Perspectives

JOURNAL OF MICROBIOLOGY & BIOLOGY EDUCATION, December 2010, p. 135-139 Copyright © 2010 American Society for Microbiology DOI: 10.1128/jmbe.v11i2.220

Perspectives

Clinical Microbiology in Pharmacy Education: A Practice-based Approach Olla Wasfi1, Mary Power2 and Roderick A. Slavcev*1 1School of Pharmacy and 2The Centre for Teaching Excellence, University of Waterloo, Waterloo, Ontario, CANADA The increasing incidence of multi-drug resistant pathogenic bacteria, alongside viral and fungal human pathogens, supports the argument that skills in microbiology and infectious disease diagnosis, treatment and prevention are of growing global importance to be held among primary care clinicians. In Canada, inevitable future astronomical health care costs largely due to an aging population, have forced eyes upon pharmacists as one of (if not) the primary clinical professions to accommodate the growing need to accommodate patient access to health care while maintaining lower health care costs. As such, the role of pharmacists in health care is expanding, punctuating the need to enhance and improve Pharmacy education. Accurate assessment of the current gaps in Pharmacy education in Canada provides a unique opportunity for a new Pharmacy School at the University of Waterloo to establish a non-traditional, outcomes-based model to curricular design. We are applying this iterative curriculum assessment and design process to the establishment of a Medical Microbiology program, deemed as a prominent gap in former Pharmacy educational training programs. A pilot study was carried out distributing a comprehensive survey to a local group of pharmacists practicing in a variety of settings including: hospital, clinic, community, independent, industry and government, to assess perceived gaps in Pharmacy microbiology and infectious disease education. Preliminary findings of the surveys indicate that practitioners feel under-qualified in some areas of microbiology. The results are discussed with respect to a curricular redesign model and next steps in the process of curricular design are proposed.

INTRODUCTION Antibiotic control programs are of paramount importance due to increasing incidence of antibiotic-resistant nosocomial (hospital acquired) infections world-wide, aggravated by a dwindling arsenal of antibacterial options at our disposal.This growing global dilemma is reaching calamitous proportions and has been called one of the world’s most pressing public health problems (3). Over the last decade, almost every genus of bacteria has demonstrated genetic pliability in its ability to overcome the consistent and increasingly ubiquitous selective pressures imparted by widespread global antibiotic use. As such, this artificial natural selection has resulted in lack of even “last resort” treatment options in many life threatening infectious disease (ID) cases. These antibiotic-resistant “superbugs” are highly contagious and pose a dire threat to other hospitalized patients and/or the general populations. These IDs are more difficult and expensive to treat and in the worse case scenarios

*Corresponding author. Mailing address: School of Pharmacy, University of Waterloo, 200 University Ave. W., Waterloo, Ontario, Canada N2L 3G1. Phone: 519-888-4567 x. 21301. Fax: 519-888-7910. E-mail: [email protected]. Volume 11, Number 2

are untreatable. In addition the emergence of new and exotic viral infections and protozoan parasites is of equal importance. Therefore, the inclusion of infection prevention programs is an essential requirement (6).At the rudimentary level, the development of an integrated program in hospitals is the key to controlling nosocomial infections and antibiotic resistance.This requires strong, consistent communication and understanding between departments of epidemiology and infection control, microbiology (laboratory), occupational health services and pharmacy (6). As such, clinician proficiency in microbiology and diagnosis, treatment and prevention of infectious disease is becoming more important than ever before. Canada health care system is facing enormous pressure from a growing elderly population, making economical and practical access to health care a leading concern and growing requirement. By definition, the profession of pharmacy will always be intimately involved with illness and its treatment, the management of medicines, and promotion of health. Arguably, the most important and fundamental role of a pharmacist is as a front-line advisor to health professionals and the public alike, to effectively counsel on all aspects of pharmacotherapy (4). The current demographic environment and political pressures are forcing pharmacists into the role of the front-line primary care distributor, making this clinical profession the most suitable to investigate for adeptness in ID practice, now and into the future.

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Wasfi, et al.: Clinical Microbiology in Pharmacy Education

DISCUSSION What are the gaps in microbiology and infectious disease education? Microbiology and IDs are generally taught at quite a basic level amongst pharmacy programs in Canada, with some exceptions, and may not be provided with adequate practical skills to adeptly interpret results and treat ID. Typically, Canadian pharmacy education curricula are comprised of either one or two terms of basic microbiology and/or ID topics that often lack a clinically relevant laboratory component (see Table 1). The transfer of clinically relevant medical microbiology skills to pharmacy students is essential to effective and forward-looking practice, but is generally deficient based on our investigation of Canadian Pharmacy programs (Table 1). As such, the incorporation of a casebased, clinically relevant microbiology and ID programs into the curriculum represents a remarkable opportunity to improve the standard of national pharmacy practice. To assess the potential knowledge gaps based on the investigation of pharmacy curricula, an on-line pilot survey that received University of Waterloo, Office of Research

Ethics approval (ORE # 15747) was distributed locally. Forty-four surveys were completed, representing community pharmacists (48%), hospital pharmacists (39%), long-term care facility pharmacists (20%), and members of family health care teams (7%). The majority (75%) of the respondents received their training more than 10 years ago, with 7% having graduated within five years. The survey results indicated that a minimum of 60% of respondents frequently or sometimes feel under-qualified discussing microbiology and ID both with patients and with other health professionals, as well as providing suggestions for alternative treatments (Fig. 1). We also identified areas of specific deficit with respect to different areas of microbiology (Fig. 2). For instance, only 20% of respondents felt they held a sufficient understanding of virology and were proficient in offering treatment options for ID. Even fewer felt that they possessed an adequate understanding of parasitology and mycology. Although respondents generally had a greater understanding of bacteriology, half of them still felt that they required more training. When asked the reasons for their feelings of inadequacy with respect to microbiology, respondents most commonly indicated a lack of education in and understanding of concepts and practical skills.

Table 1. Summary of Canadian Pharmacy Microbiology Programs. A brief synopsis of the curricular components among the bachelor level pharmacy programs in Canada. Pharmacy Program

Courses

Practical Component

MICB 202: Introductory Medical Microbiology & Immunology

No practical component

University of Alberta

PHARM 407: Infectious Diseases I

2 hr/ week for 13 weeks

PHARM 477: Infectious Diseases II


MCIM 224: Microbiology for Pharmacists and Nutritionists


MBIO 2100: General Microbiology A


University of British Columbia

University of Saskatchewan University of Manitoba University of Toronto

LMP 232Y1: Microbiology of Infectious Diseases

University of Waterloo

PHARM 232: Medical Microbiology Laboratory 1


PHARM 233: Medical Microbiology Laboratory 2


PHARM 220-420: Integrated Patient Focused Care (Modules 1-9)


PHARM 363:Global Infectious Diseases Management


MICI 1050: Basic Microbiology and Immunology for Pharmacy


PHAR 3030: Infectious Diseases


3103: Microbiology of Infectious Diseases


Dalhousie University Memorial University of Newfoundland

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(Full year) Term 1: No practical component Term 2: 2 hr/ week for 12 weeks

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Figure 2. Areas in microbiology requiring more training or understood proficiently. Survey summaries of subdisciplines of microbiology that respondents feel they understand proficiently or require more training in. Bacteriology is the most understood (96%) and yet 48% feel they still require further training. Fewer than 25% feel they understand the other areas proficiently. [Ethics approval for questionnaire was obtained from the University of Waterloo, Office of Research Ethics, ORE # 15747.]

Figure 1. Pharmacist’s perception of qualification discussing microbiology and infectious disease. Summarized results of responses to survey questions regarding feelings of under-qualification in discussing microbiology or infectious diseases with (A) patients, (B) fellow health care professional, and (C) recommending alternative treatment options. Approximately 60% of respondents feel underqualified in these areas frequently or sometimes. [Ethics approval for questionnaire was obtained from the University of Waterloo, Office of Research Ethics, ORE # 15747.]

A new course offering: why a different microbiology approach? The preliminary findings described above support our initial assumption that there may be an unmet need in education of primary care clinicians, at least in pharmacy. To address this identified gap in ID education, both in knowledge base and practice, and to build proficiency to meet the growing incidence of ID, we are designing a practice-based, co-operative education curriculum with two primary goals: i) combining didactic teaching with experiential learning, and ii) integrating educational material to simulate real case scenarios. To build practical capabilities in ID, we have incorporated a medical microbiology laboratory component that runs temporally and logically in coordination with the School’s highly integrated therapeutics program. By way of this design, our clinically-relevant microbiology course is administered in Volume 11, Number 2

parallel with an integrated therapeutics program that focuses in depth on real-life, case-based scenarios that integrate ID, medicinal chemistry, pathophysiology, immunology, pharmacology, clinical biochemistry, critical appraisal and patient-focused care. We anticipate that this union creates a cross-disciplinary, real-life clinical approach to ID education. The educational efficacy of this approach is currently under investigation but, from preliminary observation, it may well provide a powerful repertoire of new clinical skills and knowledge to students. In recent years, there has been a paradigm shift sweeping through health care education towards outcomes-based education – looking at the end result as much as the educational process itself (1). A similarly integrated design has been implemented at the University of Georgia’s College of Pharmacy, for their entry-level Pharm D. (ELPD) curriculum in 1995. At the College, an introductory ID course incorporates pertinent clinical microbiology, antiinfective medicinal chemistry and drug treatment of common ID entities along with applied microbiology skills (2). Similarly, the Chinese University of Hong Kong’s School of Pharmacy has implemented not only an integrated approach but also various clerkships and projects, and has studied the effectiveness of the implementation over a four-year period (5). The results obtained from this longitudinal study indicated that the curriculum development process was highly effective in improving the development of both professional and generic capabilities. Lastly, the University of Sydney’s Faculty of Pharmacy has also recently developed an integrated, evidence-based, collaborative curriculum, replacing the previous discipline-based approach (7). The overarching goal of all of these programs is the integration of knowledge-based learning and the development of practical skills.


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Integration and practicality – pushing the envelope for infectious disease training The University of Waterloo’s School of Pharmacy has designed a novel program comprised of a classroom-based, case-based constituent of the integrated therapeutics program called “Integrated Patient Focused Care” (IPFC). This curriculum is coordinated with and complemented by a hands-on practical, clinically-relevant training of microbiology and ID. The medical microbiology program, herein referred to as “Med Micro”, is designed to be administered to the students during their second year, as two temporally distinct courses (Part I and II) over a two-term (eight-month) duration, separated by a four-month co-op session. The first half of Part I focuses on delivering basic microbiological skills and knowledge in techniques such as staining and culturing, and microscopy, in order to prepare the students for the more in-depth applied information to follow in the second half of Part I (that inaugurates the Med Micro program and is continued through Part II).The program is anatomically sectioned into modules that are coordinated with IPFC. This strategy is maintained throughout Part II, the Med Micro laboratory, again coordinated with anatomically categorized therapeutics modules.The medical microbiology laboratory program covers the different microorganisms and ID, with emphasis on the clinically-relevant microbiology procedures and precise interpretation of results to properly manage the real-life cases employed. Figure 3 illustrates the Med Micro program’s strategic educational alignment, designed to maximize achievement of expected outcomes and minimize impertinent and

Figure 3. Strategic course alignment. Effective delivery of knowledge requires strategic and meaningful alignment of the course’s learning objectives, teaching approaches and delivery techniques, and formative/summative assessment methods. Primary course goals have been closely aligned with assessments and teaching methods to confer an effective learning environment.

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nonpractical material with the goal of developing more confident and competent graduates. The Med Micro program also includes a hospital clinical laboratory field trip capstone to orient students through work-ups of real-life cases, from sampling and diagnosis through to treatment, as demonstrated by medical laboratory and clinical experts in real time. By way of organized meetings with the microbiology hospital staff and clinical pharmacists, students are able to fully appreciate the importance of a clinical microbiology laboratory and the value of understanding the procedures and results with respect to effective diagnosis and treatment of patients. In addition, students have access to four co-op (four-month experiential learning) opportunities during which they have the option to specialize in, for example, ID treatment, hospital laboratory, vaccine design, or prevention and public health. Course evaluation and future plans In order to evaluate the course content and delivery and its benefit from the students’ perspective, a survey that will include a case study to be administered to students at the end of the two semesters and after their graduation, is currently being crafted. Additionally, the needs assessment survey that was piloted in the Waterloo Region will be distributed across Canada to assess the ubiquity of the knowledge gap in the field of ID in Pharmacy practice nationally. The preliminary results from the pilot survey suggest and request that we develop continuing education courses in the area of Med Micro for pharmacy professionals – a task that will be undertaken in the near future. Particular topics in microbiology, such as mycology and virology, on which to focus further attention in the program have also been identified and will be addressed. We believe that the movement of Med Micro instruction to an outcomes-based approach as begun by ourselves and others (2, 5, 7) will help to provide the students with the necessary skills to more confidently and accurately provide clinical therapeutic assessment and treatment. The iterative approach of these models is key to keeping the microbiology curriculum current and abreast of the changing needs of the profession and the evolving spectrum of infectious disease globally. Although this outcomes-based model of curriculum development is currently being developed and researched in a specific area of the pharmacy curriculum, we feel that it is a model that has great potential both within Pharmacy, as a front-line primary care profession, and also across all clinical disciplines.

REFERENCES 1. Austin, Z., and M. Ensom. 2008. Education of pharmacists in Canada. Am. J. Pharm. Educ. 72: Article 128. 2. Beach,W.J., J.W. Cooper, G.E. Franciso, and R.A. Langford. 1998. An integrated infectious disease course for


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Wasfi, et al.: Clinical Microbiology in Pharmacy Education an entry-level Doctor of Pharmacy curriculum. Am J Pharm Educ. 62:296–301. 3. Centers for Disease Control and Prevention. Get smart: know when antibiotics work. Available from: http://www.cdc. gov/getsmart/antibiotic-use/anitbiotic-resistance-faqs.html 4. Harman, J.R . 2001. Handbook of pharmacy health education, 2nd ed. The Pharmaceutical Press, London, UK. 5. Ho, S.S.S., D. Kember, C.B. Lau, M.M. Au Yeung, D. Y. Leung, and M.S. Chow. 2009. An outcomes-based approach to curriculum development in Pharmacy. Am. J.

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Pharm. Educ. 73: Article 14. [online] http://www.ncbi.nlm. nih.gov/pmc/articles/PMC2690866/ 6. Nelson, K.E. and C.M. Williams. 2007. Infectious disease epidemiology: theory and practice. Jones and Bartlett Learning, Sudbury, MA. 7. Ryan, G., J. Hanrahan, I. Krass, E. Sainsbury, and L. Smith. 2009. Best practices assessment to guide curricular change in a Bachelor of Pharmacy Program. Am. J. Pharm. Ed. 73: Article 12. [online] https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC2690863/


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