Two recent widely-publicized and disseminated reports, the “GREP Report” [1] and the Robert Wood Johnson Foundation Report [2], have focused on the importance of teaching the basic medical sciences in a conceptual framework which forms the rational basis for medical practice. The recommendations included the use of instructive techniques which employ clinically-oriented problem solving approaches; courses which involve conjoint, interdisciplinary teaching between basic science and clinical faculty and student examinations based on questions requiring reasoning and interpretations. The new format for the USMLE (medical licensing examinations), particularly Step 1, aslo places greater emphasis on problem soling approaches using brief clinical vignettes [3]. This provides an additional impetus for basic science departments in Schools of Medicine to utilize such pedagogical approaches. Recent reports in this newsletter have indicated that this approach is already occurring.
The purpose of the present article is to review briefly key elements in the progress and continued success, both in this institution and elsewhere, with two clinically oriented problem solving techniques to enhance the teaching of basic pharmacology in medical and other curricula. The first approach to be discussed is the well-known Patient-Oriented-Problem-Solving (POPS) exercises, sponsored and supported by the Upjohn Company. The first 6 exercises in this series were printed and distributed in 1985. The author currently serves as coordinator for this project, as overseen by the American Medical School Pharmacology (AMSP) chairmen group. The other technique is the use of case conferences in pharmacology, as written by faculty members in Pharmacology and several clinical departments at the East Carolina University School of Medicine, beginning in 1978.
Details on the writing and use of both the POPS exercises and the case conferences in pharmacology have been published previously [4,5].
There are currently 7 Upjohn-sponsored POPS exercised in print and they are available, free of charge, through the Upjohn Company’s Medical Service Liasion representatives in local area. These are as follows:
Complications of Analgesic Therapy by Gourley,
D.R.H. and Wooles, W.R.
Drug Overdose Toxicity by Rogers, J.F.
Pharmacokinetics Applied to the Treat of Asthma
by Reton, K. W. and Neims, A.H.
Treatment of Essential Hypertension by Burford,
H.J. and Williams, P.B.
Drug Use in the Elderly by Singh, G and Bayne,
J.R.D.
Several of those listed have been revised once, or even twice since 1985, and others are under consideration for revision. Several new exercises are currently in preparation.
Since 1985, many thousands of the POPS exercises have been used in pharmacology courses by students in Schools of Medicine, Dentistry, Pharmacy and other allied health professions. The exercises are, in general, well like aned accepted as effetive teaching and learning devices y both faculty and students. The basic plan which each exercise follows ia s simulated case, or series of cases, containing a number of problems which are to be worked out by a team of 4 students. Each student has the solution to his (her) assigned part only, and when the group meets to solve the problems, the student possessing the solutions must act as discussion leader to encourage resolution of the problem by the rest of the group. Each part of the solution contributes to the approach to the overall problem. Each exercise requires from 2 to 3 hours of class time and several hours of preparation time, before the group meetings. The use of textbooks, journal articles, and other resources, during the group session is encouraged. Faculty remain immediately available to act as resource persons during the exercise, but do not actively participate in the group discussion.
The preliminary part of each exercise contains clearly state learning objectives, which are used by the students in preparing for the exercise. , the exercises are distributed 3 or 4 days prior to when the groups are scheduled to meet. Each exercise has 10 pre? test and 10 post-test questions which are similar in subject makeup and are congruent to the stated learning objectives and exercise subject contents. Each student is supplied with only part of the pre-test answers and explanations beforehand and the exercise calls for a discussion of the correct pre-test answers and explanations beforehand and the exercise calls for a discussion of the correct pre-test answers before the groups begins conjoint work on the clinical case problems(s). In addition to answers to the individual case problems, feedback on learning is also provided by the post-test, which is taken individually by each student, soon after completing the group session. Post-test answers, which explanations, are supplied only after the post-test is completed.
Whether or not students receive a course grade for their performance on the POPS exercises, or the post-test results, or both, varies with the user institution. In our course, we request that students turn in an answer sheet, identified only by student number, containing both pre and post-test answers This provides us with an estimate as to whether learning has resulted from use of the exercise. Generally, the results are slightly better on the pst-test than on the pre-test, as would be expected. Since our students have already been exposed to the subject material for the POPS exercises via lectures, before the exercises are run, the pre-to post-test differences are not as great as they would be if tests were administered to a pharmacologically na?ve student group, e.g., before they had any formal instruction in pharmacology [4]. We do not use the post-test scores as part of our grading process, although some schools do. We do consider it important to collect the pre and post-test answers, not only to provide us with information on the effectiveness of the exercise, but also to act as an incentive for the students to complete the post-test, which is done on their own time. It is of interest in this regard, that Dr. Parker A. Small, originator of the POPS concept in Microbiology/Immunology, and his colleagues at the University of Florida, have devised a unique POPS peer evaluation system [6], in which students evaluate each other based on knowledge and preparedness, how well they were able to teach each other and to interact in group learning, and other attributes. The method was found to facilitate peer interactions during the exercise and to improve student preparedness. This latter issue has sometimes surfaced in some of our student groups here, wherein one or two of the four students was ill-prepared to participate in the exercise. This creates an undue burden on the others, causes considerable resentment and undermines the effectiveness of the approach. We have not yet found an answer to this problem. Perhaps the peer-evaluation approach offers a solution.
While the POPS exercises have proven to be very successful and widely used, there are, admittedly, some difficulties in their use, there are, admittedly, some difficulties in their use. These include the following: (1) the curricular time required ( from 2 to 3 hours per exercise); (2) The requirement for numerous small conference rooms or large rooms with multiple subdivision; (3) the faculty time needed for familiarity with and conduction of the exercises; (4) concepts or information presented in the exercises which may differ somewhat from lecture material; (5) students who may dislike the approach (I.e. “loner learners,?) or who do not assume their fair share of the responsibilities. Each user institution may have their own unique solutions to these problems, which we hope to share soon with POPS users. The AMSP/POPS committee will conduct a POPS user survey in the near future which should provide us with much needed information on POPS use.
The second clinical case-oriented problem
Solving technique to find wide acceptance in basic pharmacology courses for many years has been the case conference. This has involved a wide variety approaches. A commonly used one involves small group discussions of a written case with presiding faculty being either a single basic pharmacologist, or with the addition of a clinician. Other approaches might involve the presentation of a patient(s) before the entire class. The clinical cases might be either real or simulated, and be based on documented causes from the clinical literature o on those encountered by clinical faculty at teaching institutions. A historical perspective on the use of clinical case conferences for teaching basic pharmacology has been published elsewhere [7]. The Summer, 1992 issue of THE FORUM contains two papers discussing the use of clinical correlations; one in a Microbiology/ Immunology course and the other in a Biochemistry course in the medical curriculum.
since 1978, we have developed approximately 50 clinical case conferences, most based on actual cases of pharmacotherapy. Many were originally written for us by a semi-retired adjunct faculty internist/cardiologist, based on experiences either acquired in his own practice, or that of a colleague. Others were written by members of the faculty of various clinical department here, and still others were written b our own faculty, based on literature reports. The subject areas of pharmacology are varied, corresponding to those currently being covered in the lecture part of an approximately 150 hour medical curriculum course in basic pharmacology. In general, the topics have a disease orientation, e.g., drug treatment of asthma, hypertension or breast cancer, although a few are more generally inclined, e.g. drug interactions or toxicities. In any one year a total of form 14 to 16 case conferences may be schedule, usually on a weekly or bi-weekly basis. Student groups of no more than 8 per faculty preceptor meet for a 50-minute discussion session with one student acting as discussion leader, on a rotating basis. Faculty act only as moderators to keep the discussion moving and focused and to act as an information source, or to provide a different perspective not considered by the students. The conferences are very much a student effort and the working groups are allowed to determine whether the discussions to be a free flowing exchange or to follow a more definitive format of answering a set of supplied questions or questions of their own makeup.
The atmosphere of the conferences is relaxed and conducive to learning, with each student being allowed ample chance to participate. Students relate that they feel comfortable about the way the conferences are conducted [5]. Each student ears a conference grade equivalent to 10% of their course grade. The grade is somewhat subjective, based on the faculty preceptor’s perspective of how each student conducted the conference or contributed to the discussion. Some students are very animated during the discussions and others much less so. Many prepare extensively for the session, with readings from their pharmacology text or from clinical medicine texts or literature reports. Some actually come supplied with handouts of their own creation, for their classmates. From our 14-year experience with the case-conferences thus far, there is little doubt that they are great motivators of student learning they are consistently evaluated by each class as among the best features of the course. An unanticipated benefit of the conferences for both faculty and students is that some otherwise marginally-performing students do exceptionally well in the conferences. Thus, they provide an alternative approach to student evaluation in addition to conventional, formalized, predominantly recall-oriented examinations.
As might be expected of a Ph.D.-based pharmacology department faculty, there was some initial reluctance by our faculty to be involved in teaching clinically oriented materials. The original guidance of the adjunct clinician who wrote many of the initial conferences was a considerable help to us in helping overcome this reluctance. With each new conference introduced, a faculty review session is planned with the clinician author, in which we discuss key elements of the case, ad possible answers to the questions posed. With over 40 current conferences in our files, we have enough to alternative these yearly so as to discourage students from obtaining conferences and problem solutions from their upper-class colleagues.
At the outset we make it clear to the students that our faculty will not attempt to teach clinical medical in the conferences. Rather, the main emphasis is to encourage the students to learn how to apply principles of basic pharmacology to solve problems in clinical medicine. The conferences also serve to introduced the concept of clinical judgment as applied to clinical pharmacology. There is frequently no one best approach, or solution, but various alternatives to be considered. The alternatives are sometimes not well defined and are open to various interpretations as to advantages and disadvantages. This is not unlike situations the clinician is likely to encounter in everyday drug therapy. Second year medical students here have proven themselves to be remarkably adept at dealing with clinically related aspects of the cases, which sometimes require comprehension normally only expected of upper-class tdents or residents. They mange to channel their interest in learning to formulate surprisingly sophisticated solutions to the problems, given their relatively limited clinical knowledge of disease states.
While the presence of clinicians on a basic pharmacology faculty would no doubt facilitate writing and using clinical case conferences in the basic sciences, they are not absolutely essential. Our own faculty have written some excellent conferences and these have been favorably critiqued by clinical faculty in other departments here. We find the key to writing these to be to incorporate as many principles of basic pharmacology as possible into realistic every day clinical problems.
References
1. Physicians for the Twenty-First Century. Report of the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine; S. Muller, Chairman (?The GPEP Report?), J. Med. Ed. 59: Part 2, Nov. 1984.
2. Commission on Medical Education: The Sciences of Medical Practice. Medical Education in Transition. R.Q. Marston and R. M. Jones, Editors, Princeton, NJ. The Robert Wood Johnson Foundation, July 1992.
3. Swanson, D. B., Case, S.M., Melnick, D.E. and Volle, R. L. Impact of USMLE Step 1 on Teaching and Learning of the Basic Biomedical Sciences. Supplement to “THE FORM?, vol,2, no. 1, Winter 1991; reprinted in Academic Medicine, 67: 553-556, (1992).
4. Burford, H. J., Ingenito, A. J. and Williams, P.B. Development and Evaluation of Patient-Oriented Problem-Solving Materials in Pharmacology. Academic Medicine 65: 689-693 (1990).
5. Ingenito, A.J., Noble, B. G. and Wooles, W. R. The Case Conference Approach to Teaching Clinical Pharmacology. J. Clin. Pharmacol. 32: 502-510 (1992)
6. Small, P.A. Jr. and Stevens, C.B. Peer Evaluation and its Use with the POPS System. Pp. 32-34 in Proceedings of the Workshop on the Teaching of Pharmacology to Medical Students. San Diego, CA, Aug. 1991. (Organized by the Association of Medical School Pharmacology).
7. Ingenito, A.J. Lathers, C. M. and Burford, H. J. Instruction in Clinical Pharmacology: Changes in the Wind. J. Clin. Pharmacol. 29: 7-17 (1989)