Medical Residents' Informal Learning from Pharmacists in the Clinical Workplace.

Workplace-based interactions between residents and pharmacists, though relatively underexplored, might contribute substantially to learning. This international study sought to investigate the affordances residents use for informal learning about medications, their interactions with pharmacists and patterns of resident-pharmacist engagement, as well as residents' perceived impact of these interactions on their learning. Contextual differences between US and Dutch residency training and electronic health record (EHR) may impact informal learning about medications. We conducted a cross-sectional, online, 25-item survey study, including closed-format and open-response questions among current resident physicians (post-graduate years 1-6, from a variety of residency programs n = 803) from the University of California San Francisco, the University of Minnesota, and the University Medical Center Utrecht. Responses from 173 residents in both countries revealed that these physician trainees were afforded opportunities to engage in a wide variety of pharmacotherapy-related activities but engaged differently with social and environmental resources for support. Residents from the United States (US) utilized pharmacists and Up-To-Date, whereas Dutch residents preferentially utilized the online Dutch medication information site and EHR-embedded medication resources. US residents interacted with pharmacists significantly more frequently than Dutch residents. Pharmacists provided residents with a wide range of useful information, much of which is integrated into the medication resources in the Dutch EHR-based decision-support system. While US residents reported overwhelmingly that informal interactions with pharmacists contribute to their learning about medications, Dutch residents' responses did not confirm this. Intentionally designing residents' training to include opportunities for interactions with pharmacists could potentially positively impact residents' informal workplace learning. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01784-1.

Preliminary evidence for a Tool to Observe the Construction of Knowledge in Interprofessional teams (TOCK-IP).

Collaborative knowledge construction (KC) is an important process in interprofessional learning and a logical assessment target. A tool supporting the formative evaluation of KC behaviors ideally would be: 1) applicable to interprofessional teams of learners in clinical contexts; 2) informed by contemporary learning frameworks; 3) feasible and useful. No existing assessment tool meets these criteria. This paper describes the development and preliminary validity evidence for a Tool for Observing Construction of Knowledge in Interprofessional teams (TOCK-IP). Following literature review and needs assessment, the TOCK-IP was drafted based upon Gunawardena's five-phase KC model. Educational expert review established content validity. Response process and internal structure validity, feasibility, and utility were assessed through step-wise evaluation. Faculty raters applied the tool to four videos of simulated interactions between health professions learners. Faculty ratings were compared to expert consensus ratings. Thematic analysis of post-rating survey and debrief allowed assessment of feasibility and utility. Across videos, faculty raters' agreement was fair (n = 25; Fleiss' kappa = 0.40, <0.001). Excellent agreement (95%) was found for raters' scores compared to consensus rating. Faculty supported tool feasibility and utility. The TOCK-IP meets the three criteria for evaluating team-level KC and offers a progression roadmap to help learners move toward collaborative learning.

Getting outside the box: exploring role fluidity in interprofessional student groups through the lens of activity theory.

Health professionals' roles and scopes often overlap, creating a need for role clarity in interprofessional teamwork. Yet, such clarity does not mean roles are fixed within teams and some literature suggests role flexibility can enhance team functioning. Interprofessional practice competencies and learning activities often emphasize knowledge and definition of roles, but rarely attend to the dynamic nature of roles and influential contextual factors. This study explores role fluidity in interprofessional student groups using an activity theory framework. Using a collective instrumental case study approach, the authors examine the fluidity of one physical therapy (PT) student's role within 3 different interprofessional (medical, pharmacy, PT) student groups completing nursing home patient care plans. Field notes, group debriefing interviews, and care plans were collected and coded from all care planning sessions. Codes mapped to group-specific activity systems that compared role-influencing interactions and tensions. The PT student's role fluidity varied in each group's activity system, influenced primarily by system tensions from implicit rules (e.g., encouraging questions), division of labor (e.g., rigid profession-based task assignment), and tool use (e.g., computers). Attention to modifiable system elements, such as tool use and explicit rules of inclusivity, could foster role fluidity and improve interprofessional teamwork and learning environments.

An interaction analysis model to study knowledge construction in interprofessional education: proof of concept.

A goal of interprofessional clinical learning experiences is to facilitate learning through co-construction of knowledge in support of patient care. Yet, little is known about knowledge construction processes among health professions students working together to care for patients. Understanding knowledge construction processes can guide health professions educators in the design of interventions to support knowledge construction and high-quality learning in clinical placements. In this article, we describe findings from a proof of concept study that explores the feasibility and utility of using Gunawardena's Interaction Analysis Model (IAM) to evaluate health professions students' knowledge construction processes in clinical placements. The IAM has been used to study knowledge construction processes in computer-supported collaborative learning environments, but not in interprofessional education. The IAM describes five phases of knowledge construction - sharing/comparing; exploring dissonance; co-constructing meaning; testing; coming to agreement/applying co-constructed knowledge - each representing a progressively higher-level learning process. Application of the IAM to learner dialogue proved labor-intensive but feasible and useful as a research tool to characterize learners' knowledge construction behaviors. Our findings suggest that the IAM warrants further study and may offer a framework to guide the design of clinical placements and analysis of interprofessional learning behaviors.

Development of an interprofessional rotation for pharmacy and medical students to perform telehealth outreach to vulnerable patients in the COVID-19 pandemic.

This report describes an interprofessional rotation for pharmacy and medical students focused on telehealth outreach to patients at high risk for delays in care due to the COVID-19 pandemic. The curriculum was designed around core competencies of interprofessional education. Student activities included participating in interprofessional huddles, collaborating on patient interviews, and practicing interprofessional communication. Three pharmacy students and two medical students completed the rotation. Evaluation was conducted via survey and exit interview. All students successfully increased their knowledge of their own and others' professional roles and demonstrated interprofessional communication and collaboration through telehealth.

A Mobile Learning Module to Support Interprofessional Knowledge Construction in the Health Professions.

Objective. To develop and evaluate a mobile learning module to support knowledge construction between medical and pharmacy students through structured dialogue prompts. Methods. Rheumatologists and pharmacists collaboratively developed a two-week, case-based, asynchronous interprofessional learning module that was delivered via a mobile app and focused on collaborative medication management of a complex case involving a patient with systemic lupus erythematosus. The clinical case evolved over three phases: diagnosis, initial treatment, and medication-related complications. Dialogue prompts were incorporated in each phase as a mechanism to support knowledge construction among learners. Pharmacy and medical student pairs were randomized to receive either high guidance or low guidance prompts for collaborative learning. The student pairs worked together, asynchronously, online, to develop three collaborative care plans. The evaluation of the learning module to support knowledge construction included: analysis of text-based dialogue coded for knowledge construction phases; the accuracy and completeness of the three collaborative care plans; and quantitative and qualitative participant feedback. Results. Sixteen pairs of medical and pharmacy students (n=32) participated. Pairs who received high guidance engaged in all phases of knowledge construction more often than pairs who received low guidance. Guidance phase did not differentially impact collaborative care plan scores. Ninety-eight percent of students agreed or strongly agreed that the module improved their clinical reasoning, interprofessional communication, and knowledge of systemic lupus erythematosus. Conclusion. The knowledge construction framework can guide the design and evaluation of educational interventions such as a mobile learning module to support knowledge construction among health professionals.

Fostering Interprofessional Geriatric Patient Care Skills for Health Professions Students Through a Nursing Facility-Based Immersion Rotation.

Introduction: Interprofessional (IP) clinical care is ideally taught in authentic environments; however, training programs often lack authentic opportunities for health professions students to practice IP patient care. Skilled nursing facilities (SNFs) can offer such opportunities, particularly for geriatric patient care, but are underutilized as training sites. We present an IP nursing facility rotation (IP-SNF) in which medical, pharmacy, and physical therapy students provided collaborative geriatric patient care. Methods: Our 10-day immersion rotation focused on four geriatric competencies common to all three professions: appropriate/hazardous medications, patient self-care capacity, evaluating and treating falls, and IP collaboration. Activities included conducting medication reviews, quarterly care planning, evaluating functional status/fall risk, and presenting team recommendations at SNF meetings. Facility faculty/staff provided preceptorship and assessed team presentations. Course evaluations included students' pre/post objective-based self-assessment, as well as facility faculty/staff evaluations of interactions with students. Results: Thirty-two students (15 medical, 12 pharmacy, five physical therapy) participated in the first 2 years. Evaluations (n = 31) suggested IP-SNF filled gaps in students' geriatrics and IP education. Pre/post self-assessment showed significant improvement (p < .001) in self-confidence related to course objectives. Faculty/staff indicated students added value to SNF patient care. Challenges included maximizing patient care experiences while allowing adequate team work time. Discussion: IP-SNF showcases the feasibility of, and potential for, engaging learners in real-world IP geriatric patient care in a SNF. Activities and materials must be carefully designed and implemented to engage all levels/types of IP learners and ensure valuable learning experiences.

Are We on the Same Page? Shared Mental Models to Support Clinical Teamwork Among Health Professions Learners: A Scoping Review.

PURPOSE: To conduct a scoping review to explore the construct of shared mental models (SMMs) in the context of clinical teamwork among health professions learners. METHOD: The authors searched the PubMed, ERIC, CINAHL, Scopus, Web of Science, PsychINFO, and EMBASE databases for English-language articles published between 2000 and 2016. Eligible articles mentioned SMMs in relation to clinical teamwork and included health professions learners. Two reviewers screened studies for eligibility and extracted data to determine the depth and breadth of the literature on SMMs. The authors examined definitions of the SMM construct in the context of clinical teams, educational interventions using SMMs, and the measurement of SMMs. RESULTS: Of the 1,273 articles retrieved, 23 met the inclusion criteria. SMMs were defined in less than two-fifths of the articles (9/23). All articles applied the construct to improvements in hospital-based patient safety, often in high-intensity settings (14/23). Most articles included graduate-level physicians (21/23) within clinical teams (18/23). Interventions designed to foster SMMs (6/23) included teamwork curricula/training and teamwork supportive tools. Measurements of SMMs (7/23) included a qualitative task analysis, quantitative analyses of speech, a concept mapping, and Likert-type surveys. CONCLUSIONS: In health professions education, the SMM construct lacks clear definition. Few studies described educational interventions aimed at SMM development, and few attempted to measure the construct. The authors propose an operational definition of SMMs in health care and illustrate how interventions intended to foster SMMs, such as team trainings or planning exercises and communication tools, could be developed, implemented, and assessed.

Changes in clearance, volume and bioavailability of immunosuppressants when given with HAART in HIV-1 infected liver and kidney transplant recipients.

Solid organ transplantation in human immunodeficiency virus 1 (HIV)-infected individuals requiring the concomitant use of immunosuppressants (IS) [e.g. cyclosporine (CsA) or tacrolimus (TAC)] and antiretrovirals (ARVs) [e.g. protease inhibitors (PIs) and/or non-nucleoside reverse transcriptase inhibitors (NNRTIs)] is complicated by significant drug interactions. This paper describes the pharmacokinetics of CsA and TAC in 52 patients on both IS and NNRTIs, PIs or combined NNRTIs + PIs, in studies conducted at 2 weeks, 3, 6, 12 and 24 months after transplantation. Cyclosporine and TAC blood concentrations were measured by LC/MS/MS. This multisubject, varied ARV-IS drug combination, longitudinal observational patient study provided a unique opportunity to examine the effect of different ARV drugs on IS pharmacokinetics (PK) by comparing the ratios of parameters over time and between PK parameters. Subjects taking concomitant PIs exhibited increases in CsA and TAC exposure (AUC/dose) due to the increased apparent oral bioavailability and decreased apparent oral clearance. Those subjects taking CsA and concomitant efavirenz (EFV) showed time dependent increases in exposure due to ~30% increases in the apparent oral bioavailability over time as well as a decreased apparent oral clearance, while subjects on TAC and EFV showed time-dependent changes in all PK parameters. The increased bioavailability was not observed in patients on CsA and nevirapine (NVP). These differences between IS drugs and the changes in PK parameters are not easily predicted, illustrating the importance of continued therapeutic drug monitoring in patients on these complex medication regimens. Published 2013. This article is a U.S. Government work and is in the public domain in the USA.

An inhibitory metabolite leads to dose- and time-dependent pharmacokinetics of (R)-N-{1-[3-(4-ethoxy-phenyl)-4-oxo-3,4-dihydro-pyrido[2,3-d]pyrimidin-2-yl]-ethyl}-N-pyridin-3-yl-methyl-2-(4-trifluoromethoxy-phenyl)-acetamide (AMG 487) in human subjects after multiple dosing.

(R)-N-{1-[3-(4-Ethoxy-phenyl)-4-oxo-3,4-dihydro-pyrido[2,3-d]-pyrimidin-2-yl]-ethyl}-N-pyridin-3-yl-methyl-2-(4-trifluoromethoxyphenyl)-acetamide (AMG 487) is a potent and selective orally bioavailable chemokine (C-X-C motif) receptor 3 (CXCR3) antagonist that displays dose- and time-dependent pharmacokinetics in human subjects after multiple oral dosing. Although AMG 487 exhibited linear pharmacokinetics on both days 1 and 7 at the 25-mg dose, dose- and time-dependent kinetics were evident at the two higher doses. Nonlinear kinetics were more pronounced after multiple dosing. Area under the plasma concentration-time curve from 0 to 24 h [AUC((0-24 h))] increased 96-fold with a 10-fold increase in dose on day 7 compared with a 28-fold increase in AUC((0-24 h)) on day 1. These changes were correlated with time- and dose-dependent decreases in the metabolite to parent plasma concentrations, suggesting that these changes result from a decrease in the oral clearance (CL) of AMG 487 (e.g., intestinal/hepatic first-pass metabolism and systemic CL). The biotransformation of AMG 487 is dependent on CYP3A and results in the formation of two primary metabolites, a pyridyl N-oxide AMG 487 (M1) and an O-deethylated AMG 487 (M2). One of these metabolites, M2, undergoes further metabolism by CYP3A. M2 has also been demonstrated to inhibit CYP3A in a competitive (K(i)=0.75 microM) manner as well as via mechanism-based inhibition (unbound K(I)=1.4 microM, k(inact)=0.041 min(-1)). Data from this study implicate M2-mediated CYP3A mechanism-based inhibition as the proximal cause for the time-dependent pharmacokinetics of AMG 487. However, the sequential metabolism of M2, nonlinear AMG 487 pharmacokinetics, and the inability to accurately determine the role of intestinal AMG 487 metabolism complicates the correlation between M2 plasma concentrations and the time-dependent AMG 487 pharmacokinetic changes.

Nelfinavir pharmacokinetics in stable human immunodeficiency virus-positive children: Pediatric AIDS Clinical Trials Group Protocol 377.

OBJECTIVE: Pharmacokinetic data obtained from children who have human immunodeficiency virus (HIV) infection are essential for the safe and effective use of antiretroviral agents in pediatric populations. The objective of this study was to assess the impact of body weight on the pharmacokinetic disposition of nelfinavir (NFV) in the absence and presence of nevirapine (NVP) and compare the pharmacokinetic profiles of twice-daily (BID) and three-times-daily (TID) NFV regimens. METHODS: This was an intensive pharmacokinetic substudy nested in a phase II, multicenter, randomized, open-label trial. Forty-five HIV-infected children receiving NFV 30 mg/kg TID and 6 HIV-infected children receiving NFV 55 mg/kg BID were enrolled in this study and assigned to 1 of 4 stavudine-containing regimens, 3 containing NFV and 2 containing NVP. Area under the plasma concentration-time curves from 0 to 8 hours (AUC(0-8 hours)) and from 0 to 12 hours (AUC(0-12 hours)) for the TID and BID regimens, respectively, were determined. For comparative purposes, the AUC(0-24 hours) was also calculated for each regimen. RESULTS: NFV exposure in the absence of NVP was decreased in children who were <25 kg compared with those who were >25 kg (a 2.6-fold difference in median AUC(0-8 hours)). NFV pharmacokinetics in the presence of NVP did not differ between the <25 kg and >25 kg groups. The AUC(0-24 hours) for children who were <30 kg and on NFV BID was comparable to the AUC(0-24 hours) for children who were >25 kg and on NFV TID but was 2.7-fold greater than AUC(0-24 hours) for children who were <25 kg and on NFV TID. CONCLUSIONS: NFV in the absence of NVP resulted in less than half the drug exposure in children who were <25 kg compared with children who were >25 kg. NFV dosed at 55 mg/kg BID in children who are <30 kg provides comparable exposure to that measured in children who are >25 kg and receiving NFV 30 mg/kg TID.

Pharmacokinetic interactions between cyclosporine and protease inhibitors in HIV+ subjects.

With advances in antiretroviral therapy, many HIV+ individuals are living longer lives and some are developing end-stage renal and/or hepatic disease requiring transplantation. These patients require concomitant use of immunosuppressants (e.g., cyclosporine [CsA]) and antiretrovirals (e.g., protease inhibitors [PIs]), which exhibit narrow therapeutic windows and are substrates and inhibitors of cytochrome P450 3A enzymes and the cellular transporter P-glycoprotein. In this pilot study, HIV+ subjects on either oral nelfinavir (NFV) or indinavir (IND) with nondetectable viral loads and normal renal and hepatic function had 12 hour pharmacokinetic (PK) studies on 3 separate days: PIs alone, PIs+intravenous CsA, and PIs+oral CsA to determine the extent of PK interactions between these medications. PIs and CsA concentrations were measured by LC/MS in plasma and whole blood, respectively. Nine subjects (n=7 on NFV, n=2 on IND) completed the study. Only the results of those subjects taking NFV are reported. Oral co-administration of CsA increased NFV T(max) from 2.6+/-0.9 to 3.2+/-0.8 h (p<0.05), and AUC(0-infinity) from 27.9+/-15.2 to 43.2+/-27.1 mg(*)h/mL (p=0.06). Intravenous CsA did not appreciably alter oral pharmacokinetics of NFV. Both CsA and NFV PK parameters exhibited a high degree of intersubject variability, underscoring the need for routine therapeutic drug monitoring of both CsA and PIs in HIV+ subjects undergoing transplantation.