itself, is an innovative phenomenon. I will proceed to the next stage of this philosophic barrage with a few quotations. The first comes from Alfred North Whitehead (1929); “Education is not a process of packing articles in a trunk.”5 This sentiment is particularly relevant to the kinds of concerns we are addressing today. One of the main criticisms of traditional medical education is that we are continually pushing a bewildering volume of facts at students and insisting that they pack these into their overworked brains. It has been suggested that medical education can be compared with the process of learning to drink from a fire hose, and I think this an apt analogy. From the same essay, the Aims of Education,5 in 1929, Alfred North Whitehead said, “In universities I have been much struck by the paralysis of thought induced in pupils by the aimless accumulation of precise knowledge, inert and unutilized.” This was a recurring theme with Whitehead: the idea that we have been promoting inert ideas in the university setting. He urged our forebears to get beyond this to promote the “joy of discovery.” Such a sentiment is very much the essence of problem-based learning as an educational philosophy. Problem-based learning definitely serves to promote the joy of discovery, and this outcome is true not only for the students, but also for the faculty. I hope to convince you of that. Derek Bok has said, “More and more, the United States will have to live by its wits, prospering or declining according to the capacity of the people to develop new ideas, work with sophisticated technology, create new products and imaginative new ways of solving problems. Of all our national assets, a trained intelligence and the capacity for innovation and discovery seem destined to be the most important.”6 It should be noted that problem-solving and prob-

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lem-based learning are not the same thing. In a thoughtful essay, Norman has recently compared the concepts of problem-solving and problem-based learning.7 He makes a convincing argument that what we are discussing as relevant to medical education is problem-based learning. There are unquestionably people who are very good problem-solvers who lack the necessary breadth of knowledge and the necessary integration of their knowledge to permit them to practice medicine effectively. There are some major trends in health professional education now in evidence. For example, we are moving toward an approach that will put a premium on greater flexibility and innovation. In that vein, we should be encouraging a certain amount of iconoclasm in our health professional students. Learning, to be effective, must become increasingly self-directed. It must be recognized that there is room for substantial individualization in the way in which students learn, and it is very important that we find ways of making education a life-long phenomenon, of making it self-renewing. Licenses of various kinds and specialty qualifications are now being given with a time limit so that we will need to prepare our students to be able to renew their qualifications periodically. I perceive this as a major challenge in clinical pharmacology, as it is in other disciplines. Ingenito et al.8 have provided an excellent summary of where we are in clinical pharmacology education, and highlight some of the places we need to go in the immediate future. A small quotation from that article bears consideration: “The adult learner who can self-study and problem-solve will be in the best position to respond to expanding drug information. Self-learning and group-learning will offer the best means of continuing education for clinical pharmacology.” This represents a clarion call for action around an important concept that we may consider further through proposing and attempting to answer a series of questions germane to the issues of problem-based learning of pharmacology. What

Kind

of Doctors

Do We Need

in the

Future?

It appears likely that demand will be relatively limited for the kind of graduates that have been produced in the last two decades. Our future doctors will need to be more adaptable and committed to lifelong learning and maintenance of competence. They will need to be well-versed in skills such as critical appraisal and in clinical epidemiology. An important part of this skill set is technology assessment, and this and related concepts are especially applicable to drugs. We must do a much better job of teaching our students how to handle overwhelming

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BENOWITZ

amounts of information. Clearly, information technology and medical or health informatics will become a standard part of the medical curriculum. There are many related issues that have, as their base for understanding, health economics, and pharmacoeconomics is a field of growing importance. We must prepare our students to make rational judgments, not just in therapeutics, but also in other areas that take into account changing economic realities. What Based

are the Potential Learning?

Advantages

of Problem-

Problem-based learning is extremely adaptable and flexible and, therefore, well suited to use in a rapidly changing environment for medical education. An interesting advantage that may be of more interest to us in Canada is that problem-based learning accommodates linguistic diversity. In a time of increasing internationalization in medicine, this may be important for a variety of reasons. Effective problem-based learning techniques are readily exportable to any part of the world. All that is required is the ability to translate a problem into the language of choice and a tutor who understands the concepts and is able to lead the group in the language of the students. This feature is potentially important as we look at medical educational problems in the developing world. Perhaps the major advantage of problem-based learning, at least from the perspective of a medical school dean, is that this teaching method encourages intellectual excitement and a sense of involvement on the part of students and teachers. There are some essentials, of course, in problembased learning. It must be recognized that problembased learning is soundly based on a hypotheticocognitive system and breaks down if the students do not possess the necessary knowledge to formulate reasonable hypotheses. To use this system, there must be some assurance that students either have the necessary knowledge base, or that they have some way of obtaining that knowledge effectively. There are also related skills that are important, such as critical appraisal and self-directed learning skills. Problem-based learning is not a system that is immediately suitable for every student; however, it is possible for most students to develop the necessary personal qualities during their studies. Many pitfalls can be avoided if the right students are selected in the first instance. Pre-existing knowledge base and skills for acquisition of new knowledge are essential factors in problem-based learning. A tempting smorgasbord of recent knowledge concerning the new biology relevant to pharmacology is now in circulation

WORKSHOP

ON

CLINICAL

PHARMACOLOGY

and ready to be offered to our students. A whimsical and mildly satirical chart recently appeared showing the year-by-year increase in the weight of the cumulated Index Medicus.9 There is an amazing annual increment in the amount of available information, and it should not be necessary to convince you that it is impossible to communicate all of that information to all students or even to identify what constitutes core knowledge. Your acceptance of that premise is essential to serious consideration of innovative educational approaches to basic and clinical pharmacology, therapeutics, and toxicology. What is the Future Medical Education?

of Lecture-Based

Most medical educators now share the view that lectures have little future as the primary vehicle for medical education. Medical schools across North America range from about 1300 hours of lectures given over a medical school curriculum in the most traditional schools, to McMaster, where we have less than 100 hours of formal lectures given over 3 years of medical school. It is very hard to show that the difference between 100 hours and 1300 hours translates into any major difference in the final product; we need to ask whether lectures are, indeed, an effective medium for teaching. Obviously, lectures provide an efficient way of communicating large numbers of facts, but one must accept this outcome as an important objective in medical education to endorse this teaching format. It is not necessary that all schools adopt the nihilistic approach of McMaster, but it is probable that most programs could get by with considerably less than their current lecture complement. Harvard, for example, has gone to, I believe, a maximum of 2 hours per day in the preclinical years. The day begins and ends with a formal lecture given by an expert bringing a new synthesis of the field, or presenting some extraordinary information that could not readily be found in the literature. Such an approach represents a reasonable compromise. Will

Curriculum

Content

Continue

to Change?

We have an obligation to teach about the broader aspects of health. In most of this century, thinking in medical schools has been that health is mainly determined by what happens in the health care system, how we diagnose disease and how we treat it. I would suggest to you that it is very evident, and it has been for a long time, that there are a number of other factors at least as important as the individualized illness-care that we provide, and these would

TEACHING

CLINICAL

PHARMACOLOGY

include

AND

the environment, and a number of social-beh#{228}vioral factors. To teach effectively in clinical pharmacology, or any other medical discipline, oie must adopt an awareness of these other important determinants of health. It is possible to design educational programs that are relevant to a number of these other health priorities. It is important, if we are going to do this, that we recruit, train, and prepare a new generation of educators and facilitators who are able to teach the essence of medical practice in this kind of environment. It is my impression that Schroeder et al.4 are not a voice crying in the wilderness. There is a need for medical schools to become more responsive to societal demands. To do that, we must look to the kinds of teachers that we have and also seek out visionary leadership in education and research. social

such

THERAPEUTICS

things

as nutrition,

support

systems,

genetics,

What Does Pharmacology?

Education

Change

Mean

for Clinical

Clinical pharmacology has a great deal to offer the medical school as an integrating subject in common with other “bridges” such as ethics, genetics, informatics, molecular biology, epidemiology, toxicology, ecology, social sciences, etc. It is my particular bias as a clinical pharmacologist that we are uniquely well positioned to play this new game in medical education because most of us have a foot in several of these cross-disciplinary camps and consequently are able to play a catalytic role in the revamping of medical school curricula. Let us examine some curriculum-relevant issues related directly to drug therapy. Do We have Prescribing?

a Current

Problem

in Drug

This is really a rhetorical question for an audience made up of basic and clinical pharmacologists. I am not totally familiar with the figures in the United States, but I am familiar with the figures in Canada, and they show that drug prescribing costs are growing at the rate of 12 to 15% per year. This figure is well in excess of the growth in the consumer price index, or the growth in the gross national product, or in the growth of population. Obviously, such increases are in excess of increases in costs of other aspects of health care. It might be argued that this all represents appropriate and essential drug therapy, but I do not think any of us really believe that. There is a strong prima facie case for emphasis on the evaluative science that will support appropriate drug prescribing, and this will become an essential part of

783

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clinical pharmacology problem-based approach. Why Should Medical in Quality Assurance?

teaching

Schools

well

suited

to

AND

BENOWITZ

a

to apply critical appraisal to what we are doing in postgraduate training. Many clinical pharmacology educators have routinely used case studies as a way of approaching problem-based teaching. In that context, there are particular opportunities to be derived from the use of medicolegal cases. Such cases have the added advantage of immediacy in that there is usually some intriguing court challenge. A good example is the Libby Zion case.1#{176}Of course, we are familiar with this as the case that led to the debate about hours of work for residents in teaching hospitals. It may be forgotten that Libby Zion, on the day she presented to the emergency department, was on a formidable array of drugs, including pheneizine, oxycodone, erythromycin, chiorpheniramine, imipramine, oxazepam, diazepam, tetracycline, and doxycycline. She was receiving these either at the time she presented, or had been taking them in the few days beforehand. She had a history of frequent marijuana use, and in hospital she was given meperidine, haloperidol, and acetaminophen. Postmortem, there was also some debatable evidence of recent cocaine use. Somehow this medical saga was oversimplified in the courts as a case of what a resident might do wrong because of fatigue. Instead, one should have questioned the responsibility of the medical schools who trained the physicians who prescribed this array of drugs; or queried the preparation of the resident to recognize the potential hazards of giving meperidine to a patient who was on phenelzine. A case of this kind may be built rather easily into a 2- or 3-hour problem-based tutorial in clinical pharmacology, therapeutics, and toxicology.

Be Interested

We have ample evidence of inappropriate care; furthermore, we know from a variety of studies that there is wide variation from place to place in practice patterns, indicating that we have not been very good at defining standards of practice. In the background are economic pressures in the health care system: we cannot fund what has been called surplus health care activity and expect to have money left over at the end of the day to support more worthwhile enterprises, including research and improved educational approaches. I am sure that none of us doubt that if one applied an “inappropriate/appropriate” label to drug therapy as practiced in the United States or Canada we would find 30 to 40% at least that would be deemed “inappropriate.” As educators, we must find ways of addressing that situation and of teaching our students to apply reasonable criteria of “appropriate” and “inappropriate” to therapy with the ultimate objective of evolving practice guidelines for drug therapy. Problem-based learning is likely to prove a good way of approaching that question, provided that students are encouraged to develop parallel skills in critical appraisal. -

-

Is Improved

Education

a Part

to Our Drug Prescribing

of the

Solution

Problem?

There are many things that we can teach in medical school that will help our graduates to be better prescribers. In addition to teaching them about individual curative care, we must teach them something about population health concepts. We must prepare them for advocacy in relation to better drug therapy and better use of technology. They will need to be effective managers. Some will become educators. Some will be research scientists. Some, ideally, will become social scientists. I think there is a role for pharmacology and clinical pharmacology educators in health policy analysis, and certainly in innovation as it relates to therapy and care as well as to medical education. The use of problem-based learning with respect to drug therapy should, in my view, extend to the training of interns and residents. It is my belief that our postgraduate training programs are, perhaps, more lacking than even our undergraduate programs in this respect. I think that the real challenge for those of us responsible for those programs is to learn

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CONCLUSION In 1929, Alfred North Whitehead wrote: “Students are alive, and the purpose of education is to stimulate and guide their self-development. Teachers should be alive with living thoughts, should protest against dead knowledge, against inert ideas.”5 This was a popular theme with Whitehead, the danger of the inert idea, the importance of promoting the joy of discovery. Perhaps this is an appropriate concluding thought, which underscores the attraction of problem-based learning as a way of revitalizing medical education programs. It will bring a new sense of purpose to your faculty, and I guarantee you that your students will thank you for it. REFERENCES 1. Spaulding cal School;

1991.

WB: Revitalizing The Early Years

Medical 1965-1974.

Education: McMasterMediPhiladelphia: BC Decker,

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ON

CLINICAL

PHARMACOLOGY

2. Neufeld yR Woodward CA, MacLeod SM. The McMaster MD Program: A case study of renewal in medical education. Acad Med 1989; 64:423-432. 3. Colloton )W: Academic medicine’s changing covenant with society. Acad Med 1989; 64:55-60. 4. Schroeder SA, Zones JS, Showstack JA: Academic a public trust. JAMA 1989; 262:803-812. 5. Whitehead AN: The Aims of Education and Other York: MacMillan, 1929. 6. Bok 13: Higher Press, 1986. 7. Norman problem-based 8. Ingenito pharmacology: 6. 9. Madlon-Kay N EngI J Med

10.

Sounding

Learning.

Cambridge.

MA:

Harvard

medicine Essays.

as New

University

CR:

Problem-solving skills, solving problems and learning. Med Educ 1988; 22:279-286. AJ, Lathers CM, Burford HJ: Instruction in clinical Changes in the wind. J Clin Pharmacol 1989; 29:1DJ: The weight 1989; 321:908. Board:

The

of medical

Libby

Zion

knowledge case.

N EngI

still gaining.

J Med

1988;

318:771-775.

A CASE-ORIENTED IN THERAPEUTICS OF CALIFORNIA, Neal

L Benowitz,

COURSE AT THE UNIVERSITY SAN FRANCISCO MD

I will describe the clinical therapeutics course at the University of California, San Francisco, as an example of a course using a case-oriented, seminar format. This will contrast to the course that will be described by David Robertson, in which a large group lecture format has been successfully developed. The University of California, San Francisco, course in therapeutics is offered as an elective within the Department of Medicine in the clinical years. The department offers a series of “pathophysiology courses,” through which students can spend 1 or 2 months during their third or fourth years intensively studying one specialty area. For example, there are courses in cardiology, endocrinology, nephrology, etc. Our “pathophysiology” course is called “clinical therapeutics.” The students are primarily fourth-year students, who spend 4 weeks full-time with us. The course is held in the winter or spring, so it is one of the last courses taken by the students in medical school. Because of the seminar nature of the course, we have limited enrollment to 35 students. The small class size is a problem. Many more students would like to take the course but cannot because of space limitations. Teaching is conducted using a case-oriented approach. The faculty are largely faculty of internal medicine who are selected because they are both good teachers and good clinicians. Sessions on principles of therapeutics are taught by faculty and fellows

TEACHING

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PHARMACOLOGY

AND

THERAPEUTICS

who have been trained also in clinical pharmacology. The philosophy of the course is that the students should learn to appreciate the thinking processes of an expert practitioner-therapist. The goals of the course as presented to the faculty and students are as follows: We would like the students (1) to develop a systematic approach to patient therapy, (2) to develop specific skills in constructing and executing a plan of treatment, and (3) to develop a critical attitude and objective approach concerning the efficacy of individual therapeutic maneuvers as part of an overall treatment plan. The students are taught that good therapeutics involves a sequence of logical steps and decisions that result in a therapeutic plan. The faculty are asked to try to communicate their thinking and decision-making processes as they analyze the cases with the students. Some faculty can do so quite well; some cannot. The specific approach to therapeutics is presented to students and faculty as a series of steps: 1. Establish a Understand 3. Choose the cology and 4. Understand points. 5. Individualize characteristics concomitant etc. 6. Assess the appropriately 7. Weigh risks and during 2.

working diagnosis. the pathophysiology of the disease. best drug, based on matching pharmapathophysiology. and set therapeutic (and toxic) endtreatment, based on individual including age, gender, presence of use of other drugs, diseases status, results in therapy and modify therapy to achieve the desired end-point. and benefits of therapy, both before therapy.

A common problem we have with our faculty is a. tendency to overemphasize steps 1 and 2 of the approach to therapeutics as described above. Many faculty prefer to spend their time discussing diagnosis and pathophysiology, with only a brief discussion of therapeutics. Some faculty say that students do not understand pathophysiology so, therefore, we cannot teach them therapeutics. At the same time, the students complain that they have heard pathophysiology discussed many times and want at this point to learn about therapeutics. With appropriate feedback from the course organizer to the faculty, most of them are able to modify their presentations to provide the appropriate balance between diagnostics, pathophysiology, and therapeutics. Table I summarizes the topics that are covered in the course. There are 13 sessions in general clinical pharmacology that deal with pharmacokinetics, therapeutic drug monitoring, drug interactions, etc. The

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TABLE Clinical

Therapeutics

Course,

1990

Workshop

(2)

Therapeutic Drug Monitoring Monitoring of Aminoglycosides Drug Allergy/Anaphylaxis Drug Interactions (2) Rational Drug Use in Pediatrics Drugs in the Elderly Decision Making on Risks and

Benefits

of Chronic

Drug

with

Angina

Hematology

I

(2)

Therapy Renal Failure

and

Chronic

Obstructive

Patients

Gases (2) Lung

Disease

(2 hours)

Anticoagulation Rational Use of Blood Dermatology (2 hours) Drug-Induced Skin Rational Dermatologic

Products

Disorders Therapy

Glucocorticoids Cancer (2 hours) Principles of Cancer Chemotherapy Medical Treatment of Common Cancers

1 hour unless indicated

in parentheses.

effectiveness of these sessions seems to be proportional to how clinically relevant they are perceived to be by the students. If the students are given a theoretical lecture on pharmacokinetics, the students complain about the material as not being useful. But if a clinician presents a case in which a patient has gotten into trouble as a result of a failure to consider pharmacokinetic principles, or if the optimal management of a patient requires consideration of pharmacokinetics, the students think that learning pharmacokinetics is worth their time. To give a flavor of the seminar format, I present one case that is used and describe how it is discussed.

786

Patients

Arthritis/Gout

Pulmonary (3 hours) Respiratory Failure/Ventilators/Blood Asthma

(2)

Lipid Disorders

are allocated

Vomiting

(3 hours)

Renal (2 hours) Fluid and Electrolyte Acute and Chronic

Thyroid Disorders Parenteral Nutrition

All topics

Neurology

Inflammatory

Pneumonia

(2) Therapy

Francisco)

Rheumatology/Analgesic (3 hours) Management of Pain (2)

(2)

Antiviral Therapy Outpatient Infections Infections in Immunocompromised Endocrine/Metabolic (6 hours) Diabetes Rational

San

Headache Parkinsonism

Learning About New Drugs Cardiovascular (11 hours) Shock

Infectious Disease (7 hours) Principles of Antibiotic Therapy Sepsis

of California,

Seizures

Food and Drug Administration

Cardiac Failure (2) Ventricular Arrhythmias Supraventricular Arrhythmias Arrhythmia Workshop Angina Pectoris Myocardial Infarction/Unstable Pharmacology of CPR

(UniversIty

Psychiatry/Substance Abuse (4 hours) Psychiatric Pharmacotherapy in Medical Drug Abuse (2)

Therapy

Hypertension

I

Gastrointestinal/Liver Disease (4 hours) Management of Diarrhea, Constipation, Peptic Ulcer Disease Liver Disease Inflammatory Bowel Disease

General Clinical Pharmacology (13 hours) Introduction to Clinical Pharmacology

Pharmacokinetics

BENOWITZ

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A 27-year-old white man presents to your office with a blood pressure of 150/95 mm Hg. He has been generally healthy, drinks several cocktails per day but does not smoke cigarettes, and has no family history of hypertension. His cholesterol is 220 mg/dL; his fasting blood glucose is 90 mg/dL. Chest x-ray and electrocardiogram are normal. Echocardiogram shows increased left ventricular wall thickness. This case is intended to introduce the students to the evaluation presentation and management of mild hypertension. A series of questions are posed to the students, to individual students first and then to the group. The questions include: (1) Is the patient

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hypertensive? We discuss how the presence of hypertension is established. (2) What is the pathophysiologic disturbance? We discuss the hemodynamics of mild hypertension. (3) What is the goal of treatment? We review some of the trials of treatment of mild hypertension and discuss how one decides which mildly hypertensive patients need treatment and which do not. (4) What sort of therapy? We discuss dietary recommendations, life-style changes, and then pharmacologic therapy. (5) How does the drug work? As the students mention various drugs that might be selected for use in this case, we talk about the pharmacology of the drug and making decisions as to which drug is expected to work best for particular types of hypertension. We also discuss side effects and risks versus benefits for particular drugs. (6) How will the effectiveness of treatment be monitored? We discuss how to monitor effectiveness and to set up end points both for therapeutic benefit and toxicity. (7) How much drug will you give? We discuss dose-response relationships, both for therapeutic and toxic effects. As an example, we discuss the dose-dependence of efficacy and toxicity of thiazide diuretics and how selection of the dose might influence the overall balance between benefits versus risks. (8) For how long should the patient be treated? We discuss the issue of whether mild hypertension is a lifelong disease. We discuss recent papers that indicate that after a period of successful treatment, particularly when there has been a modification of life-style, weight loss, etc., some patients remain normotensive when medications are stopped. Thus in some cases, lifelong therapy may not be required for all patients. (9) Warning to patients. We discuss how to talk to a patient about drugs and about hypertension in general. Discussion of this one case on mild hypertension would take an hour. For other topics, such as drug interactions, rather than a detailed analysis of one case, I present 12 different brief cases and we discuss the pathophysiology of drug interactions and strategies for anticipating and avoiding adverse drug reactions. As is a problem in many medical school courses, we do not have a formal way to evaluate how well the students have achieved the objectives of the course. We do, however, administer a final examination. Most students and faculty dislike final examinations. Our examination is primarily an educational exercise, however, with no individual grades, and is liked by the students. The examination is less work for the faculty as well because the questions for the final examination are written by the students as one of their course assignments. Each student is assigned to prepare examination questions on two topics. Each question is to be based on a case vignette and to

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have multiple choice answers. In addition, a referenced rationale for their answer must be included. After these cases are submitted to me, I send them to the faculty person who gave the lecture for comments. I use questions written by the previous year’s students for the current year’s final examination. The examination consists of 30 questions and is graded, but the grades are not connected to individual students. The students enjoy the examination because immediately afterwards, we go over each question in detail so that students receive direct feedback on their performance. The final examination also provides me a little information on how well the students have learned some of the factual material, although it is unclear how well learning such material translates into improved therapeutics. At the end of the course, students are asked to evaluate individual instructors and the course as a whole. The students are asked to rate various items on a 0 to 5 scale. In response to questions on how successful was the course in meeting specific objectives, we obtained the following student evaluations last year: “To develop a systematic approach to therapy,” 4.98; “skills in developing and evaluating a planned treatment,” 4.09; “a critical attitude and objective approach concerning the efficacy of individual therapeutic maneuvers as part of an overall treatment plan,” 4.22. Considering that these are senior medical students who are in general highly critical of everything having to do with formal medical school education, our course performs very well. Several students have stated that the therapeutics course is the best course they had in medical school. This is gratifying because it is the perception of many faculty that fourth-year students at the end of their final year are refractory to education. Our experience suggests that a practical course in clinical pharmacology and therapeutics is something that medical students really do want and, it is hoped, profit from taking (Table I).

A COURSE

IN THERAPEUTICS

AT VANDERBILT David

Robertson,

UNIVERSITY,

NASHVILLE

MD

Vanderbilt University and its antecedent, the University of Nashville, based their medical instruction on the didactic model until 1895, when Chancellor James H. Kirkland, impressed by the new laboratory emphasis at Johns Hopkins, greatly reduced the five daily hour-long lectures to a combination of classroom recitation supplemented by laboratory exercises. Materia Medico was taught to second-year students. In 1914, Materio Medica was divided into

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two courses, Pharmacology, which treated the general principles of drugs and laboratory demonstrations of their effects, and Therapeutics, which we would now term “clinical pharmacology.” Both were taught to preclinical students. In 1925, with the advent of G. Canby Robinson as Dean of Vanderbilt Medical School, the Hopkins model and the recommendations of the Flexner report were completely adopted by our institution, and pharmacology teaching, confined essentially to the second year, remained largely unchanged until 1979. Immediately before 1979, our curriculum was still very similar to that of most other medical schools in the United States, with anatomy, physiology, and biochemistry in the first year; pathology, pharmacology, and microbiology in the second year; inpatient care in the third year, and outpatient/inpatient care in the fourth year. Year I was 90% lecture based and year 2 was only slightly less. In years 3 and 4, however, lectures became vestigial, largely in response to student sentiment in the 1960s that the clinical sciences were most productively inculcated by patient-oriented instruction. This perception on the part of Vanderbilt students had changed by the late 1970s, when they began to feel a need for additional formal lectures. Indeed, the initial impetus to develop a new course in the fourth year emanated from the students. In 1978, Drs. Grant W. Liddle, John A. Oates, and I decided to pursue a new approach in teaching fourth-year students. We thought that our students needed a formal learning opportunity after they had both clinical experience and basic pharmacology. We did not call this course “Clinical Pharmacology,” but rather Clinical Management. There were several reasons for this. First, we believed that some of the issues relating to, for example, a cholecystectomy were really rather similar to issues surrounding the digitalizing of a patient; we really believed that surgical therapeutics-and perhaps even psychotherapy-might belong in such a course. Second, we thought that it would be good to have some of the nonmedical therapists, to teach their disciplines within the frame of reference of clinical investigators and in the presence of people likely to be quite critical of techniques. We thought that the environment of this course would limit any tendency to teach on the basis of testimonial rather than on the basis of careful analysis of clinical studies. We believed that participation in this course might encourage such individuals to teach in a slightly different way. Although I think the nonmedical therapists were doing a good job, I do believe that this course resulted in improvement in terms of nonmedical therapy teaching in our institution. We also thought that exposing

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nonmedical departments to the approaches of clinical pharmacology had an advantage apart from that in terms of their own research as well. The course as I conceived of it in 1978 was to be targeted to fourth-year students, was to be 1 month in duration, and was to be full-time. It should be an elective because if students were required to come, we believed we would never really know if we were succeeding. Finally, perhaps our most important innovation was the use of the short lecture. As I student, I always thought I learned a lot more in the first half of the hour lectures than in the last half. And so with this course, it was decided that there would be no last half of the lecture; we would just have the first half and see how that worked. One thing this did was require all teachers to review their lecture notes and recognize that they could not impart everything about their topic in that period. It also enabled them, I think, to improve their handout materials, and to use their brief time slot to challenge the students to go out and learn more. We left wide latitude for the instructors to use the case study approach or whatever approach best suited them; and I might say, we were very eclectic about it; we were really willing to accept a great many teaching styles. We thought it wise to use local building materials. Some teachers preferred to give a lecture, a straightforward lecture for 35 minutes; some people can do that very well and be spellbinding; others really like to come out among the students and talk to them using more of a case study approach, with Socratic give-and-take. There were five areas that we thought needed special attention, and we developed workshop activities in those. These included pharmacokinetics, respiratory support (including the use of a respirator), resuscitation (we spend a lot of time on this), and then, because we thought that young house officers are not as good with chronic as with acute illnesses, we have workshops on two chronic diseases, diabetes mellitus and arthritis. Finally, at the end of the course, we have a rigorous course evaluation and course pruning by the students. Students are asked to rate each lecturer and each lecturer’s handout. They also are asked many other things: what other topics should be covered, what topics should be left off in the next year, and other such questions. Over the years, we have made great changes in the faculty, based largely but not entirely on student recommendations. In starting this course, we employed primarily clinical pharmacology faculty, and I gave a large number of the lectures myself, but as the years have gone by, we have brought in more and more other clinical investigators; so in 1990, the only thing one has to do to be a lecturer in this course is be an active investigator in our Clinical Research Center. Of

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course, to continue to be a lecturer, it must be the opinion of most of the students and the course director that what one is saying and doing is worthwhile. This course finally got underway in 1980, and 32% of our students elected to take it. Consequently, that number rose rapidly, and by about 1983, we had just about as near a complete subscription as one can reasonably expect a lecture course to garner; and then in the mid-1980s, we began to get visitors from other institutions-most recently in 1990, we had 24 students from other medical schools who came to Vanderbilt in February to take this course. Some things happened as this course has developed over the past 10 years that I did not really foresee. One thing is that it has developed a social function. It is given in February of the senior year-the students are about 4 months from being interns, at which time many of them will never see each other again or, at least, not for a long time. Furthermore, for about a year and a half, they have been scattered over various rotations in small groups-in some cases, in different hospitals, and most recently just before the course, they have been traveling around the country looking at different house staff programs. So they are all together again for the first time in more than a year, and-in terms of extended daily contact-also for the last time, and there is, I think because of that, perhaps a sense of nostalgia that contributes to their enthusiasm to take the course. It is also a time when they are anxiously waiting for internship and commiserating with each other about it. They have made their internship choices, but now they are waiting to hear where they will be on July 1. There also have been effects on our faculty. Faculty teaching has been more concise and up-to-date. The idea of brief lectures has begun to go out and appear in other courses at Vanderbilt. We surveyed f’or the first 5 years all students and asked which they preferred-the short lecture time or the traditional hour lecture, and in all those 5 years, there was not one student who believed the traditional hour lecture was preferable to the shorter lecture format. Handout materials have improved a great deal. So, that fire hose that Dean MacLeod was talking about earlier is a little smaller than it was before. At least the students know what we think is important and we do not throw them without guidance into an ocean of facts. Finally, because of the success of the course, instructors often volunteer, unlike the early days when I had to ask and got many people to turn down teaching roles in this course. After 3 postgraduate years, we surveyed one group of house officers in the mid-i 980s as to what course at Vanderbilt helped them the most in their medical

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AND

THERAPEUTICS

practice. They seemed quite pleased with their educational experience at Vanderbilt in general, but I was happy to note that this course was chosen by more house officers as their best experience than any other medical school course. There are, however, in this course, some promises unfulfilled, and they are unfulfilled for various reasons. One unfulfilled promise is that we have not been able to divide the class up into smaller groups as often as we would like to do it. That is an area that we need to work on in the near future. The second unfulfilled promise is that we do not employ computers yet in this course. Our third unfulfilled promise is our lack of problem-based learning that emphasizes student-student interactions. On balance, however, our use of the brief lecture format represents, I think, an important didactic advance that deserves much more widespread use in the medical curriculum at Vanderbilt and other medical centers. For those who are interested in learning more about our course, a detailed description was published in the Journal of Clinical Pharmacology.’ DISCUSSION Dr. Vestal: I’d like to say to both David and Neal that I think their descriptions represent rather inspirational examples of very successful, but quite different, courses in their respective medical schools and they certainly give all of us some ideas. Dr. Theo van der Hoeven (Albany Medical College): What is the role of the basic scientist in the courses in clinical pharmacology? Can you elaborate, perhaps starting with Vanderbilt? Dr. Robertson: Most of the lecturers in our course at Vanderbilt are physicians because we invite people who are active investigators in the Clinical Research Center. There are, however, some basic scientists who do clinical research at Vanderbilt. They are invited to teach and often do a very good job. Dr. Benowitz: In our course at UCSF, there are currently no basic scientists teaching. We have had some, and the problems were that they were not comfortable dealing with the therapeutic thinking process that the students wanted and that we were trying to communicate through the course. At present, all of our faculty with one or two exceptions are clinicians who actively care for patients. Dr. Juan Lertora (Tulane University): Regarding the participation by basic science faculty, something that has worked very well at Tulane is a workshop or round table format, in which basic scientists and clinical scientists participate jointly in discussions of clinically relevant topics. Dr. John Wilson (LSU Medical Center): It is extraor-

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dinary that people who have discussed the courses this morning have been able to make so much progress in the integrated teaching of clinical pharmacology. The importance of including in such courses discussions of drug therapy for special patients or conditions, such as the elderly, children, mental illness, and pregnancy, should be emphasized. Dr. Lertora: Dr. Robertson, I was impressed by the percentage of the senior class that register for your elective. How is your attendance in the course during the month that course is offered? How many students elect not to take your course? Dr. Robertson: The attendance on any given day is about 85%. That’s generally higher than the required courses. With about 90% or so of the senior class enrolled, there are only about six or seven students per year who do not take it. Dr. Addison Taylor (Baylor College of Medicine): The two very successful courses described by Drs. Benowitz and Robertson contain different proportions of clinical case material, didactic lectures, and so forth. I would like to ask Dean MacLeod if there’s any experience with admixing the patient-oriented, problem-solving approach as it is done in its entirety at McMaster with a more traditional, didactic type of approach. Dr. MacLeod: There are relatively few lectures at McMaster. Tutors, but not students, have crib sheets that outline the learning issues that can be addressed during the study of particular clinical problems. The crib sheets only serve to help the tutor better guide the students and to assure that most of the high points are mentioned during the course of the tutorial. Incidentally, an average problem would take 4 to 6 hours to discuss. Dr. George Sweeney (McMaster University): Although the courses at UCSF and Vanderbilt are clearly excellent and well received by students, such courses would not be allowed at McMaster. We believe that our mandate is to produce physicians who can prepare and learn material for themselves with guidance as needed. They have to gain this independence because they will soon go out into the world where the course is no longer available to them. Dr. Robertson: I have no personal experience with the McMaster approach, but some of our other courses are experimenting with a similar format. We must not be stampeded into uncritical acceptance of nontraditional teaching modes, such as problembased learning, especially if they become exclusionist and seek to “ban” traditional modes that have served us well for centuries. Dr. William Elliot (University of Chicago): I am amazed at the similarity between Dr. Robertson’s course and the one that we have been running in

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BENOWITZ

Chicago since 1984-quite independently, I should say. We were successful in getting 94% of the people registered for this year’s course. Someone has accused me of merely pandering to the students because we pay a lot of attention to the feedback that we get and trim our lectures accordingly. Many peopie on the faculty-including, in fact, the Dean at our institution-have also told me that it is wonderful that we can get the students to sign up for this sort of thing. They insist that we need to establish the relevance and importance of this course in some objective way, however, showing that we are actually doing something useful besides getting the folks to sign up. As David Nierenberg has shown at Dartmouth, National Board scores may be a good measure of the impact of our course on students’ fund of knowledge and clinical judgment. Dr. Robertson: There has not been a noticeable increase in the National Board scores of Vanderbilt students since the inception of our course because scores have always been good. So it may be hard for us to really know the impact of a course like ours. Looking back I believe that my’ judgments as a student were pretty good and I do take opinions of the current students seriously. Dr. Fred Aoki (University of Manitoba): I want to echo the same sentiment. One of the big challenges is to improve the techniques for teaching clinical pharmacology, but we have to measure the impact on the practice patterns of our graduates. I remain skeptical about the effects of the very facultyand time-intensive McMaster approach compared with a more traditional approach. Dr. Benowitz: Even with our course, faculty time is a problem. We need 39 faculty to teach the 35 students who enroll on a first-come-first-serve basis. We need to find ways to reach more students. We have been requested to hold a second month-long course each year, but it is an enormous amount of work and I just cannot do it twice a year. Dr. David Nierenberg (Dartmouth Medical School): Dr. McLeod, some of us are at schools that are in a traditional mode and we would like to take steps toward a more problem-oriented learning mode. When we try to bring this up to course chairmen or curriculum committees, the two most common responses are: (1) Lecture formats are much more efficient in terms of the number of person-hours of time of the faculty. If you have 100 students in your class, you only have to devote one faculty member per 100 students, whereas if you divide up into groups of six or eight, many more faculty are required. (2) If the faculty member is a facilitator, that faculty member can facilitate discussions in areas far removed from his area of research expertise. If the faculty member is a

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lecturer, however, he believes he can only lecture in two or three areas in which he does his research or clinical work. I wonder how you dealt with a faculty that basically says,”No, we can’t spend more time, and even if we could, we do not dare move into areas removed from where we feel comfortable.” Dr. MacLeod: The question of efficiency is really a tough one to address. Actually, the amount of formal contact with faculty members in our system is not that great even though it is organized around small group tutorial sessions. The way that works out is that in an average week, the students would spend about 5 hours with a tutor in their formal tutorial sessions and maybe an equal amount of time with a clinical skills preceptor, again in a small group session or in a clinical skills teaching laboratory. If you add it all up and you factor in that we run a 3-year program, our use of faculty time is not much greater than that in traditional schools. Of course, the clinical clerkships and the postgraduate training are very similar to what they are in other institutions. The other question is more difficult to answer. How does the tutorial leader as a facilitator handle the digressions off into other territories? We do that mainly through the provision of an extensive list of resource people surrounding any given problem, so that although we do not expect the tutor to be an expert, we do expect the tutor to recognize an opportunity for some learning to go on and to direct the students off to meet with the resource person, be it in pathology or in a basic science laboratory or whatever. That, in turn, leads to an informal demand on faculty time that could be considerable and that is very difficult to quantify. It probably works better in the Canadian health care system, where our incomes are not so closely tied to volume of patient activity. REFERENCE 1. Robertson D: Role of the teaching clinical management.!

CRITERIA

FOR

EVALUATION Jean

Gray,

general clinical Gun Pharmacol

SELECTION OF

GOOD

research 1991;

center 31:691-696.

in

AND TEACHING

CASES

MD

Meaningful teaching material that instructs students in clinical pharmacology is not plentiful. Before this workshop, the American Society of Clinical Pharmacology and Therapeutics decided to develop a catalogue of teaching aids available for clinical pharmacology instruction in North America. Letters were sent to all heads of basic science pharmacology departments in North America as well as to all pro-

TEACHING

CLINICAL

PHARMACOLOGY

AND

THERAPEUTICS

gram directors for residency or fellowship training programs in clinical pharmacology. About 60 answers were received (after much coaxing), and about 40 institutions had some sort of material they were prepared to share. The catalogue is now available from the American Society for Clinical Pharmacaology and Therapeutics office for those who wish more information. Based on careful study of these submissions, seven criteria for a good teaching aid in clinical pharmacology were developed. The remainder of this paper develops these criteria with appropriate examples. In some instances, the examples are too lengthy for inclusion, but contact with the appropriate medical school will enable the reader to obtain not only the specific example cited, but also other cases and experience not provided here. The following principles appear to characterize successful learning experiences: 1. Establish your objectives. 2. Make sure the clinical situation presented is realistic. 3. Use “therapeutic” problems, not “diagnostic” problems. 4. Incorporate decision making, not just recall. 5. Allow students to learn from other peoples’ mistakes. 6. Incorporate skills, not just knowledge. 7. Use good evaluation tools.

At my own university, we do not believe that clinical pharmacology is a discipline “stuck on at the end of the curriculum,” when the student has already acquired many bad habits, but rather one in which the student should be immersed from the beginning of his or her medical school career. With this in mind, our clinical pharmacology staff work very closely with the basic scientists who teach the second-year pharmacology course. We also provide a clinical correlation problem at the end of each subsection in the basic course. For example, at the end of the series of lectures on autonomic pharmacology, we use a case study from the laboratory of Dr. David Robertson previously published in the New England Journal of Medicine.1 The students are presented with the case report and all the laboratory investigations, but they are responsible for writing the discussion section of the paper. The objectives of this exercise are to reinforce the knowledge acquired in the lectures on autonomic pharmacology, as well as to demonstrate the clinical relevance of the basic material. Discussion occurs in small group sessions led by basic scientists. The students are expected to review the case, to understand why the tests are done, and to arrive at their own conclusions. We provide “prep-

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Case: A 56-year-old female who was previously well arrives at the Emergency Department complaining of a thumping sensation in her chest and fatigue of several hours duration. On physical examination her heart rate was 180 per minute and irregular, blood pressure 100/62 mm Hg, there was no sign of heart failure. A 12-lead EKG showed rapid atnal fibrillation. At this time, the patient was in moderately severe distress. Questions: 1. Write the admission

orders treatment

for this patient. have been different

if this patient had presented with the above story, together with prolonged chest pain and signs of myocardial ischemia on the EKG? 3. Which drug would you select for long-term therapy, and write a discharge prescription for this agent. 4. If the patient is sent home on drug treatment and returns with the same arrhythmia with a rate of 1 60/mm, what do you suspect is happening? Is there any test that would be helpful to confirm your suspicions? What measures would you take to control the heart rate or return it to normal sinus rhythm? 2. How

Figure

would

1. Make

sure

your

the clinical

situation

presented

is realistic

(University

aration” sheets for the faculty and, at the end of each session, the same sheets for the students. More and more of the students are now able to identify the paper (which is presented to them without the name of the journal or date) by searching Medline, a skill they learn in their first year of medical school. This is a desirable reinforcement of this skill, so the efforts are not discouraged. The second important principle is that the clinical situation used in teaching must be realistic. In reviewing the teaching aids available in North America, it quickly became obvious that there is a great deal of contrived material used by faculty teaching clinical pharmacology. But students are more satisfied with cases that reflect “the real world.” One example selected to illustrate this principle comes from the University of Toronto (Figure 1). After the case are several questions that take the student through

Case: A 52-year-old thrombophlebitis. is 1800

of Toronto).

both the acute management of atrial fibrillation and the long-term treatment and follow-up. As well, the student is instructed to actually write the appropriate prescriptions, enabling the instructor to reinforce a skill as well as the knowledge required. Many schools submitted material (my own included) that force the student to spend a lot of valuable time arriving at the diagnosis, rather than concentrating on the treatment. So the third principle involved in choosing good cases has to be that the case must NOT concentrate on diagnostic methods. Clinical cases designed to study the use of antibiotics often spend far too much time on diagnosing the clinical infectious disease. One particularly good example, however, of a case involving antibiotic management of septic thrombophlebitis was provided by Stritch School of Medicine at Loyola University (Figure 2). Here is an excellent opportunity to guide the

70-kg man in the ICU is being treated with vancomycin and gentamicin for IV-catheter induced septic His creatinine has risen from 1.1 mg/dl on day 4 to 2.3 mg/dl on day 6 to 4.0 mg/dI on day 8. Urine output

cc over the last 24 hours.

Ultrasound

shows

no obstruction.

Questions: 1. What is the cause of renal failure? 2. What part of the kidney is involved in aminoglycoside-induced nephrotoxicity? 3. Is the unne output of 1800 cc per day typical of aminoglycoside nephrotoxicity? 4. Are some aminoglycosides more nephrotoxic than others? 5. What are the risk factors for aminoglycoside nephrotoxicity? 6. How frequently do patients on gentamicin experience nephrotoxicity? 7. How do we monitor for aminoglycoside-induced nephrotoxicity?

8. Besides

ototoxicity

Figure 2. Try to avoid Center).

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and nephrotoxicity, that

require

1992;32:779-797

the student

are there other toxic manifestations to make

the diagnosis,

almost

excluding

of aminoglycoside the therapeutics

toxicity? (Loyola

University

Medical

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Case: Lois Lane is a perennially

31-year-old newspaper reporter who visits you reporting of a painful swelling of her right calf x 15 hours, which has developed during the last few hours of her long drive back to Metropolis from California in her Porsche. She was disappointed to learn that her venogram was positive, and that she now requires anticoagulation. Write orders to get the process started, including the time and test you want to have drawn by the floor nurses. Please also include an order for starting her coumadin 5 days hence, so you won’t forget it then. Three months after stopping warfann therapy, she returns to you complaining of postprandial midabdominal pain, relieved temporarily by Perry White’s Maalox, but she “hates the taste and inconvenience of chalk.” She claims to be under great stress, both at work and in her love life. Her UGIS shows a 2 cm duodenal erosion. Suggest a regimen designed for maximal compliance and ulcer healing. Success? She reports back to you in 8 weeks saying that her pain is much improved, as is her love life. She asks you for birth control pills, as she has a “super date” in 3 weeks. She currently smokes 2 packs/day, has a cholesterol of 126 mg/dI, and migraine headaches x 14 years. What would you recommend? Figure

3. Provide

cases

that

incorporate

decision-making,

not sure

factual

student through the monitoring process for antibiotics as well as to consider antibiotic-induced nephrotoxicity. Many excellent examples of cases that stimulate decision-making rather than just knowledge recall are present in the catalogued material. One particular set from the University of Chicago involved the use of humor as well as decision making (Figure 3). For this reason, I am sure the students thoroughly enjoyed working through this material, learning all the while. Woven through the cases are drug interactions, the impact of multiple diseases on therapeutic selection, priority setting, and order writing. At Dalhousie, we have allowed the students to learn from the mistakes of others. We have several case studies of this type in our curriculum. One set of examples involves situations plucked from consultations done by our clinical pharmacology staff in which inappropriate therapeutic drug monitoring occurred (Figure 4). The students are presented with the case and invited to pick out the error. Adding a few examples that were handled correctly enables

recall

(University

of Chicago).

them to quickly understand how to write the orders and, most importantly, interpret the data. Another particularly topical example has actually been in the curriculum for several years, but after the Seoul Olympics gained considerable popularity (Figure 5). Clinical pharmacology is not just a set of facts to be learned. It also encompasses many skills that also can be taught. One example, again from Daihousie University, involves the critical evaluation of drug advertisements.2 Drugs for use in this section are selected to reflect the broad spectrum of pharmacology (Figure 6). The students are presented with the advertisement, the product monograph, and whatever other information the company provides to practicing physicians. In groups of four, the students have 4 weeks to do a critical evaluation of the claims made by the advertisement. On several different afternoons, the students present this material to their classmates. Although they must hand in a formal, written report on which they are graded (and this exercise constitutes 10% of the final mark), they are allowed to present the material in any form they

Analyze the errors in determining serum concentration in each of the following cases: 1. A 72-year-old male is admitted with congestive heart failure. He is begun on a maintenance dose of digoxirt with no loading dose. A serum digoxin level is ordered for the following morning. 2. A 28-year-old female is admitted to a psychiatric unit with a diagnosis of acute mania. She is begun on lithium carbonate and daily lithium levels are ordered. 3. A 52-year-old post-op patient is begun on intravenous gentamicin every 8 hours therapy at 8:00 PM. An order is written to obtain a gentamicin blood level at 8:00 AM the following morning. 4. An 1 8-year-old male with epilepsy has been seizure-free for more than a year. Several witnesses corroborate his story of taking exactly 300 mg phenytoin each day. He has no side effects from his medication. A random serum sample is drawn, and the serum phenytoin level returns at 92 jzmol/L (therapeutic = 40-80 mol/L).

Figure

4. Allow

TEACHING

students

CLINICAL

to learn

from

other

PHARMACOLOGY

people’s

mistakes

regarding

therapeutic

drug

monitoring

(IJalhousie

University-Example

1).

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Case: You are appointed to be the physician on the Canadian Olympic Team. One of the coaches (of questionable repute) approaches you and indicates that some of his athletes will be using amphetamine to boost their performance. He asks you if you can do anything to prevent the detection of the drug in the usual urine tests, which are conducted in each athlete after their event. Questions:

1. Assuming that you go along with this scheme, how might you approach this problem? 2. Can you suggest any ways in which the Olympic Committee could prevent such deception? 3. Can the principles you have discussed be used more ethically in the practice of medicine?

Figure

5. Allow

students

to learn

from

other

peoples’

mistakes

(Dalhousie

wish. We have seen skits, lectures given with appropriate accents or mannerisms exhibited by faculty members, raps, slide-tape presentations, and even orchestrated videotapes. Beside the obvious entertainment value of this type of learning, the students can also address issues we do not cover in the formal course, including the role of drug combinations, slow-release preparations, alternative routes of delivery, the use of generic drugs, etc. As well, the stu-

Small

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Schedule Evaluation

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(1988)

Drug

Al A2 A3 A4 A5 A6 A7

Rocephin Becloforte Lorelco Tenormin lntron A Elixophylline Darvon

A8 Bi B2 B3 B4 B5 B6 B7

Feldene Isoptin SR Asacol Ecotrin PCE (Erythromcin) Ludiomil Hygroton Zyloprim

Cl C2

C3

Vasotec Pondocillin Questran

C4 C5 C6 C7

Sinequan Sulcrate Glucophage Trental

Figure 6. The students must learn skills as well as knowledge-critical evaluation of drug claims (Dalhousie University).

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2).

dents are expected to do a full cost-benefit analysis of their product. Carrying out this exercise enables them to become familiar with journals such as the Medical Letter, Drugs, Clinical Pharmacokinetics, and other useful sources of information about new drugs. Another skill to which faculty devote inadequate attention is that of therapeutic communication. A number of years ago, a resident commented that his entire medical school career had taught him “how to enter a patient into the system,” but no one had ever taught him how to “help the patient leave the system.” So an elective experience in therapeutic communication skills was developed for medical students. The objectives for this series of sessions are: to learn to delineate the patient’s therapeutic problems (not diagnostic problems), to learn to use the resources of the Drug Information System, and to convey clear therapeutic directions to patients. The students can do this at the second-year level (which involves one half day per week) or at the third-year level (which can be either a 2-week or a 4-week experience). Almost all the third years who have used this elective have published a review article or a case report at the end of this time. All students who have taken this elective believe they have acquired knowledge about how and when medications should be taken, the use of sophisticated drug information sources, and the importance of drug interactions. Meaningful evaluation is very important in the design of any medical school course. Students quickly recognize that the evaluation process drives the curriculum. This is particularly true in medical schools that use a traditional curriculum. In many instances, clinical pharmacology courses use a limited number of hours in that curriculum, and therefore, have few questions on any examination. This means that students quickly decide that the “course does not count.” To avoid this problem, we indicate to our students at the beginning of the year that we will review every question on the integrated final exami-

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nation, including those that we did not submit. If a questions uses principles taught in the course, we will consider it a “clinical pharmacology” question. Instead of having one question per hour of taught material, we now have three or four questions per hour. These are usually evenly divided between multiple choice questions and short answer types. One example of a good evaluation tool is the practical exercise provided at the University of Chicago by Dr. W. Elliott.3 A great deal of humor is used in developing this examination, but all the relevant issues in clinical pharmacology are examined. Again this examination stresses that learning can be fun, not just a drudgery. Introducing clinical pharmacology into the curriculum requires some of the knowledge gained by those who have practiced guerrilla warfare. A presence in multiple parts of the curriculum, ranging from the physical diagnosis course (teaching the elements of a good drug history), through the basic science course and into the clinical material, indicates to the students that this is an important subject. Once the students appreciate this, they are potent allies when change is being considered. Most medical students are happiest when doing what they came to medical school to do: learning about how to care for patients. That is what clinical pharmacology is all about!! REFERENCES 1. Robertson D, Goldberg MR, Onrot J, Hollister AS, Wiley R, Thompson JG, Robertson RM: Isolated failure of autonomic noradrenergic transmission. Evidence of impaired -hydroxylation of dopamine. N Engl I Med 1986;314:1492-1497. 2. Gray J, White T, Dresel P: Drug advertisements tool. Journal of Medical Education 1987;62:440-441.

as a teaching

3. Elliott WJ, Geppert E: Development of a successful fourth-year medical school elective course in therapeutics. Clin Pharmacol Ther 1991;50:249-253.

DISCUSSION Dr. Sweeney: One of the ingredients that is so easy to forget is that faculty enthusiasm and commitment is so much more important than all the theory when it comes to good teaching. Dr. Arthur Grollman (State University of New York, Stoney Brook): I would like to return to the role of the basic pharmacologist in part because there are relatively few clinical pharmacologists to serve as faculty for courses in clinical pharmacology. Many of our programs are based around one or two people, and if that person leaves, the program folds. There is a cadre of MD-PhDs, many of whom identify themselves primarily as basic pharmacologists, who now

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are a little afraid of talking about clinical medicine. This group of people, with some help from clinicians, could contribute importantly to the content of clinical pharmacology courses. Perhaps Dr. Gray could elaborate on how basic scientists participate in her course. Dr. Gray: At my university for the last 20 years, I have been the only clinical pharmacologist and yet we have quite an ambitious teaching program. The only way you can implement a teaching program like that is to use all the resources that are available to you. We had a lot of concern on the part of the basic scientists initially about getting involved. They were petrified about being faced with questions they could not answer. We have developed a series of crib sheets that incorporate not only information that they need to conduct the tutorial or the seminar, but also suggested responses to questions that the students might ask. In fact, some of the them have become quite comfortable in this environment and are able to respond with confidence to both the clinical questions and the basic science questions that might arise out of the tutorials. Dr. David Cook (University of Alberta): I add my support for the involvement of basic scientists. In Alberta, our department of clinical pharmacology is too busy with its own clinical practice to be involved extensively in the teaching, so the basic scientists do it or it does not get done. Also, not just clinical pharmacologists but internists can involve themselves in the process. To give an excellent basic course, we need to be in contact with what is clinically practiced and what is clinically important. Conversely, to give a good clinical pharmacology course, it is essential to have continuity with the basic course that preceded it. Dr. Sweeney: The basic scientist-the person who is involved in research-is in a good position to act as a tutor or as a guide. The researcher is there to find brand new information and the problem-based learner is there to find out what of the available information is applicable to solve the problem. Dr. Richard Weinshilboum (Mayo Clinic): Ideally, clinical pharmacology represents an opportunity to deal with the quite understandable anxieties that physicians and basic scientists have, both of whom like to think that they are both omnipotent and omniscient, but realize down deep in their hearts that they are neither. We should take advantage of the opportunities to deal with those anxieties and to bring together the unique strengths of both groups. Dr. Vestal: Dick, you and others have used the term “bridging discipline” to describe clinical pharmacology, and there are other examples of bridging disciplines, such as clinical immunology and clinical nu-

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trition. This is where we are in clinical pharmacology. We have that unique opportunity to bridge clinical medicine and basic science. Dr. Sweeney: I would like to comment further on the need for good evaluation techniques. The evaluation process must be appropriate to the goal of making sure that our graduates are physicians who are suited to a lifetime of growth as they practice medicine, as knowledge changes, and as new drugs come along. They must not be people who think they are suited to practice because we have given them all the information they need to know. Of course, this theme has been restated often, but it is still something that is lost sight of in discussions around medical education. If you are using problem-based learning, you find that to some extent you lose control over the content the students learn. In a traditional program, the lectures determine content. With problem-based learning, you tell the students to go at it and learn what they need to solve the problem. They will determine the content and it is for you to judge whether it is appropriate or not. This creates problems for evaluation, and although there are certain areas of content on which we could probably all agree, we would certainly never all agree on all the content the students are going to learn through their problem-based learning. And so, content alone as a yardstick for successful problem-based learning is inadequate for evaluation. I suggest that when you consider evaluation, you are looking at behavior as much as you are looking at content. This can be assessed by how students approach actual clinical problems in therapeutics. Dr. Vestal: Dr. Lertora, you stated in one of the group discussions that you believe it is important to reach students early, before the fourth year, and then build on this. Should we insist that there be clinical pharmacology material in the second-year courses? Dr. Lertora: Ideally, an integrated approach begins in the second year. Some elements of clinical pharmacology and therapeutics should be incorporated into the basic pharmacology course. This material can then be reemphasized and expanded during the clinical years. Dr. Vestal: Dr. David Spence (Victoria Hospital, London, Ontario) described a very interesting approach in our group discussion. At his institution, they have their basic pharmacology course in the first year. In the second year, with the introduction to clinical medicine, they have a parallel course in therapeutics. It consists of 1 hour per week throughout the year, during which time case material is reviewed, analyzed, and discussed. This includes an assignment to write orders for taking care of the pa-

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tients that are described in the problems. Essentially, this is an effort to prepare students to enter the wards where they are going to have clinical responsibilities. In addition, they have a fourth-year course, which he indicated is mainly didactic. Dr. Gray: Getting back to the need for an objectivestructured clinical evaluation of competence in pharmacotherapeutics, Dr. R. Hardin and his colleagues published a paper on this particular examination technique as applied to clinical pharmacology courses taught at Dundee about 4 or 5 years ago in the Medical Teacher.1 It looked intriguing, but when I have attempted to set it up myself, I have found it to be very labor intensive and rather expensive. It is much more difficult when you are the only clinical pharmacologist. At McMaster, I understand that it costs about $3000 to prepare this type of examination for 100 students, and the number of situations that you can set up for an examination is actually quite limited. Thus, there are significant problems associated with this approach to evaluation. At this point, written or oral examinations that incorporate clinical case materials appear to be the most practical approach. REFERENCE 1. Peden NR, Cairncross RG, Harden RM, Crooks): Assessment of clinical competence in therapeutics: The use of the objective structured clinical examination. Med Teach 1985; 7:217-223.

SUMMARY

OF

AND

CONCLUDING

Robert

E. Vestal,

SMALL

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COMMENTS MD,

and

Neal

L. Benowitz,

MD

The groups began by surveying what faculty are doing at their respective institutions, which varied greatly in terms of time commitment and the material taught. The use of problem-based learning and case discussions was considered in detail. Although there was general appreciation for its value, the costeffectiveness of problem-based learning was not universally accepted. A lack of availability of faculty for teaching is a problem at many institutions. Often only one faculty member is teaching the course, and the number of students at any time is small, perhaps as few as two or three students during a 3- or 4-week rotation. Such a course is basically a tutorial, and students may be asked to bring cases from the wards to review and discuss. If the course is offered several times during the year, a reasonable proportion of students in each graduating class can participate, but the cost in group faculty time is high. The view was expressed that more faculty are needed for small

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teaching, in contrast to the large lecture format. How much time is enough? Even with only 12 hours, a lot can be accomplished. It was suggested that students should begin to be exposed to clinical pharmacology early in their medical education so that they are familiar with some of the principles before taking a clinical pharmacology course in their third or fourth year of medical school. This material can be introduced during the basic pharmacology course, or through an elective during the second year. Residents as well as students need exposure to clinical pharmacology. The residents are role models for students. The charge of the second set of group discussions was to review the use of resource materials and the selection of topics and teaching cases for an ideal course on clinical pharmacology. The importance of high-quality cases was emphasized. Case material may come from attending rounds, consultations, adverse drug effect reports, subtherapeutic or toxic blood levels from the drug analysis laboratory, medicolegal issues, and cases referred to poison control centers. The possibility of sharing case material on a national level, perhaps through one of the clinical pharmacology societies, was raised. An important value of problem-based or case management teaching is that students can learn the process by which clinicians formulate management strategies. The objective with the highest priority was to teach students how to think through a therapeutic dilemma and develop an acceptable and rational solution. The student needs to learn a systematic process of thinking. Often students by the fourth year have had intensive instruction on how to make a differential diagnosis, but few students know how to formulate a therapeutic plan or do not have an appropriate approach to a therapeutic dilemma. This is a glaring deficit in our medical education system, and its remediation forms the objective and the rationale for teaching clinical pharmacology. The clinical pharmacology educator may be viewed somewhat like a repairman. A repair man has tools and skills. These include course content, methods, approaches, and processes. Problem-based learning seems to offer a desirable mechanism through which skills can be taught effectively. Although it is important to impart core knowledge, it is equally important to provide role models at the bedside who can demonstrate and guide the application of knowledge in a safe and supervised manner. The core content that was developed at the previous workshop was generally ac-

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knowledged to be appropriate to what students should know about clinical pharmacology when they graduate from medical school. Finally, attention was given to the role of basic scientists in teaching clinical pharmacology. Their most important responsibility is to teach a high-quality basic science course during the first or second year of medical school. This provides the knowledge base on which courses in therapeutics can be built. The value of round table discussions with basic scientists, clinical scientists, and clinicians was discussed also. The role of basic scientists in actually teaching clinical pharmacology courses was recognized to be less evident, but clearly some are doing this rather well, particularly when clinical pharmacology faculty are not available. When all of the groups were together at the conclusion of the workshop, we attempted to determine whether there was a consensus regarding the need for a course on clinical pharmacology and therapeutics during medical school. There was virtually unanimous agreement that there should be such a course. Except for 12 of the attendees who believed that it should be elective, the group strongly favored a required course during the third or fourth year. Only five or six persons thought that the course should be presented entirely in a problem-based learning format of the type used at McMaster. As we learned from Dr. MacLeod, the educational format involves self-directed learning by students who evaluate case problems, determine the important learning objectives, and obtain the information appropriate to those objectives under the guidance of a tutor and consultants. A similar number of attendees preferred that the course be entirely didactic lectures with case examples. Most favored a combination of both approaches. Thus, based on the deliberations of the participants in this workshop, we would recommend to those individuals who plan and teach courses on clinical pharmacology and therapeutics that a component of problem-based learning be included, but not to the exclusion of more traditional teaching methods such as lectures and case discussions. The relative emphasis on these approaches will depend on the preferences and availability of the faculty of individual medical schools. The chairmen and contributors thank Dr. Richard Weinshilbourn, Dr. David Nierenberg, and Mrs. Elaine Galasso for their assistance in planning the workshop; and the group leaders, recorders. and all of the registrants whose active participation made the workshop informative and enjoyable.

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