Academic Exchange Quarterly Spring 2003: Volume 7, Issue 1

A Web Based Course in Clinical Pharmacology

Lars Osterberg, MD

Chief of General Medicine, VA Palo Alto Health Care System

Clinical Assistant Professor of Medicine, Stanford University School of Medicine

Doctor Osterberg is involved extensively in the education of medical students at Stanford University School of Medicine where he teaches several courses.

Co-authors:

Carl-Olav Stiller, MD, PhD, Associate Professor of Clinical Pharmacology

Karolinska Institutet, Sweden

Elisabeth Tornqvist, Information Pharmacist and Course Administrator

Karolinska Institutet at Huddinge University Hospital, Sweden

Mary Ayers, Computer Specialist and Course Administrator, SUMMIT (Stanford University Medical Media and Information Technology), Stanford University School of Medicine

Pat Youngblood, Visiting Scholar in Education, SUMMIT (Stanford University Medical Media and Information technology), Stanford University School of Medicine

Pia Bastholm, Course Assessments, Karolinska Institutet at Huddinge

University Hospital, Sweden

Phyllis Gardner, MD, Associate Professor of Medicine, Division of Clinical Pharmacology

Stanford University School of Medicine

Lars L Gustafsson, MD, Professor, Division of Clinical Pharmacology,

Karolinska Institutet at Huddinge University Hospital, Huddinge, Sweden

Abstract

Because of the many new drugs available and the vast information on the appropriate usage of newly approved drugs, improved methods are needed to teach medical students clinical pharmacology. We developed a case based course in clinical pharmacology on the web for advanced medical students. Twenty cases outlining several key learning objectives centered on two goals: learning key clinical pharmacological principles and learning how to find the relevant medical information using the web. During this intensive two-week course, students spent the day solving simulated patient cases on the web using the PharmapaC tool (www.pharmapac.org). The course improved students’ knowledge of clinical pharmacology and their ability to search the web for evidence-based medical literature. This method of teaching advanced clinical pharmacology serves as a model for ongoing self-directed learning and is an appealing way to learn clinical pharmacology.

Introduction

With the cost of drugs rapidly rising and the proliferation of newly approved pharmacotherapies it is imperative that medical students be educated on the most up-to-date drug treatments. Furthermore, the students need to strengthen their critical thinking so their proficiency in critical drug evaluation can match strong marketing efforts by drug companies.[1,2] To accomplish this, new approaches are needed in medical school curriculums to teach clinical pharmacology.[3-5] We have designed a course in clinical pharmacology for advanced medical students using the world-wide-web. Advances in technology have enabled instruction on the web to be highly effective.[6-8] Advantages to using the web for medical education include, but are not limited to: 1. Distance learning 2. Access to up-to-date literature 3. Access to digital images, videos, and sound 4. Self paced and self directed learning 5. Around-the-clock access.

The teaching of clinical pharmacology is particularly suited for utilizing the Internet for education since traditional pharmacology textbooks often have outdated material as soon as they are published.[9,10] However, liberal [RJT1] use of the Internet as a source of information can also be a disadvantage for learning since there are many false advertisements and misinformation published through the Internet.[11,12] Since drug companies also use the Internet to advertise their medications to influence both physicians and patients, students need to be trained in how to critically evaluate the literature and the information in order to identify misleading information. This paper presents a two-week intensive course that utilizes the world-wide-web and advanced computer applications to teach the principles of pharmacotherapy by having medical students search for answers using the Internet.

Objectives

The two main goals of the course were to: increase the student’s knowledge of clinical pharmacology principles, which include the assessment of adverse drug reactions and the anticipation of interactions and personalized medicine according to the principles of evidence based medicine. In addition, this course was aimed at teaching how to search and critically evaluate the medical literature.

Traditional teaching of basic pharmacology is focused on the mechanisms of action and pharmacokinetic properties of drugs. However, the students are not trained how to apply what they know about medications to patient care. They learn how to apply drug therapy to patients during third and fourth year clerkships under the guidance of their interns, residents and attending physicians [RJT2] . In these situations (on the wards or in the clinics) the students themselves, however [RJT3] , are not making the decisions, [RJT4] but are usually following the recommendations of their supervisors. In order to learn effectively, students should be given opportunities to participate in the decision making for the optimal pharmacological treatment and work out patient cases on their own.[3,13] By creating realistic, simulated patient scenarios on the web, we are able to allow students to work-up a hypothetical patient and make decisions about drug treatment and interpret clinical data without any potential to cause real patients harm.

Methods

The course was developed in collaboration with The Stanford University School of Medicine and the Karolinska Institutet in Stockholm, Sweden partly funded by a grant by The Wallenberg Foundation. The course was taught as a two-week pilot course during the Spring quarter of 2001 to a group of 6 medical students from Karolinska Institutet and 6 medical students from Stanford University and then again in the Spring of 2002 to five Stanford Students and four Students from the Karolinska .During the initial course in 2001, the Swedish students came to Stanford the first week to work together with their American colleagues to work up cases on the web. The outline of the cases were prepared by primary care practitioners in Sweden and the U.S., and then modified by clinical pharmacologists, medical subspecialists, and medical educators to emphasize the course objectives.

The patient cases described patients that a general practitioner would meet in real life and with common diseases such as hypertension, depression, diabetes or chronic obstructive lung disease. Digital images, videos, and sound were added to the cases to make them more realistic. All data about the cases as well as all digital links were stored in a database in the Case Record. Case builders/teachers were able to introduce text and links without any skills in HTML-coding or programming. All cases had a unique structure and no limitations were set as to length or ramification of case. The links used would sometimes be in Swedish.

Throughout the course, the students had full access to the databases at the university libraries. In addition, it was possible to present links to key journal articles, book chapters and other reference material to explain the most appropriate treatment strategies. The course began with a tutorial on literature searching prepared by a medical librarian with expertise on medical literature retrieval. Twenty cases were prepared in all and learning objectives of each case were provided to the students prior to working up each case. Throughout the case work-up, students were asked questions related to the case that they would have to answer before a model answer was given. They could use the web to search the literature and they were encouraged to collaborate with their classmates for the answer. After completing a number of cases (one to three cases daily) a group seminar was held to review the key learning objectives. One advantage of the program was the ability to present all student answers to a particular question without identifying the author. This allowed for discussion of student answers in class using a digital projector of case without making the students feel threatened or embarrassed. Students were encouraged to collaborate by e-mail and chat when not working together in the same room or environment. This was of importance when links sometimes were in Swedish.

The questions that were asked of the students during their case work-ups assessed their knowledge of the learning objectives and each case ended with a quiz that assessed their mastery and retention of the learning objectives. By leading students to the answers through links to evidence-based resources, we enhanced the students’ ability to perform self-directed learning and guided them on how to search the literature using the web. After students gave their answer to a question, we provided them with a model answer to reinforce what they learned or to guide them in the event they were led astray. The course taught in the Spring of 2002 included a pre and post test of clinical pharmacology and of searching the literature with a total of 10 questions. This course used only 10 revised cases (compared to 20 in the first course) in the 2 week period The pre-test questions were different from the post-test questions, but were matched to include similar degree of difficulty and content.

Course Evaluation

Both the Stanford and Karolinska students indicated their approval of the course and that they enjoyed participating in it. They either agreed or strongly agreed that they would recommend the course to someone else. Students from both universities liked the style of the course in general and agreed that the two-week time frame and length of the seminars were sufficient. The students were most critical about the technical difficulties [e5] with the computers and the time pressure on them for solving the cases prior to the case discussion in the seminars. They did feel the cases were well done, logical and realistic. They did suggest that the questions were at times too long and could have been broken down into a few more focused questions. They felt that getting to know their colleagues and working with them was useful, however they felt the chat function was not useful. They felt that they did not have enough time to chat about the case in the hour allotted especially since chat sessions do not allow a person to put a question “on hold” and then get back to it after they had thought about it or read more. Students also felt the Case Record of the patients was not easily reviewed. [e6] . The Stanford students were not happy to find that sometimes the only web link to a case was in Swedish and then there was not enough time to find a Swedish colleague with whom to discuss the link. The Swedish students were disappointed to discover that some of the online resources they used in the U.S. were no longer available to them when they returned to Sweden as these sites were restricted to those with only Stanford affiliation. However, Swedish students were able to use clinical guidelines or databases and websites in Swedish language. Students would have also appreciated more feedback midway through the course on how they were doing with their responses to the questions. Student performance during the second year, on the post-tests compared to the pre-tests were unanimously improved except for one student whose score was unchanged.

Discussion

After these pilot courses, we realized that we were overly ambitious in our expectations of the performance of the medical students. We had far too many cases and questions for the students to solve during the two-week period and many students became frustrated since they couldn’t actively participate in the seminars without having completed the cases before the discussion sessions. Some of the technical difficulties slowed them down as well as further complicating their learning of the material. The students did receive the course well and with the reduction of the second year course to only 10 cases and focusing the learning objectives to the two main themes (clinical pharmacology and literature searching), we achieved greater student satisfaction. The students that participated in pre and post course testing in the second year all showed improvement except for one student whose score was unchanged. This may have been because this student had scored high on the pre-test and therefore had little room for improvement. The general improvements in the scores on the post tests could be criticized due to a greater degree of difficulty in the pre-test compared to the post-tests. This is currently being reviewed by reversing the order of the tests (using the previous post-test as a pre-test and vice-versa). Preliminary results with 4 out of 5 students have shown that reversing the pre- and post- tests still leads to consistently improved post-test scores.

We will be expanding the pre- and post- tests to more questions and to assess the degree in which other students taking traditional pharmacology courses improve in the pre- and post- testing. Our hypothesis is that our method of teaching clinical pharmacology and teaching retrieval of medical information is superior to traditional methods and that students using PharmaPaC will have more improved performance in the post-testing than the students using the traditional methods [RJT7] .

We have continued to use fewer cases than the original plan of 20 cases and have corrected the technical problems we had last year. We are improving the interface of the web-pages and adding web link-checking in addition to improving the content of the course material. We will also continue to focus our questions on topics of clinical pharmacology or searching the literature.

This case based method of teaching is ideal particularly for students to learn about making their own decisions about drug treatment and applying self directed learning. Using the PharmaPaC tool, students make their own decisions and subsequent to their decision, a “model” answer is given to guide them down the preferred path of treatment or testing. We also feel that this is the way students will be learning about medicine in the future. As lifelong learners, they will not be “spoon fed” the facts they need to know in lectures or seminars and they will need to take a more active role and practice self-directed learning. The web is already a key resource to many physicians in learning how to care for patients. Teaching students early on how to properly do this and making sure they are finding high quality information is important early in their training. Lifelong learning in medicine is required. Doing this properly and effectively requires training and it makes the most sense to do so in the midst of medical student training. The fact that the course is run in two different countries increases the students’ awareness that good evidence for optimal treatment is universal and does not stop at borders.

Conclusion

With the advancement of digital technology, images and sounds of patient exam findings and studies can be transmitted over the web to make cases realistic and comprehensive. In addition, direct access to on-line literature sources makes retrieval of medical information fast and efficient. The PharmapaC tool that employs case-based teaching using the world-wide-web and advanced digital technology is well received by medical students and demonstrates success in teaching clinical pharmacology through self-directed learning. It remains to be proven, however, if this method of teaching is superior to the traditional methods of teaching clinical pharmacology.

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Acknowledgements

We are grateful to all efforts by several members of the development team at Karolinska Institutet, Stanford University School of Medicine and at Umea University. This work was supported by grants and resources made available from the Wallenberg Foundation, Karolinska Institutet, Stanford University, SAREC (Swedish Agency for Research Collaboration with Developing Countries) and Stockholm County Council.