Learning Outcomes and Student Preferences with Flipped vs Lecture/Case Teaching Model in a Block Curriculum.

Objective. To assess the impact of using a flipped classroom instructional approach on Doctor of Pharmacy (PharmD) students' learning outcomes and instructional preferences in a pharmacotherapy course within a block curriculum. Methods. Select topics in a gastrointestinal and liver pharmacotherapy course were taught using a flipped classroom method that required students to view lecture modules and respond to self-assessment questions prior to class. Classroom time included quizzes, application exercises, and discussion. The following year, teaching of these topics was switched back to a lecture/case format, and different topics were taught in the flipped classroom format, Student performance under each teaching method was examined, and student preferences and study habits were collected via a survey administered before and after experiencing the flipped classroom. Results. Combined mean formal assessment scores were higher for all four topics taught using the flipped classroom format compared to the lecture/case format. This pattern persisted when topics were examined individually, except for scores on one review topic. Survey responses reflected acknowledgement by about half of the students that the flipped format was more beneficial than traditional methods, but they still clearly preferred live lectures over prerecorded lectures. The majority of students reported that the amount of preparation time required for the flipped classroom was appropriate and that they had a positive or neutral experience with the flipped classroom overall. Conclusion. This study supports use of the flipped classroom method for teaching standard pharmacotherapy topics within a block curriculum, but underscores some of the resistance expressed by students despite understanding the potential benefits of the flipped format.

Characterization of Use of the Pharmacy Curriculum Outcomes Assessment Across Accredited Colleges of Pharmacy.

Objective. To characterize use of the Pharmacy Curriculum Outcomes Assessment (PCOA) in terms of timing, manner of delivery, and application of the results by accredited colleges of pharmacy. Methods. Accredited pharmacy programs were surveyed regarding PCOA administration, perceived benefits, and practical application of score reports. Survey items were comprised of new items developed from a literature review and items from prior studies. The survey addressed five domains: program demographics, administration, student preparation, use of results, and recommendations to improve the utility of the PCOA. Results. Responses were received from 126 of 139 (91%) surveyed programs. The majority of respondent programs administered PCOA in one session on a single campus. Most indicated PCOA results had limited use for individual student assessment. Almost half reported that results were or could be useful in curriculum review and benchmarking. Considerable variability existed in the preparation and incentives for PCOA performance. Differences in some results were found based on prior PCOA experience and between new vs older programs. Open-ended responses provided suggestions to enhance the application and utility of PCOA. Conclusion. The intended uses of PCOA results, such as for student assessment, curricular review, and programmatic benchmarking, are not being implemented across the academy. Streamlining examination logistics, providing additional examination-related data, and clarifying the purpose of the examination to faculty members and students may increase the utility of PCOA results.

Designing professional program instruction to align with students' cognitive processing.

BACKGROUND AND PURPOSE: In health professional programs, training for educators in instructional design is sparse and may be absent altogether. Implementing evidence-based, systematic instructional design can improve pharmacy curricula. This paper describes Gagné's instructional design model which is particularly effective because the instructional steps align with learners' cognitive processes. The model is applied to the teaching of liver pharmacotherapeutics in a pharmacy curriculum. EDUCATIONAL ACTIVITY AND SETTING: Second-year pharmacy students completed 25 hours of liver pharmacotherapeutics instruction that was developed using Gagné's nine instructional events: gain attention, inform about objectives, stimulate recall of prior information, present information, provide guidance, elicit performance, provide feedback, assess performance, and enhance retention. FINDINGS: Students completed individual and team-based assessments including SOAP notes, recorded case presentations, web-based quizzes, a pre- and post-knowledge assessment, and midterm and final exam multiple-choice test. Students demonstrated significant improvement in liver pharmacotherapeutics knowledge from the pre- to post-knowledge assessment. Student course instructor evaluations also reflected effectiveness of the format. SUMMARY: Evidence-based instructional design strategies, such as Gagné's model, can enhance learning of challenging pharmacotherapeutics concepts using a systematic framework that aligns with cognitive processing.

Implementing a strategy for promoting long-term meaningful learning in a pharmacokinetics course.

INTRODUCTION: The purpose of this paper is to describe the evolution and effectiveness of instructional strategies that were implemented over a seven-year period to enhance the authenticity of instruction and assessment in a pharmacokinetics (PK) course. METHODS: Baseline data from 2011 and 2012 were analyzed to identify opportunities for improvement. In 2013 and 2014, lectures, PK workshops, and exam questions were modified to represent more authentic learning and assessment. Counter to expectations, 2013 and 2014 exam scores were significantly lower when compared to 2011 and 2012 scores. The course was modified further in 2015 to incorporate post-workshop quizzes that provided corrective feedback and required the use of retrieval as a learning strategy. Exam scores were compared across the three phases of course improvement (2011/2012 vs. 2013/2014 vs. 2015/2016/2017) using statistical analyses. RESULTS: The average final examination score in 2011-2012 was 84.6%. After increasing the number of authentic assessment exam items, the average on the final examination in 2013-2014 decreased to 80.3% (p < 0.0001). Following the implementation of the post-workshop quizzes, the average final examination scores increased from 2015-2017 to 85.9% (p < 0.0001, compared to 2013-2014; p = 0.08, compared to 2011-2012). DISCUSSION: Implementation of these evidence-based learning and instructional strategies (authentic learning, retrieval of new learning, and corrective feedback) was associated with higher student performance on the final examination over time. CONCLUSION: These strategies may be valuable in improving student learning outcomes in other challenging professional program courses.

Improving Pharmacy Calculations Using an Instructional Design Model.

Objective. To describe an evidence-based instructional design to improve performance and foster retention of pharmacy students' calculation skills longitudinally across the curriculum. Methods. Gagne's nine events of instructional design were employed in a longitudinal pharmacy calculations curriculum. Mean pharmacy calculation examination scores from four courses spanning the didactic curriculum for four different academic years (before and after the redesign) were compared. Results. Students demonstrated more stable outcomes with consistently higher means after the redesign, which may indicate improved retention. Additionally, the post-redesign classes have experienced fewer failures (score of <80%). Conclusion. Using an instructional design model to optimize immediate instructional outcomes is an effective method of enhancing retention of calculation skills over time.

An analysis of the use of Pharmacy Curriculum Outcomes Assessment (PCOA) scores within one professional program.

OBJECTIVE: The Pharmacy Curriculum Outcomes Assessment (PCOA) is a recent assessment requirement for US pharmacy professional programs. This study analyses PCOA scores for uses described in the 2016 Standards with data from one professional program. METHODS: PCOA data were analyzed for two consecutive classes (n=215) of pharmacy students at the end of their didactic curriculum to explore relationships among PCOA scores, grade point average (GPA), and North American Pharmacist Licensure Examination (NAPLEX) scores utilizing regression analyses. RESULTS: Decisions about student learning based on PCOA scores and GPA indicated remediation would have been prescribed for approximately 7% of students. In comparison, NAPLEX scores revealed a 1% failure rate among the study sample. Relationships between PCOA scores and GPA (r=0.47) and NAPLEX (r=0.51) were moderate to large, respectively. GPA explained a larger portion of unique variance (14%) than PCOA (8%) in NAPLEX scores. CONCLUSIONS: In this sample of students, academic decisions would have varied depending upon the learning assessment, which is consistent with a moderate correlation between GPA and PCOA scores. Although PCOA scores correlate with GPA and NAPLEX, PCOA scores explained a smaller portion of unique variance in NAPLEX scores than GPA. The ongoing establishment of validity evidence of PCOA scores is important for meaningful interpretation of scores for the intended uses.

Teachable Moments Matter for: An analysis of the use of Pharmacy Curriculum Outcomes Assessment (PCOA) scores within one professional program.

Editors Note: The Teachable Moments Matter category of articles is designed to offer readers insight into a methodological issue identified within a companion article. Written in collaboration with one of these authors, these articles provide an opportunity to focus on a challenge experienced by the authors and, in the process, provide one or more perspectives as to how to successfully navigate this issue. Notably, this "issue" is not necessarily a problem (as this first paper in this series demonstrates). The Journal hopes this case-based approach will help highlight an issue nuance in context, something that might get "lost" in the entirety of a full-length article. This article discusses the importance of communicating a conceptual framework (i.e., theory) as a basis for scholarly articles. A specific example in the companion article is use of validity theory. In our community of researchers, we need to better communicate a conceptual framework as a basis to allow others to build on and grow our knowledge in pharmacy education.

Student-led co-curricular medical Spanish training in a pharmacy professional program.

BACKGROUND AND PURPOSE: This paper describes a student-led co-curricular training program to increase pharmacy student proficiency with medical Spanish terminology. Western University of Health Sciences (WesternU) pharmacy students frequently can interact with Spanish-speaking patients in experiential rotations. Moreover, the clear majority of program graduates remain in California, a state with a high Spanish-speaking population. Developing foundational knowledge of medical Spanish terminology can enhance communication with Spanish-speaking patients, who may have limited English proficiency and experience a lack of language concordance when interacting with the healthcare system. Providing training in medical terminology in another language is important because communication barriers have been associated with adverse medical outcomes, such as poor medication adherence. EDUCATIONAL ACTIVITY AND SETTING: The development of the training logistics and materials are described for replication of the process, whether with medical Spanish or other languages. Students in the pharmacy program developed the medical Spanish training that is now a robust co-curricular activity with over 100 students participating in the training each semester. An important aspect of the WesternU co-curricular activity is that students develop materials, create learning activities, and facilitate training.

Understanding physician-level barriers to the use of individualized risk estimates in percutaneous coronary intervention.

BACKGROUND: The foundation of precision medicine is the ability to tailor therapy based upon the expected risks and benefits of treatment for each individual patient. In a prior study, we implemented a software platform, ePRISM, to execute validated risk-stratification models for patients undergoing percutaneous coronary intervention and found substantial variability in the use of the personalized estimates to tailor care. A better understanding of physicians' perspectives about the use of individualized risk-estimates is needed to overcome barriers to their adoption. METHODS: In a qualitative research study, we conducted interviews, in-person or by telephone, with 27 physicians at 8 centers that used ePRISM until thematic saturation occurred. Data were coded using descriptive content analyses. RESULTS: Three major themes emerged among physicians who did not use ePRISM to support decision making: (1) "Experience versus Evidence," physicians' preference to rely upon personal experience and subjective assessments rather than objective risk estimates; (2) "Omission of Therapy," the perception that the use of risk models leads to unacceptable omission of potentially beneficial therapy; and (3) "Unnecessary Information," the opinion that information derived from risk models is not needed because physicians' decision making is already sound and they already know the information. CONCLUSIONS: Barriers to the use of risk models in clinical practice include physicians' perceptions that their experience is sufficient, that models may lead to omission of therapy in patients that may benefit from therapy, and that they already provide good care. Anticipating and overcoming these barriers may improve the adoption of precision medicine.

Exploration of Methods Used by Pharmacy Professional Programs to Contract with Experiential Practice Sites.

Objective. To explore methods used by pharmacy programs to attract and sustain relationships with preceptors and experiential practice sites. Methods. Interviews with eight focus groups of pharmacy experiential education experts (n=35) were conducted at two national pharmacy meetings. A semi-structured interview guide was used. Focus group interviews were recorded, transcribed verbatim, and categorically coded independently by two researchers. Codes were compared, consensus was reached through discussion, and two experiential education experts assisted with interpretation of the coded data. Results. Six themes emerged consistently across focus groups: a perceived increase in preceptor compensation, intended vs actual use of payments by sites, concern over renegotiation of established compensation, costs and benefits of experiential students, territorialism, and motives. Conclusion. Fostering a culture of collaboration may counteract potentially competitive strategies to gain sites. Participants shared a common interest in providing high-quality experiential learning where sites and preceptors participated for altruistic reasons, rather than compensation.

Implementation and evaluation of activities to foster a sense of community among pharmacy students.

INTRODUCTION: The purpose of this study was to investigate the association of a series of team-based instructional activities on students' sense of community for pharmacy students assigned to the main and distance program sites. MATERIALS AND METHODS: In conjunction with a teaching objective structured clinical examination (OSCE) conducted at the program's distance site, several team-based sense of community activities were completed. The classroom and school community inventory (CSCI) was adapted and administered to students prior to and following all learning activities to measure course and program sense of community. RESULTS: Pre- and post-surveys were completed by 116 students. Course and program sense of community significantly increased among students at the distance site (p = 0.007 and p = 0.008, respectively). No significant changes were found for students assigned to the main site. CONCLUSION: For programs with multiple sites, activities designed to enhance sense of community and conducted at the distance site are effective for students assigned to the distance site.

Symptom recognition and healthcare experiences of young women with acute myocardial infarction.

BACKGROUND: Prompt recognition of acute myocardial infarction symptoms and timely care-seeking behavior are critical to optimize acute medical therapies. Relatively little is known about the symptom presentation and care-seeking experiences of women aged ≤55 years with acute myocardial infarction, a group shown to have increased mortality risk as compared with similarly aged men. Understanding symptom recognition and experiences engaging the healthcare system may provide opportunities to reduce delays and improve acute care for this population. METHODS AND RESULTS: We conducted a qualitative study using in-depth interviews with 30 women (aged 30-55 years) hospitalized with acute myocardial infarction to explore their experiences with prodromal symptoms and their decision-making process to seek medical care. Five themes characterized their experiences: (1) prodromal symptoms varied substantially in both nature and duration; (2) they inaccurately assessed personal risk of heart disease and commonly attributed symptoms to noncardiac causes; (3) competing and conflicting priorities influenced decisions about seeking acute care; (4) the healthcare system was not consistently responsive to them, resulting in delays in workup and diagnosis; and (5) they did not routinely access primary care, including preventive care for heart disease. CONCLUSIONS: Participants did not accurately assess their cardiovascular risk, reported poor preventive health behaviors, and delayed seeking care for symptoms, suggesting that differences in both prevention and acute care may be contributing to young women's elevated acute myocardial infarction mortality relative to men. Identifying factors that promote better cardiovascular knowledge, improved preventive health care, and prompt care-seeking behaviors represent important target for this population.

"I'm not just a heart, I'm a whole person here": a qualitative study to improve sexual outcomes in women with myocardial infarction.

BACKGROUND: Little is known about recovery of female sexual function following an acute myocardial infarction (MI). Interventions to improve sexual outcomes in women are limited. METHODS AND RESULTS: Semistructured, qualitative telephone interviews were conducted with 17 partnered women (aged 43 to 75 years) purposively selected from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status Registry to deepen knowledge of recovery of female sexual function following an acute myocardial infarction (MI) and to improve sexual outcomes in women. Sixteen women had a monogamous relationship with a male spouse; 1 had a long-term female partner. Most women resumed sexual activity within 4 weeks of their MI. Sexual problems and concerns were prevalent, including patient and/or partner fear of "causing another heart attack." Few women received counseling about sexual concerns or the safety of returning to sex. Most women who discussed sex with a physician initiated the discussion themselves. Inquiry about strategies to improve sexual outcomes elicited key themes: need for privacy, patient-centeredness, and information about the timing and safe resumption of sexual activity. In addition, respondents felt that counseling should be initiated by the treating cardiologist, who "knows whether your heart is safe," and then reinforced by the care team throughout the rehabilitation period. CONCLUSIONS: Partnered women commonly resume sexual activity soon after an MI with fear but without directed counseling from their physicians. Proactive attention to women's concerns related to sexual function and the safety of sexual activity following an MI could improve post-MI outcomes for women and their partners.

Admission variables predictive of academic struggle in a PharmD program.

Objective. To characterize and describe admission variables predictive of poor grade attainment by students in 2 pathways to a doctor of pharmacy (PharmD) program.Methods. A retrospective analysis of course grades of PharmD students admitted from 2000 to 2009 (N= 1,019) in the traditional degree pathway ("1 plus 5" degree program) and the provisional pathway (admitted directly from high school) was performed.Results. Four hundred three grades of D or less were earned by 183 (18%) students. There were more grades of D or less in the first pharmacy year. Receipt of an unsatisfactory grade was associated with all Pharmacy College Admission Test (PCAT) subcategory scores, PCAT composite score, cumulative prepharmacy coursework hours, prepharmacy grade point average (GPA), prepharmacy science and math GPA, and interview score for accepted students in the traditional pathway. For students in the provisional pathway, PCAT-quantitative analysis, PCAT composite score, prepharmacy cumulative GPA, prepharmacy science and math GPA, English American College Testing (ACT) score, and composite ACT score predicted poor grades. Conclusion. Admissions committees should heed PCAT scores and GPAs, regardless of program pathway, while progression committees should focus on early program coursework when designing strategies to optimize retention.

Exploring barriers to optimal anticoagulation for atrial fibrillation: interviews with clinicians.

BACKGROUND: Warfarin, the most commonly used antithrombotic agent for stroke prophylaxis in atrial fibrillation (AF), requires regular monitoring, frequent dosage adjustments, and dietary restrictions. Clinicians' perceptions of barriers to optimal AF management are an important factor in treatment. Anticoagulation management for AF is overseen by both cardiology and internal medicine (IM) practices. Thus, gaining the perspective of specialists and generalists is essential in understanding barriers to treatment. We used qualitative research methods to define key issues in the prescription of warfarin therapy for AF by cardiology specialists and IM physicians. METHODS AND RESULTS: Clinicians were interviewed to identify barriers to warfarin treatment in a large Midwestern city. Interviews were conducted until thematic saturation occurred. Content analysis yielded several themes. The most salient theme that emerged from clinician interviews was use of characteristics other than the patient's CHADS(2) score to enact a treatment plan, such as the patient's social situation and past medication-taking behavior. Other themes included patient knowledge, real-world problems, breakdown in communication, and clinician reluctance. CONCLUSION: Warfarin treatment is associated with many challenges. The barriers identified by clinicians highlight the unmet need associated with stroke prophylaxis in AF and the opportunity to improve anticoagulation treatment in AF. Social and lifestyle factors were important considerations in determining treatment.

Use of online modules to enhance knowledge and skills application during an introductory pharmacy practice experience.

OBJECTIVES: To implement and assess the effectiveness of online instructional modules to increase the consistency of learning outcomes related to students' patient-care practice knowledge and their skills application and confidence across introductory pharmacy practice experience (IPPE) sites. DESIGN: Twenty online modules were created to provide uniform delivery of instructional content that complemented classroom instruction and to introduce students to common pharmacy-practice skills in the patient-care arena. ASSESSMENT: Quantitative data were collected by means of a survey and pre- and post-module quizzes, which were completed by students to assess knowledge. More than 85% of students applied the IPPE skills. During the course, students' confidence increased significantly in all areas. For all but 1 of the 13 competencies, more than 70% of students agreed or strongly agreed that the competencies were met. CONCLUSIONS: Online instructional modules in patient care can effectively increase students' knowledge, skills application, and confidence, and improve the consistency of achieving outcomes for instructional content and activities across diverse practice settings.

Variety and quantity of professional electives.

OBJECTIVES: To compare the elective courses offered by US colleges and schools of pharmacy to establish a benchmark for individual colleges and schools to use in assessing whether they offer a sufficient amount and variety of electives. METHODS: Internet Web sites of US doctor of pharmacy (PharmD) programs were reviewed to identify the number of elective lecture-based courses and elective advanced pharmacy practice experiences (APPE) offered and required. Elective courses were grouped into categories to determine the variety of offerings. RESULTS: Pharmacy students were required to complete a mean of 7 hours of classroom-based elective courses. Thirty-two lecture-based elective courses were offered per college or school, and the mean number of categories of courses offered was 24. An average of 3 required APPEs was offered within 24 categories. CONCLUSIONS: Pharmacy programs varied in the number of and requirements for elective courses. Most elective courses expanded on what was taught in the required curriculum vs informing on unique concepts or skills.

Clinician-patient discord: exploring differences in perspectives for discontinuing clopidogrel.

BACKGROUND: Premature stopping of anti-platelet therapy has potentially fatal consequences for myocardial infarction (MI) patients who have received a drug-eluting stent (DES). Exploring multiple perspectives to identify contributing factors to the problem is essential. AIM: We gained patient and clinician perspectives as to why MI patients prematurely stop anti-platelet therapy (clopidogrel) after DES implantation. METHODS: This qualitative, descriptive study of DES-treated MI patients (n=22) and of clinicians (physicians and nurse practitioners; n=17) from multiple U.S. cities used content analysis of interview data. Findings across patients and clinicians were then compared to examine congruent and contrasting reasons for premature clopidogrel discontinuance. FINDINGS: Patients frequently identified communication and education (e.g. unaware they should be taking clopidogrel, unaware of intended duration of therapy) as the primary reasons for having stopped. Patients rarely cited cost, while clinicians most commonly cited cost as a reason for premature stopping. CONCLUSIONS: The discrepancy in perceptions of patients and clinicians as to the primary reason for early discontinuance suggests an important opportunity for improving persistence. Rather than focusing on the high costs of medications, something outside of their control, physicians should consider communicating more effectively the importance and intended duration of clopidogrel to their patients.

Medication Discussion Questions (MedDQ): developing a guide to facilitate patient-clinician communication about heart medications.

BACKGROUND AND RESEARCH OBJECTIVE: Adherence to evidence-based therapies has emerged as one of the great challenges of translating discoveries to clinical care to optimize patient outcomes. In particular, nonadherence to lifesaving medications continues to trouble health care systems. We conducted a series of studies to investigate why cardiac patients stop life-sustaining medications and to develop a tool to proactively address medication adherence issues. We could find no available preventive tools for communicating with patients about their medications in the clinical setting. In this article, we summarize the process of developing such a tool. SUBJECTS AND METHODS: We used a mixed-methods approach in a series of studies that included examining quantitative data from a large patient registry, conducting in-depth qualitative patient interviews, creating items representative of the qualitative findings, pilot testing items with heart patients, surveying an expert panel to establish content validity, and conducting in-depth interviews with health care providers to assess implementation opportunities. RESULTS AND CONCLUSIONS: Patient interviews revealed that patients' values and beliefs, barriers to treatment, and prior medication-taking behavior were of primary importance in understanding medication discontinuance. Pilot testing, expert panel review, and an implementation feasibility evaluation resulted in an 11-item communication guide to be used in a variety of health care settings. Clinicians need an efficient way of systematically communicating with patients about heart medications to identify barriers and to initiate preventive interventions when patients report barriers or challenges to medication adherence.

Exploring patients' reasons for discontinuance of heart medications.

BACKGROUND: Despite the importance of secondary prevention, nonadherence rates for patients with myocardial infarction (MI) range from 13% to 60% for prescribed, evidence-based medicines. Although rates and consequences of discontinuance vary for different medications, the existing literature provides little insight into reasons for discontinuance. OBJECTIVE: To address this gap, we explored clopidogrel and cholesterol-lowering therapy (CLT) discontinuance after an MI to understand patients' reasons for stopping these 2 medications. METHODS: In this qualitative descriptive study, 2 groups of patients who stopped a heart medication-either clopidogrel or CLT-were recruited from a prospective MI registry. Patients who discontinued CLT (n = 29) or clopidogrel (n = 11) were interviewed within 18 months of hospitalization. Patients were recruited and interviewed until data saturation was achieved. The Health Belief Model was used as an organizing framework in analyzing and coding the narrative data. The codes were then summarized for each group and compared to identify similarities and differences in reasons for CLT and clopidogrel discontinuance. RESULTS AND CONCLUSIONS: The most common reason for CLT discontinuance was adverse effects that were painful and interfered with daily life. Less common reasons for discontinuance were prescription confusion, cost, mistrust in medicines/healthcare system, and preference for alternative therapies. Reasons for clopidogrel discontinuance were duration confusion, adverse effects, and cost. Although doctors stopped patients' clopidogrel in preparation for surgery, doctors conceded to discontinuance of CLT for patients who experienced adverse effects after trying 2 to 3 different CLTs. Patients who discontinued CLT were more likely to believe that they did not need the treatment than do patients who discontinued clopidogrel. Clinicians should be aware that reasons may vary across patients and medication class for prematurely stopping therapy; thus, proactive interventions should be targeted to address these differences. Identifying at-risk patients for targeted interventions to prevent premature cardiac medication discontinuation is vital.