Teaching to Learn

by William Gust, PharmD, PGY-1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery V.A. Medical Center

Former French inspector general and poet Joseph Joubert once wrote that “To teach is to learn twice over.”¹ Joubert’s maxim is rooted in the idea that while the learner is only responsible for his or her own understanding, the teacher’s added responsibility to accurately communicate a concept to others incentivizes more active engagement of both the subject itself and one’s own deficiencies with it. Furthermore, teaching often necessitates the creation of educational materials, which requires the highest level of cognition.² Thus, promoting the sort of active engagement that teaching requires can be a powerful tool in expediting the learning process. By creating and presenting educational materials to teach others, students enhance their knowledge, comprehension, and confidence related to the subject far more than they would through traditional instructor-led methods.

Encouraging students to develop learning materials for themselves or fellow students bolsters their comprehension. Uskokovic demonstrated this during his employment of a co-creational classroom, in which students developed not only lectures and presentations but also the curriculum itself.³ In this model, the instructor assigns students a broad topic and encourages them to break it down into a series of questions that will be answered by their learning materials. Once questions are assessed for appropriateness of scope by the instructor, students are free to develop learning materials however they see fit. Following the creation of their learning materials, students present to the class for discussion who then ask questions and suggest revisions. In this study, the investigator compared exam performance using this co-creational model compared to the students' exam performance using a traditional didactic instructional model and a flipped classroom model, in which students read the material before class in preparation for elaborating on that material during class meetings. Although the sample size was small (n=8), students performed significantly better on exams when the co-creational model was used when compared to exams where the material was delivered via traditional didactic or flip methods.³

Student teaching also improves knowledge retention. In a crossover-study evaluating the benefit of peer-teaching on learning, Peets et al. randomly assigned medical students to serve as peer educators in small groups at different periods during a Gastroenterology/Hematology course.⁴ Peer educators were not given outside resources by the investigators but were responsible for coordinating and leading their assigned small group discussions. At the end of the course, the investigators administered a 94-item multiple-choice examination broken down by the various clinical cases covered during the course. After comparing student performance stratified by clinical case, students who served as peer educators for a given clinical case performed significantly better on questions than their group members who were only responsible for their own learning (Mean Score 80.7% vs 77.6%, Cohen’s d = 0.33; p < 0.01).

Taken together, these studies support the idea that student-teaching with student-created learning materials enhances student knowledge and comprehension. The results of Uskokovic make a particularly compelling case for the student involvement in the teaching process given the improvement in exam performance with the co-creational method when compared to the flipped classroom method. Had the results in both groups been similar, the better exam performance could have been explained by the presence of active learning, which is central to constructivist theory. The results of Uskokovic, however, suggest that student construction of the content to be covered as well as the learning materials promotes enhanced engagement that cannot be replicated by other active learning methods. Students who serve as peer teachers spend more time engaged with the material.  Peets et al. showed that student peer educators spent significantly more time engaging with the learning material (99 +/- 60 minutes vs 36 +/- 33 minutes, Cohen’s d = 1.3, p < 0.001) when compared to the other group members.

By encouraging (or perhaps requiring) students to create their own learning materials, teachers can improve student knowledge, confidence, and long-term retention. While the studies above focus on the creation of learning materials as a tool to teach other students in traditional classroom settings, this teaching strategy can be adapted to an array of settings, including patient education during practice-based experiences. It is important to note, however, that allowing students to teach with their own learning materials does not eliminate the need for a teacher. Critically, instructors that choose to employ student-generated materials as a teaching method must reduce cognitive load by choosing the right topics to cover and the right questions to ask. In this way, teachers can foster maximal learning in the students’ zone of proximal development while minimizing the chances the students will feel overwhelmed or bored. Overall, student-created learning materials offer a powerful way to enhance knowledge and retention by making the student an active participant.

References:

1. Joubert, J. Joubert: A Selection from His Thoughts [Internet]. New York: Dodd, Mead & Co.; 1899. Accessed 2020 Nov 23.
2. Armstrong, P. Bloom’s Taxonomy [Internet]. Nashville (TN): Vanderbilt University, Center for Teaching. Accessed 2020 Nov 1.
3. Uskoković V. Flipping the flipped: the co-creational classroom. Res Pract Technol Enhanc Learn 2018; 13(1):11.
4. Peets AD, Coderre S, Wright B, et al. Involvement in teaching improves learning in medical students: a randomized cross-over study. BMC Med Educ 2009; 9:55.

Simulation Activities Improve Students’ Perceptions and Confidence

by Erica Claire Loden, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Ledbetter E, Lau S, Enterline A, Sibbitt B, and Chen AMH. A simulation activity to assess student pharmacists’ knowledge and perceptions of oncology pharmacy. Am J Pharm Educ 2019; 84: Article 7474.

I am a student pharmacist and very interested in pursuing a career as an oncology pharmacy specialist. This study grabbed my attention because many of my classmates are unaware that knowledge regarding oncological diseases and treatments is essential in all practice settings. The study analyzed students’ perceptions of the importance of pharmacists in the treatment of cancer and measured their confidence in answering oncology-related questions. This study is necessary because improving confidence and perceptions of oncology therapeutics may help fill the gaps in patient care needs across practice settings.

The instructional activity was implemented by faculty at Cedarville University College of Pharmacy.  The intervention was a two-hour class session during week 4 of a required 5-week oncology module. There were two cohorts of students: third-year pharmacy students in 2016 and 2017. The same activity was implemented in both years. The instructional activity involved four interactive stations involving simulations in a managed care, community pharmacy, a hospital that does not have a clinical pharmacy oncology specialist, and a hospital that does have a clinical pharmacy oncology specialist. Students were placed in pre-assigned groups and given 75 minutes to complete all four stations and a 30 minute debrief followed. At the first station, students used information from a cost-minimization research abstract to examine the cost and efficacy of an oncology medication to be considered for the formulary. At the second station, students made non-pharmacological recommendations to help a patient presenting with chemotherapy-related adverse effects. At the third station, students determined when to discontinue medications and when to restart them for a patient enrolled in an oncology clinical drug trial who presented for cancer-related surgery. Students also developed a communication plan for the surgical team for this patient. At the fourth station, students utilized compounding and calculation skills to verify four prescriptions. The same faculty member facilitated the activity each year for both cohorts and led the debrief sessions. A pre-activity and post-activity survey assessed perceptions and knowledge of oncology-related topics. The same 17 item survey instrument was administered on day 1 of the oncology module (pre-activity survey) and again after students completed the activity in week 4 (post-activity survey). The survey rated items on a seven-point Likert-type scale. The survey measured two concepts: the first nine items assessed students’ confidence in answering oncology-related questions. The remaining eight items evaluated the student’s perceptions based on their level of agreement with pharmacists’ involvement in oncology patient care.

The results show that students in both cohorts had significantly greater confidence answering all nine oncology-related questions following the instructional activity than they did at baseline (p<0.001). Student pharmacists’ perceptions of pharmacists’ roles improved post-activity for all questions except one regarding hospital pharmacists’ ability to answer oncology-related questions at institutions with a clinical oncology pharmacist. Increases in knowledge between the pre-survey and post-survey were similar in both cohorts.

Overall, this educational activity adheres to some of the best practices in instructional design. The pre- and post-activity assessments were created carefully by the module coordinator and by a faculty member with experience developing surveys. Additionally, the instructional activities were kept constant between both cohorts. The study found no difference in responses based on differences in ages, ethnicity, past oncology experience, or gender. However, there are several weaknesses and limitations to this study. The instructional design was incomplete. Learning objectives were unclear and difficult to measure. Students were all from the same school; therefore, the results are less likely to be generalizable to other institutions. There are also other variables that researchers failed to consider. The increase in confidence and perceptions could be due to students completing the other instructional activities during the course before taking the post-survey, rather than the two-hour activity. Future studies could give the survey immediately before and after the instructional activity to alleviate this attribution problem. This study only addressed perceptions and not knowledge or outcomes. Responder bias is a concern because students may have given favorable ratings based on a belief that favorable survey responses could have positively influenced grades. Future studies could include administering knowledge assessments before the activity and administering longitudinal assessments to determine the long-term impact on students’ knowledge and perceptions following the course.

In a similar study which surveyed students from five pharmacy schools in Florida, the investigators found that the majority of the pharmacy students surveyed (75%) were only moderately or not at all comfortable with the field of oncology¹. They concluded maximizing experiential opportunities for students could potentially close knowledge gaps and improve confidence levels. In both studies, researchers found a desire from students to increase experiential learning opportunities related to oncology pharmacy practice. A separate study conducted at the University of South Florida showed participation in an ovarian-cancer simulation improved students' oncology-related knowledge and their perceived understanding of the roles of oncology pharmacists.² This study used a similar study design in that it utilized pre-assessment and post-assessment surveys to assess students’ perceptions.

I believe further studies are needed to produce higher quality, generalizable results. I am unsure if this educational intervention would increase students’ desire to become an oncology pharmacist. The study did show that instruction about oncology pharmacotherapy increases students’ confidence in oncology but it’s not surprising that perceptions about pharmacists' roles in oncology practice would increase after these learning activities. Insights from the science of learning indicate that the brain is malleable and that learning is an experience-dependent process.³ In that way, the 4-stations were well-designed and offered students a range of simulated experiences that illustrate what pharmacists can do across several practice settings. Another study showed experiential learning is capable of improving students’ confidence and perceptions and that students desire more experiential learning opportunities.⁴  The implications are that the best instructional activities immerse students in rich, engaging tasks that can help them achieve a conceptual understanding. Therefore, it is my recommendation that educators balance lectures with a number of simulation and experiential activities to facilitate comprehension and skills development. These activities would be more successful if done multiple times during a module. Providing oncology pharmacy experiences across all pharmacy schools and developing awareness on the importance of knowledge and training in oncology practice will better prepare students to deliver high-quality patient care.

References

1. May P, Ladd J. Florida Pharmacy Students’ Perspectives on Careers in Oncology. J Hema Onc Pharm 2017; 7 (2): 69-75.
2. Serag-Bolos ES, Chudow M, Perkins J, Patel RV. Enhancing Student Knowledge Through a Comprehensive Oncology Simulation. Am J Pharm Educ. 2018; 82(3): Article 6245.
3. Cantor P, Osher D, Berg J, Steyer L, Rose T. Malleability, plasticity, and individuality: How children learn and develop in context. App Developmental Sci. 2018; 23 (4): 307-337
4. Darling-Hammond L, Flook L, Cook-Harvey C, Barron B, Osher D.Implications for educational practice of the science of learning and development. Appl Development Sci 2019; 24 (2): 97-140.

Group-based Education for Self-Management of Type 2 Diabetes Mellitus

by Olivia Husband, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012 Jan;86(1):98–105.

Type 2 Diabetes Mellitus (T2DM) is one of the most prevalent disease states worldwide, and it is projected that the number of people diagnosed with T2DM will continue to increase over the next decade.¹ As a student pharmacist, T2DM is something I am interested in, not only because of its high prevalence but the impact a pharmacist can have on the management of people with T2DM. An integral component of T2DM treatment is patient self-care and management, including self-monitoring blood glucose and self-administering insulin injections. Patient education is crucial in ensuring that patients are getting the greatest benefit out of their diabetes treatment regimen. The authors of this study state there was very little evidence regarding the efficacy of local, group-based T2DM education.¹

This randomized controlled trial was conducted from May 2006 to November 2008 in central Norway. Participants were patients age 18 or older with a physician confirmed diagnosis of type 2 diabetes mellitus who had at least one general practitioner consultation within the previous three years.¹ There was no specific A1C requirement to enter the trial; however, patients who previously attended a diabetes education program in the past 12 months were excluded from the study.¹ Twenty general practitioners in the local area were asked to evaluate their patients to identify those who met the inclusion criteria for T2DM group education and then to mail out an invitation to participate in the diabetes management course.  Patients who accepted the invitation were then interviewed and randomized into one of two groups: the intervention group, which consisted of two cohorts, hospital 1 and hospital 2, and a control group.¹ The intervention group cohorts attended 15 hours of T2DM education delivered over three class sessions. The members of the control group were told they would be placed on a waiting list and would be offered the education program after one year.  Control group patients were instructed to continue their self-management practices.¹ The intervention received education about T2DM as well as nutrition taught by a diabetes nurse educator who had several years of experience. The education methods used included lectures, interactive skills training with activities, including blood glucose monitoring and problem-solving activities, and group discussion.¹ The primary outcomes of the study were changes in A1C (a measure of long-term blood glucose control) as well as patient response to a questionnaire that assessed their knowledge.  The outcomes were measured at baseline, at 6 months after the education program, and again at 1-year post-program.¹ The results were analyzed using both per protocol and intention to treat analysis.¹

There were no statistically significant differences between the intervention and control groups in regards to primary outcomes at 6 months.¹ But, after 1 year, the control group had a worsening of their A1C level from baseline of 0.3% while the intervention group maintained their baseline A1C (p=0.032).¹ All groups improved their diabetes knowledge after 12 months, but the patients in the intervention group significantly greater improvements in diabetes knowledge when compared to the control group.¹ The intervention group also had a higher level of treatment satisfaction at 6 months, but not at 12 months.¹ There was also a significant increase in the number of participants who avoided fatty foods and regularly self-monitored their blood glucose (p=0.027) among members of the intervention group.¹ Although the intervention group improved their knowledge of self-management of T2DM, their quality of life decreased from baseline over the course of 12 months (p=0.005).¹ This was not the case for the control group, as their quality of life scores remained unchanged when compared to baseline.¹ I think the decline in quality of life in the intervention group might be due to the more intensive monitoring and, ironically, with greater knowledge, more anxiety about the negative effects of diabetes.

Many of the participants in the study had a baseline A1C that was below the recommended treatment goal, and this is a major limitation of this study. To offset this limitation, a sub-group was performed for the subset of patients with an A1C greater than 7.7% at baseline.¹ These participants had poorer glycemic control at baseline, so they reaped the most benefit from the T2DM education program. One way the investigators could have prevented this limitation is to have a baseline A1C requirement for participants to enter the study. I think it is important to note the general decline in patient quality of life within the year following the education program perhaps due to more stress and anxiety related to the management of their T2DM. The program consisted of 15 hours of education across 3 sessions which are very long sessions and it’s hard to absorb that much information. This could have been avoided if the 15 hours was separated into more sessions. The sessions themselves seemed to use an effective combination of lectures, activities, and discussions, with breaks provided for participants.¹ I think overall, the methods of this study were appropriate because the investigators measured both glycemic control as well as patient knowledge after attending the classes.  However, I think they should have scheduled shorter sessions and perhaps included sessions about stress reduction strategies.

Several studies have analyzed the benefits of providing group-based type 2 diabetes management education and most have produced positive results. Participants saw an improvement in their glycemic control.  In one analysis patients were more likely to see improvement when the program was taught by a pharmacist rather than a different healthcare professional.² In most other studies, participants also saw an improvement in their overall quality of life, which was not seen in this study.^1-3 

This study shows that patient education about type 2 diabetes mellitus and self-care is an essential element of its management. This study reinforces the importance of patient education while providing insight on how to structure it. Learning how to manage a disease can be overwhelming, so it is important to address the stress and anxiety that can occur.

References

1. Rygg LØ, Rise MB, Grønning K, Steinsbekk A. Efficacy of ongoing group based diabetes self-management education for patients with type 2 diabetes mellitus. A randomised controlled trial. Patient Education and Counseling. 2012;86:98–105.
2. Mikhael EM, Hassali MA, Hussain SA. Effectiveness of diabetes self-management education programs for type 2 diabetes mellitus patients In middle east countries: A systematic review. Diabetes Metab Syndr Obes. 2020;13:117-138.
3. Kumah E, Sciolli G, Toraldo ML, Murante AM. The diabetes self-management education programs and their integration in the usual care: A systematic literature review. Health Policy 2018;122:866–77.

Pharmacist-Led Educational Interventions Decrease Prescribing Errors

by Michaela Shoup, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL, Oberst-Walsh LA. Pharmacist-led educational and error notification interventions on prescribing errors in family medicine clinic. J Am Pharm Assoc 2015; 55(3): 238-45. doi: 10.1331/JAPhA.2015.14130

Medication errors are a serious problem in the United States’ healthcare system. Studies have shown that medical errors account for over 250,000 deaths every year, making medical errors the third leading cause of death in the United States. Reducing prescribing errors is a vital step in decreasing the number of patients harmed and improving outcomes.  Another issue plaguing healthcare in the United States today is the lack of available positions for pharmacists and the failure of many healthcare professionals to fully realize the value and knowledge pharmacists can bring to the healthcare team. In this study to evaluate the impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic, the researchers created a program that addresses both of these issues at once. This study showed that physicians made fewer errors when writing prescriptions for pediatric patients after participating in a pharmacist-led educational program.¹

This 14-month study took place in an outpatient academic family medical clinic affiliated with the University of Oklahoma. Of the twenty-four resident physicians at the clinic, fourteen residents participated in the educational program and their prescribing habits were longitudinally assessed. The study was composed of four phases: preintervention error assessment, educational intervention, error notification intervention, and postintervention error assessment. First, prescriptions written by the resident physicians were assessed for the number and types of errors they contained, including missing information such as date, unclear directions, or incorrect dose. The researchers used multiple instructional methods to educate the residents. First, they employed a pharmacist-led lecture with active learning activities in which residents learned about the most common types of prescription errors, how to effectively use an electronic medical record (EMR), and the necessary elements of a prescription. In the error notification intervention, pharmacists used a feedback system for a period of three months to help the residents see what strengths they had and what areas they should improve. As a part of this feedback system, residents received notification of errors in prescriptions they had written and were offered assistance from clinical pharmacists. Residents also received a weekly newsletter summarizing the most common errors made and providing recommendations for improvement. The feedback and audit system likely played a vital role in training these physicians— feedback enables learners to gain perspective from others on how they can change and improve. A year after the initial data collection began, the postintervention assessment was conducted. A new set of prescriptions written after the conclusion of the program was assessed for errors to see if and how the residents’ prescribing practices had improved.

The results showed that the rate of prescribing errors was 23% lower during the postintervention period when compared to the preintervention period.  However, this difference was not statistically significant when controlling for time. The lack of statistical significance could be due to each resident having different baseline knowledge and experience. For example, the more experienced residents may not have benefitted from the program as much as the less experienced physicians, and this may have diminished the impact of the educational intervention. In addition to the primary analysis, the researchers analyzed the error rates of residents who participated in the educational program compared to those who did not. Controlling for time, pediatric prescription error rates were 36% lower among physicians who participated in the educational intervention versus those who did not participate. This difference was statistically significant, and the authors concluded that the prescribing of pediatric medications was positively impacted by the program.

This study aimed to show the value of pharmacists’ knowledge and expertise.  While the results are promising, the Hawthorne effect could have played a role in the results — physicians could have changed their prescribing habits simply because they knew they were being evaluated, possibly leading to a lower error rate than might have been seen had the physicians been unaware their performance was being evaluated. The study group was diverse—it was comprised of PGY1 through PGY4 residents.  So each physician had a different level of experience. The residents received uniform education and feedback, which is a strength of the study. However, we do not know which of the individual components of the program – the lecture, audit and feedback, or the newsletter – had the most impact.  Indeed, we don’t know if the residents actually read the newsletter.

Other studies have been conducted to show that pharmacist-led education positively impacts prescribing practices and, ultimately, the quality-of-care patients receive. The DEPRESCRIBE study evaluated the effect of a pharmacist-led educational invention on discontinuation of medications that were inappropriate for patients aged 65 and older (based on Beers criteria).² Pharmacists in this study provided education to patients (supplemented by educational brochures) and made pharmacological recommendations to their providers regarding medications that may be more harmful than beneficial in older adults. Over 40% of the potentially harmful medications were discontinued by the physicians that were educated by the pharmacist.  This substantially greater than the discontinuation rates (12%) observed when the patients and physicians were not educated.

In a time when an alarming number of patients are being by less-than-optimal medication regimens and when job positions for pharmacists are not as plentiful as they once were, pharmacists must use their training to improve patient outcomes and make their value evident. Pharmacists are capable of educating both their coworkers and patients to decrease error rates, provide high-quality patient care, and improve health outcomes. Pharmacists are in the ideal position to share their knowledge and expertise to benefit patients, colleagues, and the profession of pharmacy. 

References:

1. Winder MB, Johnson JL, Planas LG, Crosby KM, Gildon BL, and Oberst-Walsh LA. Impact of pharmacist-led educational and error notification interventions on prescribing errors in a family medicine clinic. J Am Pharm Assoc 2015; 55(3): 238-245. doi:10.1331/japha.2015.14130
2. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018; 320(18): 1889-1898. doi: 10.1001/jama.2018.16131.

Prescribing Education for Medical Students

by Danielle McGrew, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Newby DA, Stokes B, Smith AJ. A pilot study of a pharmacist-led prescribing program for final-year medical students. BMC Med Educ. 2019 Feb 12;19(1):54. doi: 10.1186/s12909-019-1486-1 

I love to find articles in the literature focused on ways pharmacists have implemented a program, educated others, or proven their worth while working on an interprofessional team. So, when I came across an article about a pharmacist-led educational program that benefited patients and prescribers alike, I was immediately intrigued.  The purpose of this study was to improve prescribing confidence and skills and to improve medical students’ understanding of the role pharmacists can play in the management of patients. It is known that prescribing medications is one of the intimidating tasks for medical students as they transition to becoming licensed physicians. One study found that recent medical school graduates did not feel prepared for prescribing in clinical practice, which they attributed to a lack of opportunities to develop the skill-based, applied aspects of prescribing.¹  Other studies have shown that medical interns often prescribe inappropriately for many common conditions.² Thus, there is a need for more training and practice opportunities for medical students to prepare them for clinical practice.

In this study conducted in Australia, all final-year medical students at three tertiary hospitals were invited to take part in an eight-week prescribing training program. The program consisted of three instructional strategies: prescribing and calculation tutorials, weekly feedback from a pharmacist regarding prescribing, and one afternoon spent in the pharmacy to learn about and observe the dispensing process. The tutorials involved allowing the students to practice either selecting and prescribing medications or calculating and prescribing a dose of a medication based on a case scenario representing the most common conditions faced by junior doctors. The common conditions included stroke prevention (anticoagulation therapy), diabetes, pain management, constipation, nausea and vomiting, asthma, and hypertension. Confidence and appropriateness of prescribing were measured upon completion of the tutorials on week one and week eight. Confidence in a variety of prescribing areas was assessed using a confidence scale adapted from a questionnaire developed by the TOPDOC study team to rate junior doctor confidence.³ The tutorials covered such topics as selecting a medication for a condition, writing a prescription order for both inpatients and outpatients, taking a medication history, identifying potential drug interactions and adverse events, monitoring effectiveness, and planning discharge medications.  To assess the appropriateness of prescribing, the students completed a prescribing exercise based on a clinical scenario. Blinded to what student was completing the exercise and to whether it was a pre- or post-assessment, a clinical pharmacist and clinical pharmacologist assessed the appropriateness of each prescription using a previously validated scale. Additionally, students provided feedback about the impact of the program at the completion of the program by participating in focus groups and completing a questionnaire. Pre- and post-program assessments were examined using permutation tests, which assesses whether two distributions are significantly different from each other without making any assumptions about the shape of the distributions.

Twenty-three students completing their rotations at three hospital sites agreed to participate, with only 16 participating in most or all of the required activities and taking the pre- and post-course questionnaires and assessments. Results showed a significant increase in confidence across all areas of prescribing skills assessed. At baseline, a majority of students rated themselves as ‘not confident’ or ‘satisfactory but lacking confidence’ in each area, but upon completion of the program none of the students rated themselves as ‘not confident’ in any area, with the exception of one student that rated him/herself as ‘not confident’ in writing an outpatient prescription. The most noteworthy improvement was found in writing inpatient prescriptions – after the program, all students rated themselves as ‘confident in most cases but would like more experience’ or ‘fully confident in most cases.’  None of the students rated themselves ‘fully confident’ at baseline. Students were most confident in writing prescriptions for medications related to the disease states discussed in the tutorials.

There was a small and non-significant improvement in the appropriateness of the students’ prescribing from baseline to week eight. However, it is important to note is that none of the students’ prescriptions were rated ‘inappropriate and potentially harmful’ after finishing the prescribing program. Student feedback was uniformly positive, with students agreeing or strongly agreeing to statements about the practical aspects of prescription writing, therapeutic appropriateness, and calculations aspects of the program.  Also, students indicated that the program helped to prepare them for their intern year. The focus group sessions revealed that students most valued the practice and immediate feedback they received.  Moreover, they learned about the support pharmacists can provide to them as prescribers. Negative comments centered on the difficulty of fitting the program into their schedule during demanding clinical rotations.

I thought that this was a good study to evaluate how influential a prescribing program may be on medical student’s knowledge and confidence in writing prescriptions. One major weakness was the small sample size. Larger studies would be needed to quantify the impact of such a program on prescribing appropriateness. Given the small sample size, assessing changes in student confidence was the most appropriate thing to measure. A major strength of the program was the immediate feedback that was provided to the medical students. I also think that the use of focus groups to gather feedback was really important, especially since this was a pilot program.

Other studies focusing on prescribing education for medical students have shown positive results as well. Medical students participating in a ‘near-peer’ prescribing education program reported increased confidence in their prescribing knowledge and skills after attending the tutorials.⁴ Similarly, results from medical students participating in a teaching program on practical prescribing showed that their knowledge of pharmacotherapy, drug information, and prescribing skills was significantly improved.⁵

Educators should pay attention to this pilot study it appears to be a well-designed educational program intended to improve the confidence and skills of future physicians. In particular, I would recommend educators replicate the content of the tutorials and providing immediate feedback. In this instance, medical students are getting to practice real-life scenarios using clinical cases. I believe the best practices of instructional design are being upheld. The material is presented in the form of tutorials, the instructor tests the student’s knowledge on what has been taught through the clinical cases, and students can reflect on their performance based on immediate feedback. Educators should take into account the challenges of offering this program due to time constraints during demanding clinical rotations. My recommendation would be to initiate the prescribing program earlier in the medical school curriculum (perhaps during an early practice experience) and to reduce the weekly workload required. One medical school has already implemented “Safe Prescribing Teaching” earlier in their curriculum, resulting in students feeling remarkably more confident in prescribing situations.⁶ This strategy allows students to revisit and build on the knowledge they learn each week and would likely yield even better results.

 References

1. Rothwell C, Burford B, Morrison J, et al. Junior doctors prescribing: enhancing their learning in practice. Br J Clin Pharmacol. 2012 Feb;73(2):194-202. doi: 10.1111/j.1365-2125.2011.04061.x. PMID: 21752067; PMCID: PMC3269578.
2. Pearson S, Smith AJ, Rolfe IE, Moulds RF, Shenfield GM. Intern Prescribing for Common Clinical Conditions. Adv Health Sci Educ Theory Pract. 2000;5(2):141-150. doi: 10.1023/A
3. George JT, McGrane DJ, Warriner D, et al; TOPDOC Study Team. Protocol for a national audit on self-reported confidence levels, training requirements and current practice among trainee doctors in the UK: the Trainees Own Perception of Delivery of Care in Diabetes (TOPDOC) Study. BMC Med Educ. 2010 Jul 27;10:54. doi: 10.1186/1472-6920-10-54.
4. Gibson KR, Qureshi ZU, Ross MT, Maxwell SR. Junior doctor-led 'near-peer' prescribing education for medical students. Br J Clin Pharmacol. 2014 Jan;77(1):122-9. doi: 10.1111/bcp.12147. PMID: 23617320; PMCID: PMC3895353.
5. Javadi MR, Khezrian M, Sadeghi A, Hajimiri SH, Eslami K. An Interprofessional Collaboration between Medicine and Pharmacy Schools: Designing and Evaluating a Teaching Program on Practical Prescribing. J Res Pharm Pract. 2017 Jul-Sep;6(3):178-181. doi: 10.4103/jrpp.JRPP_17_16. PMID: 29026844; PMCID: PMC5632939.
6. Lloyd N. Pharmacist-led teaching as a longitudinal theme for medical school curriculums - a solution for reducing prescribing errors in junior doctors? BMC Med Educ. 2019 May 29;19(1):173. doi: 10.1186/s12909-019-1632-9.