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Table of Contents
ORIGINAL ARTICLES
Year : 2022  |  Volume : 5  |  Issue : 2  |  Page : 53-61

Authentic pharmacotherapy case study enhances learning outcomes in pharmacology in preprofessional undergraduate students


1 Biomedical Sciences Department, Grand Valley State University, Allendale, MI, USA
2 Department of Pharmaceutical Sciences, South University School of Pharmacy, Savannah, GA, USA

Date of Submission11-Apr-2022
Date of Acceptance26-Jul-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
Dr. Babasola Fateye
Biomedical Sciences, Grand Valley State University, 316 Henry Hall, Allendale, MI 49401
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EHP.EHP_9_22

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  Abstract 

Introduction: Professional health training curricula that integrate basic and clinical sciences are associated with improved learning outcomes. Authentic clinical case studies that capture the complexity of a typical patient are frequently used in clinical training programs to model to students how to integrate information across disciplines to justify management plans. The value of such authentic case studies in preclinical students is less studied. This study seeks to know (i) if preclinical students in a large midwestern liberal arts college would be interested in participating in an optional case study assignment and (ii) if participation is associated with improved learning outcomes in a third-year pharmacology course. Material and Methods: Demographics, motivation, and vocational experience were assessed by an online survey. Binary multivariate logistic regression was used to assess the relationship between participating in the voluntary case study and performance on case-related and noncase-related questions. Results: More than two-thirds of the students participated in the case study, and their decision was driven largely by interest and/or experience in a healthcare vocation. Completing the case study was associated with better performance on case-related multiple-choice questions on midterm exams (Wald’s χ2 = 2079; P < 0.001). Conclusions: This study suggests that there are potential benefits to using case studies in preclinical curricula to drive improved student outcomes by underscoring the link between prerequisite courses and clinical practice. It also proffers a potential tool for assessing the efficacy of case study interventions.

Keywords: Case study, healthcare education, integrated curriculum, preprofessional


How to cite this article:
Fateye B, King AO, Adeniji A. Authentic pharmacotherapy case study enhances learning outcomes in pharmacology in preprofessional undergraduate students. Educ Health Prof 2022;5:53-61

How to cite this URL:
Fateye B, King AO, Adeniji A. Authentic pharmacotherapy case study enhances learning outcomes in pharmacology in preprofessional undergraduate students. Educ Health Prof [serial online] 2022 [cited 2022 Dec 3];5:53-61. Available from: https://www.ehpjournal.com/text.asp?2022/5/2/53/355841




  Introduction Top


The terms “prerequisites” and “preprofessional” connote—at least to students—educational content that once completed and are no longer required in future professional training and careers. The traditional approach to health professions training starts in undergraduate institutions with preprofessional undergraduate curricula that cover foundational biomedical sciences (anatomy and physiology, pathophysiology, pharmacology, etc.). Simultaneously, students complete the prescribed didactic and experiential pre-requisites for admission to professional graduate schools.[1],[2],[3] However, in virtually every professional health training program, increasingly, there is a shift toward the integration of the basic sciences with the clinical sciences.

Integration, in the scholarship of teaching and learning literature in clinical professions, most commonly pertains to the integration of the basic and clinical sciences within the entire program curricula.[4],[5],[6],[7],[8],[9],[10] Curricula are generally classified as “horizontally” or “vertically” integrated.[7],[8],[10],[11] In horizontally integrated curricula, students learn content around unifying themes (e.g., body systems, categories of disease) and within a finite period of time; content is drawn from biomedical science courses (biochemistry, physiology, pharmacology), social and behavioral sciences (psychology, sociology, etc.), and clinical sciences.[6],[10] Vertically integrated curricula are divided into the H- and the Z-formats.[10] In Z-type vertically integrated curricula, there is a gradual change from predominant basic medical science content initially to clinical training almost exclusively in the latter years of training, whereas in the H-type, basic science is essentially a discrete phase in which students have little or no clinical exposure.[10],[11] The preprofessional model where students complete prerequisite courses in the basic and applied sciences before transitioning to clinical training (often in new institutions or in another department within the same institution) fits with the H-type vertical integration model .

Operationally, clinically integrated curricula are described as one that emphasizes “clinical problem-solving using case studies, collaborative learning, and application-based assessments as methods of instruction.”[12] Improvements in the immediate and long-term learning outcomes and student goals have been attributed to integration. Even a head start to clinical reasoning among preprofessional undergraduate basic science courses may pay dividends in immediate course outcomes and later.[12] Wijnen-Meijer (2009) documented an increased rate and earlier commitment to professional specialties among medical students who had been exposed to clinically integrated curricula.[11]

From a pedagogical perspective, case studies create an opportunity for instructors to model the decision-making process of the expert practitioner to novices, thereby empowering the latter to attain higher orders of learning (e.g., analysis, synthesis, and evaluation). Case studies have been used in teaching pharmacology and therapeutics in advanced clinical students with improved affective and cognitive outcomes.[13],[14] Most published reports of the effectiveness of case studies have been done in the context of clinical stages of programs (e.g., nursing students in clinical preceptorship[15] or in graduate clinical programs[16],[17],[18],[19],[20]). There is a dearth in the literature, of reports of clinical case studies in undergraduate preprofessional students.

Ma et al. analyzed and differentiated the content of clinical case studies based on three drug-related disciplines—“mechanism of action, pharmacology, and pharmacotherapy”—based on the National Board of Medical Examiners (NBME) guide.[21] Pharmacotherapy cases “assessed students’ knowledge of the use of pharmaceuticals to treat disease,” and involved integrating multiple dimensions of the case presentation. For our purposes, we described such complex pharmacotherapy case studies as “authentic” cases because, like real patient files, they include the patient’s multiple diseases, multiple medications, physical examinations, lab tests, genetics, and other determinants of disease, etc. In authentic cases, therefore, students interpret, prioritize, and apply (i.e., integrate) multiple information in order to justify an individualized treatment goal.

Hoffman described an example of a case study used in the undergraduate nursing education[22] in which students were presented with a vignette of a patient and asked eight questions: three nursing-specific and five that implicitly required students to revisit information from “prerequisites” as they consider the patient’s assessment data and clinical manifestations (pathophysiology) to justify rational drug therapy (pharmacology/therapeutics). The vignettes such as the one reported by Hoffman are usually reduced to focus on a single organ system with germane, but limited information. Such case studies are akin to “mechanism of action” and “pharmacology” case vignettes as defined by Ma et al.[21]

From the Vygotskian constructivist perspective,[23] conceptual relationships between basic and clinical science translate discrete facts into concepts that can then be used to justify clinical decisions. Professional students in clinical programs are required to build the conceptual relationships across and between the contexts of didactic instruction in the classroom with direct patient care in the clinic; in this model of the integrated clinical training, they are expected to integrate foundational and clinical sciences. We posit that preclinical students can be introduced to the habit of mind of foundational–clinical science integration. However, there has been little empiric evidence to support the use of authentic case study in students that are not yet in the clinical training phase. Many of these students have jobs in healthcare either for financial need or often as requirements for admission to health programs.[2],[3] By presenting information that requires multiple disciplines and skills especially through a clinical case study, students are forced to integrate information from the current and previous preprofessional coursework and across disciplines.[11],[12],[22] In this context, students have the unique opportunity to consider the whole patient and to obtain cues from prerequisite classes, from research, and from peers in a collaborative endeavor to manage the patient’s case. This begs the question why authentic cases are not widely used in preclinical students?

There are a lot of challenges and benefits to introducing clinical cases in preprofessional programs. First, there are concerns that introducing clinical reasoning earlier may cause cognitive overload and that it is difficult to objectively document learning gains[12]; second, many basic biomedical science programs lack faculty with clinical experience.[10],[12] In most cases, students are removed temporally and institutionally from clinical experiences. Many liberal arts colleges are not set up to teach clinical sciences except in the exceptional cases where instructors are also practitioners. These instructors provide such clinical experiences on their own volition.

Here, we report the experiences of undergraduate preclinical students that completed an authentic pharmacotherapy case study in a large mid-western (USA) university. This study models key aspects of clinical reasoning—the cognitive operations that help “observe, collect, and analyze information, resulting in actions that take into account a patient’s specific circumstances and preferences.”[12] The unique approach in this study is (i) we used an authentic case study that presents the full complexity of patient care and not a reductionist clinical vignette; (ii) we explicitly asked students to integrate pertinent basic and applied biomedical sciences in justifying pharmacotherapy choices; e.g., to compare physicochemical properties of drugs and congeners to their pharmacokinetic characteristics or to justify the choice of drug therapy by relating prerequisite content (e.g., pathophysiology at the cell and molecular level) to pharmacodynamic properties of drugs; and (iii) we temporally scaffolded the case such that it complemented didactic course content where possible [Table 1].
Table 1: Alignment of the case with didactic content

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Our specific objectives of this article are: (i) to determine the proportion of students that signed up to do the optional, semester-long authentic case study; (ii) to determine what aspect of the case study was relevant to students and motivated (personal, vocational) them to do the case study; and (iii) to assess if the participation in the case study is associated with improved performance on relevant examinations.


  Materials and Methods Top


Study context: The class: Composition and instructional methods

The course, Pharmacological Aspects of Biomedical Sciences, is a 300-level course that “introduces students to the principles of pharmacology and the pharmacological aspects of the major classes of drugs used in the treatment of disease....” The class comprises upper-level students in a liberal arts college; many are not yet committed to a professional path (Biomedical Science majors; BMS), but most are preprofessional Allied Health Science (AHS) majors (prephysician assistant, premedical, and prepharmacy). The course is required for many students in the physician assistant (PA) program (graduate) and is an elective for the BMS major and other AHS majors. The class is taught in the traditional, sequential, and vertical manner around organ systems. In the sequence of courses, students take Introductory Biology, a sequence of three Anatomy and Physiology courses and Pathophysiology. The class was presented as a traditional face-to-face (W21, F21) or online (W21OL, F21OL).

Clinical case study

In 2019, the case was adopted from a course textbook by the authors, who are all licensed pharmacists and modified over the next three semesters. Because not all students are going into clinical careers, the case study was an optional assessment. To incentivize students to do it, the cumulative scores on the case study could replace the lowest one of four midterm exams. Teamwork is an important part of clinical care. Therefore, students were grouped into pairs; occasionally, there were student groups of three and some who preferred to do it alone.

Student demographics and relevance of the case study

We assessed the relevance of the case study to students’ lives—why and how they connected with it, using a modified Hartwell and Kaplan’s relevance questionnaire.[25] Anonymously, the questionnaire was sent to students as Qualtrics survey in the 12th week of the semester. The questionnaire included Likert scale and open-ended questions.

Impact of the case study on learning outcomes

In Fall 2021, students were allowed to choose any of the case patient’s diseases to develop a therapeutic management plan. We investigated the performance of students who did the case study and those who did not in both OL and traditional sections of the Fall 2021 semester. We selected all multiple-choice questions that had discrimination index greater than 0.2 in both OL and traditional sections of the course in Fall 2021.[26] A multiple-choice question on the exam was classified as a case-related question (CRQ) if it assesses the knowledge of (i) a drug (or another congener in the same drug class) that is covered as a part of the content in the current module of the class; (ii) any one of the patient’s comorbidities and/or drugs included in the patient’s drug history; (iii) the drug listed in the question stem or in the answer choices of the module exam. For example, a question that assesses knowledge about nifedipine (a drug covered in the module on cardiovascular pharmacology) is considered a CRQ if the question is about a patient’s previous or current cardiovascular disease for which a calcium channel blocker is indicated (the patient in the case has hypertension [HTN] and his drug history included amlodipine, a congener of nifedipine). Questions that do not meet these criteria are considered noncase–related questions (NCRQ). Sixteen out of 43 (37%) questions (eight CRQ and eight NCRQ) each in module 4 exam were selected for this analysis. We excluded question types that typically show limited discrimination ability, e.g., T/F questions, matching or K-questions from our analysis.[26]

We presume that students who completed the case study (i) would have considered the patient’s disease and/or drugs as they chose aspects of the case to focus on; (ii) would have considered in collaboration with their case study partner—and independent of lecturer—the pathophysiology of the disease and pharmacologic basis for using the drug(s) for the specific disease state. We therefore hypothesized that the likelihood that a student correctly answers question on the didactic portion of the class is related to whether the question is case-related and whether he or she completed the case study.

Data analysis

Qualitative content analysis

We analyzed students’ response to the open-ended question, “…how does what you are doing and learning in the case study connect to you personally.” We deductively analyzed students’ comments relating to their experience on the case study and its connection with categories described in the relevance questionnaire[25]; data were coded according to these categories.[27] Comments from students who completed the case study were assessed for congruence validity with ratings on Likert scale questions on the relevance survey.[28]

Ordinal or continuous data on the survey were summarized as means ± standard error. Proportions were presented as percentages and compared using chi-square test. Means of percentage grades were compared with an analysis of variance or independent samples t-tests using SPSS. We conducted a binary multivariate logistic regression to assess the relationship between participating in the voluntary case study and performance on CRQs and NCRQs. The outcome variable was performance on eight questions on cardiovascular pharmacology (CRQ) and eight questions on respiratory pharmacology (NCRQ); for each question, 1 = correct, 0 = incorrect. Explanatory variables were categorical, with the category assigned a value of zero used as controls in the logistic regression model: whether the student completed the case (yes = 1; no = 0); what aspect of the case the student chose to do their pharmacotherapeutic plan on (0 = no case; 1 = H. Pylori; 2 = type II diabetes mellitus; T2DM; 3 = HTN); the delivery format (OL = 0; traditional = 1). We report the Wald’s chi-square statistics. The P < 0.05 was considered significant.

Ethical approval

The study was approved by the Institutional Review Board. All surveys were anonymous.


  Results Top


Overall 63 of 84 students opted to do the case study and 60 completed it. The distribution (gender, academic major, class category, and prior cognate vocational experience) of students who did the case study in the four semesters was similar [Table 2]. Comparison of the cumulative percentage grades for all questions on four midterm exams for each of the four semesters of this study between students who did and who did not do the case study showed no particular trend; students who did the case study seemed to do better than those who did not, but this was only statistically significant in Fall 2021 (traditional class). Overall mean examination grades were similar in students who took the class OL or in the traditional delivery format (78.2% ± 1.7% versus 78.0% ± 2.3%, respectively; P = 0.94) or across the four sections (P = 0.119).
Table 2: Demographic and academic characteristics of respondents

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Why is the case study relevant: What motivated students to do the case study?

Given that the class comprises mostly senior students and that pharmacology is considered a content heavy “difficult” course, we wanted to know what motivated them to do the optional case study. Overwhelmingly, it was vocational: 54 of 60 respondents who did the case study had prior clinical experience, mostly as certified nursing assistants, medical scribes, and medical assistant; other cognate experiences included home health aide, emergency medical technicians, etc. Most of the students in the class who completed the case study were headed toward clinical careers after graduation: PA school, BSN, MD/DO/DMD, and PharmD in a decreasing order of frequency.

Connections to the case study

Survey responses on a five-point Likert scale confirmed students’ connection and motivation [Figure 1]. Most respondents minimally connected with the case study on the personal level. The case study was somewhat related to their everyday life (3.0–3.4); this connection was much more to their future (4.1–4.9) than to the describing, explaining, or comparing (2.4–3.1), something about themselves personally. The connections that respondents made were mostly to career goal (4.6–4.9) and interest (4–4.2) and to a job they have/had (4.2), i.e., vocational value. They also made connections with other classes they were taking or had taken (4.3–4.5). As a pedagogical tool, the case helped students engage cognitively and for some—presumably the more advanced students, it served as a tool for optimally learning and assessing the material covered in the class [Table 3]. This is evident in the sample student comment in box 1:
Figure 1: Relevance of the case study: affect and value students ascribed to the case in OL and traditional (TR) sections of the course

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Table 3: Most common connections that students made with the case study (number of times construct occurred in the survey response text)

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This case study … has been extremely informative. I find case study assignments to be MUCH more conducive to learning and retention of information as opposed to quizzes or exams. From this case study project, I have been able to learn more about the specifics of H. Pylori and acid reflux etc., but also how to research any issue and keep an open mind about the root causes of the issue.

Interestingly, we observed that several students indicated a desire to do the case study but could not participate due to conflicting time or work obligations. When we compared the characteristics of students who did versus who did not do the case study, we found that they had similar career ambitions and vocational experience. As a respondent alluded to, staff shortages in health facilities lead to increased work shifts for many technicians. This healthcare worker shortage can be attributable to the COVID-19 pandemic at this time.[29]

Impact of the case study on performance on the module exam

Overall, completing the case study and the choice of focus for the case study were associated with better performance on multiple choice question (MCQ) in module exams (Wald’s χ2 = 2079; P < 0.001) and with the type of question; performance was better in CRQs compared with NCRQs (Wald’s χ2 = 8.41; P = 0.0037). Interestingly, students who completed their pharmacotherapeutic plan on H. pylori were no different than those who did not do the case study at all (Wald’s χ2 = 1.54; P = 0.21). Peptic ulcer disease was covered in the first two weeks of the semester, and the case study was submitted after the module exam; therefore, for these students, we can presume that they did not do the independent work on the patient’s other comorbidities (HTN, T2DM, etc.), which were relevant to the content covered later in the semester [Table 1]. For these students, although they participated in the case study, it did not influence their performance on CRQs; on the other hand, students who chose to complete a pharmacotherapeutic plan based on T2DM/HTN performed better [Table 4].
Table 4: Logistic regression analysis of students’ performance on MCQ as a function of participation in the optional case study

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  Discussion Top


Most students in North America go into clinical graduate programs (e.g., MD, DO, PharmD, PA, etc.) after completing an undergraduate associate or bachelor’s degree usually at community colleges or in liberal arts colleges. For example, only seven of the 159 PharmD programs in the United States offer straight 6-year programs; majority are 2–4 year programs that most apply to after completing pre-requisites and an admission exam.[3] Many of these students can be classified as preprofessional students because, presumably, they have not had didactic clinical instruction. However, over the past decades, there has been a push to introduce clinical science earlier in the curriculum, to present it with basic sciences to permit integration in a horizontal model of integration. Many professional programs in the United States and worldwide, including pharmacy, medicine, and dentistry, have implemented horizontally integrated curricula.[5],[6],[7],[8],[10] The goal ultimately is to enable students use basic science knowledge in clinical scenarios. However, for many North American students, their undergraduate programs are dissociated from professional schools and are mostly taught by basic science—and not clinical—instructors.

First, we find that many of these students are motivated to do case studies if presented with the opportunity. Second, we find that because nine in 10 students had prior or current clinical experience, they bring rich funds of knowledge that can be used to motivate, engage, and scaffold learning in these students. Indeed, future clinical career aspirations were the most commonly cited reasons for doing the case study in survey responses. Beyond the relevance of introducing pharmacotherapy to these students, the case provides, for the first time for most students, the opportunity to integrate their experiences in their vocational or volunteer clinical roles with didactic content.

We find that clinical case studies could be a good way to scaffold information and differentiate learning in diverse classes such as this. It is not uncommon in prerequisite classes to have returning nontraditional students who are changing careers or are taking such classes to revise important courses prior to certification examination. In an anecdotal example, an adult student who had several years of experience as an emergency medical technician turned in over 40 pages of written report in response to the patient case. For these students, the case study was within their zone of proximal development[23] as they integrated their experience with theory. The use of an authentic case study is important for eliciting such depth of response in such experienced students as well as traditional undergraduates. Many respondents alluded to the “real world scenarios” and the opportunity to relate one or more of the patient’s comorbidities with their own/family member’s health conditions or that of the patients in their healthcare work settings.

We also find that beyond the vocational utility that the case study also enhanced student performance on MCQ’s on midterm exams. This is noteworthy because it suggests—albeit indirectly—that students improved in the quality of their case study (hence the ability to integrate) submissions, which translated to better scores on CRQs versus NCRQs compared with those who did not do the case study. Many studies seldom correlate case-based learning with outcomes of summative assessments, and when they do, these scores do not always correlate with participation in case-based learning.[18] It is possible that the composite summative scores do not offer the level of granularity as would individual question to assess learning gains.

Performance on discriminating multiple-choice questions differed between those who did versus those who did not do the case study; this implies that such questions may be used as a proxy for assessing learning gains from case-based learning activities. Multiple-choice questions are easier to grade and with much less variability than essay questions.[15],[19],[20] Based on composite scores, there was no statistically significant difference in those who did versus did not do the case study except in one cohort (Fall 2021, traditional). This may be due to a small number of those who did not do the case study (four of the eight students who did not do the case study and who performed poorly in that semester had contacted the instructor citing personal circumstances that impacted their ability to complete coursework).

In summary, we demonstrate that preprofessional students find clinical case studies highly relevant and are motivated to perform integrative learning tasks such as case-based learning. We also show that students’ motivation stems primarily from their future career goals. Lastly, our study suggests that the participation in the case study was associated with improved performance on CRQs in a module exam at the end of the semester.

Limitations

By making the case study optional, we may have inadvertently selected the more motivated students who have a higher sense of self-efficacy. Thus, we cannot generalize the findings herein to all students. We did not include an a priori assessment of individual students’ baseline academic ability/knowledge and clinical experience. Such an assessment may be used to control for the students’ academic ability although some studies suggest such measures “have limited predictive power” and are biased by many other aspects of student’s characteristics.[30] Finally, the number of students in the logistic regression (48) and questions (16) used for this study is small. Definitive conclusions about the value of the authentic case studies to preprofessional students would require an experimental study design.

Acknowledgments

The authors acknowledge the technical assistance and helpful discussions of the GVSU Statistical Consulting Center and the Pew Faculty Teaching and Learning Center, respectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical approval and/or institutional review board (IRB) approval

The study was approved by the Grand Valley State University Institutional Review Board (Protocol 20-145-H).



 
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