Download Clinical and Therapeutics - CPT Course Review

Review of Year 4 Clinical Pharmacology and
Therapeutics course
• Course occurs in Feb of Year 4
• Course Director – Drs. Nierenberg and Lewis
• Course has 47 curricular hours
• Course was last reviewed in May 2013
Action Plan from Prior Review
• Action Plan from 2013 Review:
– Student concerns about Pass/Fail vs H/HP/P/F
• Move to Pass/Fail next year as an experiment, but with detailed feedback to
students on papers continued, and personal notes to students in top 10%
– Done in 2014 and 2015
– New administrative assistant who communicated directly with class, always with good
intent, but sometimes with unintended adverse consequences
• All communications will come through Dr. Nierenberg, as in all previous years
– Done in 2014 and 2015
– Student concerns about classmates being “too competitive” or “over the top” in
preparation of their group presentations
• Reinforce time limit of 12 min per group presentation
• Remind student to focus on “core issues”
– Discontinued in 2015
Action Plan from Prior Review
– This class had less class discussion and participation than we have seen in prior years
• We will incorporate more ARS as well next year for shy students
– Done and Peer Small Group Sessions started 2015
– Provide greater clarity about written assignments:
• We will continue to describe written assignments in class, answer questions, and
give an example of each from prior year
• We will write out description of each written assignment in the syllabus, at the
beginning of the course
– Done, now on canvas
– Some cases or figures were outdated:
• We will continue to provide examples using mostly recent drugs and recent data
• We will continue to refer to older information about older drugs when the
educational point can’t be made as well with newer drugs (e.g. example about
enzyme induction)
Action Plan from Prior Review
– Too much focus on review of pathophysiology material and basic pharmacology
material
• We feel it is important to build our new, more complex material upon this
foundation
• This review was helpful to many but perhaps not all students
• We will shift more review material into the “prework” for specific sessions, thereby
allowing us to focus more time “in class” on working through problems and cases,
which we already do
– Done
– Students became “too competitive” in their group presentations to the class:
• Changing to P/F next year should help reduce this competition
• We still want to obtain best work from student groups
• More strictly enforce 12 min time limit on group presentations
• Dr. Lewis and I felt that overall these group presentations were superb, and we plan
to continue them: excellent peer-to-peer teaching, good problem-solving skills
– Group presentation discontinued, new group format devised
Action Plan from Prior Review
– Students going into Peds and Ob felt that some topics were less relevant to them:
• We believe that the large majority of these topics are relevant to all students
regardless of choice of specialty
• We will make special effort to incorporate more case examples into each lecture
dealing with pediatric and ob-gyn patients and issues
• Next year, we will again give separate lectures on pediatric clinical pharmacology,
and issues related to pregnant and breastfeeding women; these were combined
this year due to loss of 4 hours of contact time (a one-year issue)
– Done, separate lectures in both
– Lack of clarity up front on grading policy, written assignments:
• These were explained during the first hour of class
• Next year, we will add written material to the orientation packet addressing both of
these issues right on day one
– Done, available on canvas
– “General topics” (e.g. drugs and the kidney) not as useful as specific emergency
therapeutics topics (e.g. management of shock)
• We continue to seek balance between these two areas
• A general approach to addressing therapeutics problems will remain of value even
as new drugs are continuously developed into the future
Course Objectives
• The following objectives are grouped by Geisel
Competencies
• The column on the left shows the old objectives and
the column on the right shows the new proposed
objectives.
Course Objectives
Objective 2014
Objective 2015
Medical Knowledge
Medical Knowledge
Review basic pharmacology of a number of common
drugs
Describe basic principles of biostatistics as it applies to
studies of drugs (both observational and interventional)
1a
3
Review common serious diseases (e.g. MI), common
medical emergencies (e.g. anaphylaxis) and their
treatment
1c
4
Describe how clinical pharmacology bridges basic
pharmacology and clinical medicine, and utilizes
knowledge from new areas such as pharmacogenetics
1d
5
Describe the clinical pharmacology of drugs used to treat
pain, for palliative care, etc. Explain medical-legal issues
related to drug development and prescribing, ethics of
clinical and translational research, ethics of relationships
with drug companies
1e
Explain medical-legal and ethical
1e
issues related to drug development
and prescribing, clinical and
translational research, and drug
advertising and promotion
6
Explain the various ways that drug therapy plans need to
be individualized to fit the needs of the unique patient
1f
Explain the various ways that drug
therapy plans need to be
individualized to fit the needs of
the unique patient
1
2
1b
Dropped
Describe basic principles of
biostatistics as they apply to
studies of drugs (both
observational and interventional
studies)
Review optimal drug therapy of
common serious diseases (e.g. MI)
and medical emergencies (e.g.
anaphylaxis)
1b
1c
Dropped
1f
Clinical Skills
2014 Objective
7
8
9
10
Course Objectives
Discuss the importance of the therapeutic contract
or alliance
2015 Objective
2a,3d
Explain all of the parts of the complete drug and
ADR history
2b
Demonstrate how to document a complete drug
history, and history of prior ADRs
2d
Demonstrate the importance of developing an
expanded differential diagnosis for each patient
2e
Describe the importance of the therapeutic contract or alliance
2a,
3d
Explain all of the parts of the complete drug and ADR history
2b
Demonstrate the ability to recognize, understand, and work to
prevent drug interactions
2d,
2e
Demonstrate numerical skills necessary to estimate GFR,
calculate appropriate loading dose, calculate appropriate
maintenance dose
11
Understand common and simple clinical
procedures (i.e. venipuncture, catheterization,
simple suturing) and be able to perform these
procedures under appropriate supervision
2f
12
Demonstrate how to use sophisticated electronic
database about drugs
2g
13
Explain how therapeutic drug monitoring can be
usefully applied to specific drugs
2h Explain how therapeutic drug monitoring can be usefully
applied to specific drugs
14
Understand and participate in the performance of
common operative procedures (i.e. appendectomy,
laparotomy, pelvic surgery, complicated labor and
delivery)
2i
2f
2h
Course Objectives
Interpersonal Communication
2014 Objective
15
16
17
2015 Objective
Demonstrate how to
3a
counsel patients about
their choices for drug
therapy
Explain all of the important 3b
parts of the complete drug
history
Discuss the importance of 3c
printing up drug
information for patients
18
Communicate effectively in
all media with physician
colleagues
3d
19
Create a complete,
unambiguous, and legal
drug prescription
Participate actively in case
discussions and problem
sets
3e
20
3f
Demonstrate how to counsel
patients about their choices
for drug therapy
Write a complete,
unambiguous, and legal drug
prescription
Participate actively in group
and class case discussions
3a
3e
3f
Developing Professional Identity
2014 Objective
21
22
23
24
25
26
27
28
29
30
Demonstrate respectful behavior during class
discussions
Show responsibility by meeting all class
deadlines for written assignments
2015 Objective
4a
4b
Participate actively in the discussion about
4c
potential physician conflicts of interest in
prescribing medications
Develop your own personal approach to dealing 4d
with pharmaceutical representatives in an
honest and responsible manner in the future
Discuss ways to relate to patients who have
questions about alternative medical treatments,
and their potential interactions with
prescription drugs
Accept responsibility for all of your written
assignments and grades
Discuss how concerns about patient
confidentiality affect how you write
prescriptions
Develop your own personal plan for keeping up
with changes in the pharmacopeia each year
4e
Demonstrate personal responsibility by meeting
all class requirements and written assignments in
a timely fashion
4b
Develop your own personal approach to dealing
4d
with pharmaceutical representatives in an honest
and responsible manner in the future
Discuss ways to relate to patients who have
questions about alternative medical treatments,
4e
and their potential interactions with prescription
drugs
4f
4g
4h
Discuss the risks of substance abuse in residents 4i
and physicians
Discuss the financial implications, pros, and cons 4k
of generic vs branded drug products
Develop your own personal approach to keeping
up with changes in the pharmacopeia each year
4h
Discuss the financial implications, pros, and cons
of generic vs. branded drug products, direct to
4c
Lifelong inquiry/improvement
31
32
2014 Objective
Demonstrate ability to find accurate, up-to-date 5a
resources for drug information for two required
papers
Analyze recent primary papers about drug
therapy for accuracy, validity, and statistical
rigor
Evaluate and assess clinical care processes and
outcomes in the practice environment in which
they particpate, and understand how this
measurement relates to the improvement of
care for groups of patients
5b
Utilize the technique of root cause analysis to
discover how serious medication errors
occurred, and to identify opportunities for
improving the healthcare delivery system for
drug therapy
5d
35
Describe where you will look in the future to
obtain unbiased and accurate information
about new drugs that are approved by the FDA
5e
36
Create a learning environment within one's
own practice
5f
33
34
2015 Objective
Demonstrate ability to find accurate, up-to-date
resources for drug information
5a
Analyze recent primary papers about drug
5b
therapy for accuracy, validity, and statistical rigor
5c
Utilize the technique of root cause analysis to
discover how serious medication errors
occurred, and to identify opportunities for
improving the healthcare delivery system for
drug therapy
Describe where you will look in the future to
obtain unbiased and accurate information about
new drugs that are approved by the FDA
5d
5e
Systems based Practice
37
38
39
40
41
42
43
44
45
2014 Objective
Describe how CP On Line can be utilized in daily
decisions about drug therapy, and to optimize
drug prescribing
Describe how accurate communication with
nurses and pharmacists leads to better and
safer patient care
Describe when and how generic drugs should be
prescribed over branded drugs
Discuss the relationship between prescribing
physician, nurse, and pharmacist, with
emphasisis of medication errors and their
causes
Describe the role of physician, drug companies,
pharmaceutical reps, and advertising in
affecting prescribing practices
Explain how the concept of a "core formulary"
can relate to providing the most cost-effective
care to a population of patients, when
inadequate funding is a real concern
Discuss how various outcome studies, including
meta-analyses, are useful in ascertaining
optimal drug management of various conditions
6a
6b
2015 Objective
Demonstrate how CP Online can be utilized in
daily decisions about drug therapy, and to
optimize drug prescribing
Describe how accurate communication with
nurses and pharmacists leads to better and safer
patient care
6a
6b, 6d
6c
6d
Was redundant with 38
6e
6f
6h
Describe the importance of the physician as
6i
prescriber to serve as a catalyst for safer, more
effective, and less costly patient care
emphasized through many examples
Describe how you will work to individualize the 6j
drug therapy plan that you develop for each
individual patient, taking into account the many
variables that make each patient unique
Describe the importance of the physician as
prescriber to serve as catalyst for safer, more
effective, and less costly patient care
6i
Describe how you will work to individualize the
drug therapy plan that you develop for each
individual patient, taking into account the many
variables that make each patient unique
6j
Course Objectives – Geisel Competencies
There are 24 course objectives that fulfill Geisel
competencies as follows:
•
•
•
•
•
•
4 address knowledge
5 address clinical skills
4 address communication skills
5 address components of professionalism
4 address personal improvement
4 address systems based practice
Course Objectives – Geisel Program Objectives
The course objectives fulfill the program objectives as follows:
• Course objectives address 4 of the 6 program objectives for Geisel
competency 1
• Course objectives address 6 of the 9 program objectives for Geisel
competency 2
• Course objectives address 4 of the 8 program objectives for Geisel
competency 3
• Course objectives address 5 of the 12 program objectives for
Geisel competency 4
• Course objectives address 4 of the 6 program objectives for Geisel
competency 5
• Course objectives address 5 of the 10 program objectives for
Geisel competency 6
Course Objectives – Geisel Program Objectives
Comment here about information on previous slide.
• Are there subdomains that need greater emphasis?
– No
• Are there subdomains that aren’t addressed at all? If
yes, it is appropriate for this course?
– Yes
Course Objectives – Format/Distribution
• Do they provide course objectives in the syllabus?
– Yes
• Are they written in the correct format?
– Yes
• Do the course objectives distributed in the course
match the ones in Ilios?
– No, new ones need approval
Course Objectives – AAMC
• Comment on correlation between course objectives and what
is available in a national discipline-oriented organization, if
applicable
– AAMC MSOP - Report X - 2008
• Contemporary Issues In Medicine: Education In Safe and Effective
Prescribing Practiced
– Cover all but:
» Understand how cultural background can alter patient views of
drug therapy and disease causation
» Know role of hospital pharmacy and therapeutics (P&T)
committees
» Understand how the system can support or hinder complex
prescribing, such as for substance abuse, palliative care, and
home treatment with antibiotics
Session Objectives – Format/Distribution
• Do they provide session objectives in the course
materials?
– Yes, within power-point slides
• Are they written in the correct format?
– Yes
• Does each session objective map back to a course
objective (Ilios)
– Yes
• Do the session objectives match what is listed in
Ilios?
– No
Vertical Integration
– Prescription writing – “prescription” searched in Ilios
• Course Objective – Year 2 Pharm 217: Explain what is required to write a
complete, unambiguous, and legal prescription and also what is required
to insure the patient is fully counseled about medications, their drug
history is comprehensively evaluated and they have printed drug
information
• Course session – Year 2 Pharm 217: H-10 Nierenberg - Approach to
Prescription Writing 8-May 8:00am - Summarize the eight critical parts of
a complete, non-ambiguous, and safe outpatient prescription
• Course session – Year 3 PSCH 302: Psychopharm: Drug Prescriptions
• Essential Skill – Year 3 PEDI: Write a pediatric prescription, dosing by
weight, for a medication
Vertical Integration
• Pain Management
– Course objective
• SBM 210 apply knowledge of pain management to clinical problem
solving in MSK medicine
• ICE, OBGYN, Surgery – Year 3: Apply knowledge of pain management to
clinical problems
• Neurology Year 4: same as above
– Session
• Phar 217: Opioids and Pain Management
• Phar 217: Principles of Pain Management
• Surgery: Abd Pain small group
• ICE: Pain management
• Medicine Essential Condition: Acute Pain
• AMS: Managing GI Crises
• CPT: Approach to Pain management
Vertical Integration
• Drug Allergies
– Session Objective
• Immunology and Virology: Hypersensitivity 1
• Peds: Diagnostic reasoning: Illustrate complete history including
allergy history
• CPT: Emergency Therapeutics 1: Drug Allergies
Special Topics
• Inter-professional Education
– Session 22: View from Pharm and RN Vantage
• Cultural Awareness
– Session 42: Genetics???
Summary regarding Objectives
• Considerable effort made to decrease number and
streamline course objectives all of which seemed
appropriate to the subcommittee
Summary regarding Objectives
• Last year’s action plan was implemented.
• Course and session objectives require updating to
the 2014-2015 academic year.
• Competency subdomain mapping should be
reviewed as detailed in previous slides.
• Current course objectives overlap significantly with
AAMC and BJCP objectives.
• No redundancies were noted between the Year 2 and
Year 4 pharmacology courses.
Course Learning Opportunities
• 47 total hours
–
–
–
–
Lecture (didactic and case based with ARS) 36 hrs. (77%)
Small Group Conferences 4 hrs. (9%)
Large Group Conference 4 hrs. (9%)
Test 3 hrs. (6%)
Course Learning Opportunities
• Comments about pedagogy (e.g. are they doing
anything unique? how much active learning?)
– Small groups assigned problem sets then discussed in large
group format with small groups being called upon to give
answers (MBA model)
– Case based assessments
– Session with Pharm. D and RN
Summary regarding Pedagogy
• Several unique sessions
– Small group MBA style
– Session lead by Pharm D and RN
Assessment
• Does each Course Objective have an Assessment?
– Unclear
• Course is Pass/Fail (for past 2 years)
• Must obtain 70% score in 3 areas
– Knowledge/application
• ~3 MCQ after each learning session (replaced old MCQ final)
– Case Analysis/Writing
• 1 page paper case analysis of possible drug/drug interactions
• 5 page paper – student prepared case and analysis of clin
therapeutic question
– Final Exam (open book/computer)
• Apply learned general approaches to 2 real complex cases
Assessment
• Do the questions correlate well with session
objectives?
– Yes
• Is the emphasis of the exam balanced (i.e. not too
many questions on any particular topic)
– Yes
Assessment
• Other activities that are assessed?
– No
• Are students provided with narrative feedback?
– Papers have written feedback
Summary regarding Assessment
• Improvement made with regards to Pass/Fail format
and open-endedness of assignments.
• Content of quizzes were not always matched to
session objectives or material covered in lecture.
• Clarity of quiz questions and/or format needs to be
improved.
Measures of Quality – Course Reviews
scale [1=poor; 2=fair; 3=good; 4=very good; 5=excellent]
CPT
2012
(%)*
CPT
2013
(%)*
CPT
2014
(%)*
CPT
2015
(95%)*
Overall satisfaction of course*
3.59
Overall usefulness of lectures
3.85
Overall usefulness of small groups
3.61
Overall usefulness of large groups
3.88
*student participation rate on course evaluation
Measures of Quality – Course Reviews
• Strengths: instructor enthusiasm; real clinical cases;
open-ended essay; daily quizzes
sample comments:
•
•
•
•
“Great, entertaining, and informative lectures.”
“Loved the examples!”
“Clinical cases helped focus in the material.”
“Daily quizzes kept me on top of the material and got
me to review the ppt after lecture…”
Measures of Quality – Course Reviews
• Strengths: small group discussions; ethical issues,
emergency therapeutics lectures, drug interactions,
prescription writing
sample comments:
• “Great team based learning and fun to interact with
classmates.”
• “The specialist’s powerpoints were very helpful, such
as Dr. Bensen’s GI lecture and Dr. Duncan’s
psychiatric emergency lecture.”
Measures of Quality – Course Reviews
• Suggestions for Improvement: organization of cases
for small group, timing of small vs. large group
sample comments:
• “Please compile cases for Friday discussion.”
• “…there could have been less time given to individual
groups to discuss and more time to discuss as a
whole class, since we kept running out of time.”
Measures of Quality – Course Reviews
• Suggestions for Improvement: assessments;
electrolyte management; women’s health; MI
lecture; consider apps for pharmacology
sample comments:
• “Quizzes or final exams in this setting seems to be
unnecessary and a waste of time.”
• “Prescriptions related to women’s health (not only
during pregnancy)”
• “There should be a simplified lecture about treating
acute MI.”
Measures of Quality – Course Reviews
• Suggestions for Improvement: written assignment
grading, time points of assignments/final exam
sample comments:
• “Grading criteria were not at all clear, and many
students feel that grades differed significantly based
on whether Dr. Nierenberg or Dr. Lewis were
grading…”
• “The final exam was announced on Oasis as 9-12pm,
which is why quite a few students weren’t aware of
the 11am actual end time.”
Measures of Quality – Course Reviews
• Post and pre-op perspective
– “Perhaps a lecture from a surgeon’s point of view
on managing common post-op complications
medically.”
• Scheduling of course
– “No student enjoys having a three hour gap in the
middle of the day.”
• Reference document?
– “A brief compiled summary of the most important
topics would be nice. Something we could print
out and reference for the future.”
Summary regarding Measures of Quality
• Emergency therapeutics/acute crises management
material well-received.
• Improvements were made in regards to assessment.
• Guest lectures offered specialty-focused material,
although room for improvement in Surg/OB.
• Written directions and deadlines of written
assignments may need to be clarified.
• Scheduling of course may need to be coordinated
with HSP to increase attendance.
Recommendations
• Continue with revised course objectives as written for 2015 with exception
of maintaining 1st objective with the wording…
– “Review basic pharmacology of a number of NEW drugs”
• Consider adding session objective for “core formulary” as this was
removed from course level objective but felt to be a very important
concept
• Provide grid showing new objectives and the assessments that match
them
• More clearly designate and provide cases to be discussed in small group
sessions
• Explore option to include discussion on how a patient’s culture may effect
drug choice
• Work with OB and Cardiology to improve quality of their lectures
Action Plan