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A Three-Year Sequential Course to Enhance Students’ Understanding of Pharmaceutical Care1 David M. Ruffin, Donald F. Brophy and Lea Ann Hansen School of Pharmacy, Virginia Commonwealth University, PO Box 980533, Richmond, VA 23298-0533 The pharmacy practicum is a six semester consecutive course sequence that was implemented as part of our four-year professional degree program. Each semester features the same overall design whereby groups of 10-12 students are assigned to a faculty mentor for three years. These students are engaged in a variety of experiential activities, with a subsequent discussion of the activity among their peer-group and faculty mentor. The experiential activities of each semester are commensurate with the students’ level of professional understanding and didactic instruction. Experiential activities for this course take place in the following settings: long-term care facilities, community pharmacies, university and community-based ambulatory care clinics, basic and clinical research laboratories, hospitals, and a variety of community service organizations. In addition, students make numerous oral and written presentations related to their experiences, perform physical examinations, and conduct medical histories. This course is expected to enhance our “generalist” student education goal, facilitate student’s transition into the clerkship year, and ultimately into their chosen profession.

INTRODUCTION

Virginia Commonwealth University established its fouryear Doctor of Pharmacy degree program in the Fall of 1995. As part of this new curriculum, the pharmacy practicum course was devised in an effort to enhance the professionalization of students and their preparedness for an evolving healthcare system. Furthermore, our need to develop a sound educational curriculum has been spawned, in part, by these changes in the healthcare system and the practice of pharmacy(1). This course is a six-semester, consecutive sequence that features the same overall design each semester: one experiential learning activity during a three-week block, and a subsequent two-hour discussion session with an assigned faculty mentor and a group of 10-12 students. The faculty member remains the students’ mentor throughout the six semester sequence and also serves as their academic advisor. The faculty mentor is responsible for facilitating group discussion around specific and/or global issues related to the students’ experiences. During each semester, students have four to five experiential activities (two hours each) and subsequent discussion sessions with their faculty mentor. For example, a discussion session might center around patient-related health beliefs, barriers to receiving healthcare, the role of pharmacists in an evolving healthcare system, healthcare economics, or clinical issues. To maintain consistency within each practicum group, a course coordinator plans each semester’s activities. The fundamental principles fostered by this course have long-since been identified as germane to pharmacists(2). Experiential activities of this course are commensurate with the students level of professional understanding. Throughout the practicum, students may have experiential activities in the same settings, but the expectations of the 1

Manuscript based on a portfolio submitted to the 1997 Council of Faculties Innovative Teaching Competition.

students are different during each semester of the practicum sequence. During the first year, the experience chiefly entails a student “shadowing” a pharmacist and asking or answering a list of pre-determined questions. However, during the second and third professional years, the experiential activities challenge students to integrate patient-specific data with principles taught in the classroom. As mentioned above, the faculty mentor plays a vital role in the student’s ability to process their individual experiences, while simultaneously appreciating more subtle issues related to the activity. The experiential activities of the course will be described below. FIRST PROFESSIONAL YEAR (P-1)

Fall Semester During the first semester of the course, students’ experiential activities are designed to provide initial exposure to pharmacy practice and patients who are the focus of that practice. Selected readings are provided before each activity and each student gives a presentation about their experience to their small group during the meeting with their faculty mentor. The scheduling of the various activities is staggered among groups (Table I). Students are assigned to a hospital pharmacy and to a community pharmacy. Each site is within an hour drive, unless the student indicates a preference for another location. One three-hour visit is made to each pharmacy. Students are given lists of questions to ask the practitioners. A third activity entails obtaining a medical history from a friend or family member who has at least one chronic illness. A fourth activity involves visiting a community service organization that allows the students to interact with individuals dealing with an illness while providing service to that organization. As a fifth activity, students must also read a book that is written from the perspective of a person who has experienced illness or dying. Books that

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Table I. Experiential activities for various student sections (Fall Semester, P-1 Year) Activity number Section 1 2 3 4 5 1 I C H S B 2 C H S B I 3 H S I C B 4 S I C H B 5 I C H S B 6 C H S B I 7 H S I C B 8 S I C H B 9 I H S B C

Table II. Experiential activities for various student sections (Spring Semester, P-2 Year) Activity number Section 1 2 3 4 5 1 LTC-1 E/O R CP LTC-2 2 LTC-1 E/O CP R LTC-2 3 LTC-1 E/O R LTC CP 4 LTC-1 E/O CP LTC R 5 CP LTC-1 E/O R LTC-2 6 R LTC-1 E/O CP LTC-2 7 CP LTC-1 E/O R LTC-2 8 R LTC-1 E/O CP LTC-2 9 CP LTC-1 E/O R LTC-2

I = interview of friend or family member; H = hospital pharmacy visit; B = book report on illness or dying; C = community pharmacy visit; S = community service organization.

LTC-1 = long-term care experience 1; LTC-2 = long-term care experience 2; R = research science experience; CP = clinical practice experience; E/O = attend pharmacy professional, or write a paper or medical devices.

provide specific medical information or self-help are not used, however. The course coordinator provides a list of suitable books. In their report to the group, the students are encouraged to creatively convey that which they have learned from the book.

For the fifth experience of the Spring Semester, students must either attend a pharmacy organization meeting, or write a brief report on durable medical equipment (DME) or other commonly used medical devices. Students who elected to write the paper had to visit a pharmacy that supplies DME, obtain written materials or brochures on the equipment/devices and consult with the pharmacist about the particular equipment. In terms of the professional meeting, approximately thirty students attended the spring meeting of either the Virginia Pharmacists Association (VPhA), or the Virginia Society of Health-System Pharmacists (VSHP). Students had the opportunity to become abreast of pressing issues facing the profession, such as prescriptive authority for pharmacists, discussion of a bill that would designate pharmacists as “healthcare providers,” discussion of a bill that would allow pharmacists to vaccinate, discussion of a bill that would prevent therapeutic interchange by third party payers, and various other topics of the meetings. Table II provides a schematic of the experiential activities for this semester.

Spring Semester This semester is designed to introduce new skills and build upon those previously learned in the practicum and elsewhere in the curriculum (e.g., communications and patient interviewing). Students are introduced to long-term care and consulting pharmacy practice. Two long-term care visits are required. The first visit entails a consulting pharmacist introducing the students to the medical record; followed by the students reviewing a specific medical record. The students then interview their assigned patient to further hone their interviewing skills. During their second visit, students are required to review the medical record of the same patient and note any changes in health status or medications. Students also gain a practical orientation to research science. Each student visits a research laboratory of a faculty member or other research scientist. Prior to this visit, students are provided a list of questions that focuses the experience on the following four content areas: (i) educational background necessary for a career as a research scientist; (ii) career opportunities as a research scientist; (iii) a discussion of research methodology specific to an on-going project or study; and (iv) future trends in a specific area of research. The research areas that students visit include pharmacology, pharmaceutics, medicinal chemistry, forensic toxicology, clinical pharmacokinetics/pharmacodynamics, biopharmaceutics, and various clinical research units located on our medical campus. A clinical practice experience continues to expose students to areas in which pharmacists practice. However, unlike the previous semester in which students were acclimated to the more traditional practices of pharmacy, here students are introduced to settings in which pharmacists function as part of an integrated healthcare team. Examples include sites such as a managed care, in-patient hospital medical teams, university-based hospital clinics, and offcampus ambulatory care clinics. During this experience, students have an orientation to practice setting and responsibilities of the pharmacist in that setting. 92

SECOND PROFESSIONAL YEAR (P-2)

Fall Semester The goal of this semester is to continue building upon clinical and other hospital-related activities introduced during previous semesters. Activities are primarily focused upon patient interviewing skills, medical history-taking and understanding the medical record. Students visit an inpatient, clinical setting three times during the semester. In the clinical setting, students are precepted principally by fourth-year Doctor of Pharmacy clerkship students. This is a mutually beneficial arrangement that provides a unique educational experience for both groups of students: the practicum students gain an appreciation for the application of didactic principles in the clinical setting; the fourth-year students gain experience in preceptorship. The fourth-year students also participate in the evaluation of the practicum students. Activities specifically related to this semester includes gathering pertinent patient data that includes the following: chief complaint, history of present illness, past medical history, family and social history, allergies, physical examination results and a general summary of the medical progress notes. At the subsequent discussion session, students review with their peers the subjective and objective data they

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gathered during the activity. The second and third activities include the same detailed chart review as described above, but in addition, students interview their respective patient to obtain a general medical and drug history. The students employ the same patient interviewing format that they learned during the P-1 Fall Semester practicum. The subsequent discussion session centers around the patient data previously gathered. As a fourth activity, students are given scenarios that present ethical dilemmas for healthcare professionals, and in particular, pharmacists. Examples of the ethical scenarios include the dispensing of abortifacients, or the dispensing of drugs for euthanasia. Spring Semester This entire semester is devoted to community pharmacy practice. Each student is assigned to an individual community pharmacy located throughout the state. Over the course of the semester, and at each of the approximately 95 community pharmacies, students are required to complete the following: a population analysis (e.g., medication compliance, frequency of use, cost analysis, prescribing patterns) on medications for chronic use, such as anti-hypertensives, oral hypoglycemics, or lipid-altering drugs; a medication history from a patient at their assigned pharmacy; a report that compares and contrasts the existing computer software versus newer pharmacy software packages that are available. The pharmacist at each site precepts students to assure quality of the learning activity. THIRD PROFESSIONAL YEAR (P-3)

Fall Semester At this period in the professional curriculum, students have completed much of the coursework that provides the framework for clinical pharmacy practice. Students are equipped to begin critically evaluating drug therapy and formulating rational pharmacotherapy plans. Hence, students focus on the assessment, treatment-plan and monitoring of hospitalized patients; this is in contrast to the Fall Semester of the Second Professional Year in which students focused on gathering subjective and objective patient-data from the medical record. To carry-out this semester of the practicum, each student is assigned to a pharmacy resident or fellow on an acute care service (e.g., Internal Medicine, Critical Care, Psychiatry, Hematology/Oncology). During the first activity, the responsibility of the student is to monitor the hospital course of an individual patient during a three- to five-day period of hospitalization. The students review the medical record daily to obtain any pertinent data, perform patient interviews and physical assessments. The students’ goal is to monitor the daily progress of a patient and to devise an appropriate pharmaceutical care plan. This is then written in the format of a SOAP note, which is discussed daily with the preceptor (pharmacy resident or fellow) and other assigned practicum students. The pharmacy resident or fellow is responsible for providing feedback to the student, reviewing all SOAP notes and evaluating the students’ performance. During the Fall Semester, a separate physical assessment course is offered for all third-year students. The practicum course during this semester serves as an opportu-

nity for students to practice the physical assessment techniques they have been taught in the classroom. This is accomplished by requiring, as part of the practicum course, two physical assessment exercises. Under the supervision of a several paid physicians, the students perform full physical examinations on hospitalized patients. The physicians are also responsible for evaluating the physical examination techniques of students. Here again is an example of how this course integrates with the overall curriculum and provides unique opportunities for students to gain practical skills relevant to their didactic instruction. The final two practicum activities are designed to continue to enhance our students ability to effectively communicate their knowledge. These activities include: (i) developing a patient education pamphlet, and (ii) preparing a 3045 minute presentation on a particular disease or complication they have previously observed in a patient. For example, students were asked to design a pamphlet that would relay relevant information to a diabetic patient with an 8th grade education. For the disease presentation, students were expected to cover the relevant pathophysiology, clinical presentation, diagnosis, treatment, and prevention. The students were expected to use audiovisual aids for this presentation, perform literature searches and include published data to support their recommendations. Spring Semester This course is currently being developed by the course coordinator. Preliminary activities include focusing on opportunities post graduation (e.g., preparing for residency/ fellowship interviews and preparation of resumes or curriculum vitaes). Final approval for this course will occur during Summer 1998. CONCLUSION

The pharmacy practicum course offered at Virginia Commonwealth University School of Pharmacy has been an investment in the future of our students. This six semester course will produce well-rounded students who are better able to transition into their clerkship year and ultimately into their chosen profession. Faculty members who serve as mentors for these students have noted a marked difference in these students compared to their predecessors in terms of their professionalism and insight into the profession of pharmacy. These students have been exposed to a wide array of practice sites and functions, which is believed to be an essential attribute of an entry-level Doctor of Pharmacy Curriculum(3). Furthermore, the faculty mentors value the opportunity to become intimately involved in the professionalization of a small group of students over a threeyear period. Am. J. Pharm. Educ., 62, 91-93(1998); received 1/16/98; accepted 1/18/98. References (1) Stohs, S.J. and Muhi-Eldeen, Z, “ The transition to more clinically oriented pharmacy education and the clinical practice of pharmacy, J. Clin. Pharm. Therap., 15, 435-454(1990). (2) Smith, H.A. and Swintosky J.V., “The origin, goals, and development of a clinical pharmacy emphasis in pharmacy education and practice,” Am. J. Pharm. Educ., 47, 204-210(1983). (3) “ACCP White Paper. Pharmaceutical education: A commentary from the American College of Clinical Pharmacy,” Pharmacotherapy, 5, 419-427(1992).

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