Woodman OL et al / Acta Pharmacol Sin 2004 Sep; 25 (9): 1195-1203

Teaching pharmacology to medical students in an integrated problem-based learning curriculum: an Australian perspective

Owen L WOODMAN¹, Agnes E DODDS², Albert G FRAUMAN³, Mosepele MOSEPELE²

¹Department of Pharmacology, Faculty of Medicine, Dentistry and Health Sciences;
²Faculty Education Unit, Faculty of Medicine, Dentistry and Health Sciences;
³Clinical Pharmacology and Therapeutics Unit, Department of Medicine, The University of Melbourne, Australia

¹ Correspondence to Prof Owen L WOODMAN. E-mail owenlw@myriad.its.unimelb.edu.au

Received 2004-03-02 Accepted 2004-06-01

ABSTRACT

The world-wide move away from the didactic teaching of single disciples to integrated Problem-based Learning (PBL) curricula in medical education has posed challenges for the basic sciences. In this paper we identify two major challenges. The first challenge is the need to describe a core disciplinary curriculum that can be articulated and mapped onto the new structure. We illustrate how the British Pharmacological Society (BPS) Guidelines are used to evaluate the curriculum coverage in the medical course at The University of Melbourne. The second challenge is to ensure that foundational concepts are given adequate emphasis within the new structure, and in particular, that students have the opportunity to pursue these concepts in their self-directed learning. We illustrate one approach to teaching important pharmacological concepts in an integrated curriculum with a case study from the first year curriculum at The University of Melbourne. Finally, we propose the features of an integrated curriculum that facilitates the learning of basic pharmacology in a situation where PBL and integration sets the curriculum framework.

RECENT CHANGES TO MEDICAL EDUCATION

The last two decades have seen a major shift in teaching methods in several large Australian medical schools. In line with global trends, curriculum planning groups have responded to the call for more relevant and engaging ways of teaching medicine^[1]. These responses productively coincided with contemporary understanding of the need to encourage active and self-directed learning in all areas of tertiary education^[2,3]. In particular, the previous, traditional shift from early scientific training to clinical experience in medical curricula is now seen as fragmented, resulting in students who were poorly motivated to study foundational disciplines^[4]. Several medical schools in Australia now have made significant changes to the way they train future medical professionals^[5], drawing on a better understanding of the durability of knowledge that is acquired by students who are active learners rather than passive recipients of didactic teaching. This change has encompassed the foundational disciplines as well as clinical training.

Three major structural changes are associated with this revolution in medical education. First, Problem-based Learning (PBL) is adopted as the major curriculum method. Then, within PBL curricula, basic science disciplines have been sysnthesised in a horizontal integration of the scientific curriculum around studying the major body systems, and a vertical integration of clinical and basic sciences. Thirdly, several schools have moved to graduate entry, four-year courses for the degree of MBBS. Such restructuring means that curriculum designers must not only respond to the active learning environment, but also must organize their framework for organising teaching material more efficiently and effectively, while retaining the core scientific basis on which clinical medicine is built.

In this paper, we describe how The University of Melbourne developed a curriculum framework for active learning and for the integration of basic and clinical sciences, and in particular, the place of pharmacology in this framework. Incorporating these changes into the medical curriculum involved teaching pharmacology within a vertically and horizontally integrated PBL-based program of study. We illustrate our use of PBL for the teaching of pharmacology with a case study that demonstrates one approach to teaching important pharmacology concepts interactively. Finally, we propose the features of an integrated curriculum that facilitates the learning of basic pharmacology in a situation where PBL and integration sets the curriculum framework.

STRUCTURE OF THE MBBS AT THE UNIVER-SITY OF MELBOURNE

The School of Medicine at the University of Melbourne introduced a new medical curriculum in 1999. It remains an undergraduate degree, but has a dual entry pathway for graduates and undergraduates. Undergraduate entry students enter from school and complete a six year program, including a research year leading to the degree of Bachelor of Medical Science. Graduate entry students make up one third of the local intake and complete their degree in four and a half years. They enter in the second semester of the first year, and do not complete the extra research year.

The first two and a half years of the degree are pre-clinical. Students take two subjects during each 14 week semester for five semesters. The main science subject has two PBL tutorials at the beginning and end of each week. Five lectures and at least one practical class are delivered between the two tutorials, giving students resources for their independent study.

PROBLEM-BASED LEARNING

The rationale for relying on Problem-based Learning in medical programs has been presented in many scholarly papers over the past 15 years. Especially useful are two review papers by Albanese and Mitchell^[6] and Norman and Schmidt^[7]. The arguments in favour of a PBL-based curriculum model that encourages self-directed learning and motivates students through the use of relevant clinical scenarios are now widely accepted.

Problem-based learning comes in a variety of forms. At Melbourne, the system of `progressive disclosure' is used for paper-based cases in tutorial groups of 11 students with a non-specialist tutor (usually a basic scientist, but sometimes a clinician). The cases are quite detailed, with complex descriptions that encourage students to deal with the information as it unfolds (following the Harvard model)^[8]. In the first tutorial students are given a short scenario, followed by the progressive disclosure of the patient's history, physical examination findings and investigation results. Students spend the week between tutorials researching a set of agreed learning issues. In the second tutorial students apply the knowledge and understanding gained from their self-directed study to the problem. They are given further information on the patient's progress and the results of investigations. This information is used to finalize their hypotheses and to resolve outstanding questions. At the end of the second tutorial students are given the patient's prognosis and follow-up treatment. It is at this point that many drugs are introduced, but there is little time to investigate the reasons for their prescription.

VERTICAL AND HORIZONTAL INTEGRATION

While PBL has been discussed, advocated and evaluated to such an extent that it forms the major topic of research and writing in medical education, the issue of vertical and horizontal integration has received much less attention. However, it is the move to integration of both kinds that has the largest impact on teachers from the basic science disciplines^[9-11].

A horizontally integrated curriculum combines input from all the relevant scientific disciplines, with each making a contribution to students' understanding of a major body system (eg cardiovascular). This requires each discipline to organize the presentation of key content with novel emphases (for example, dealing with drugs in relation to a disease of the cardiovascular system, rather than as a particular class of drugs). Thus disciplinary teachers also have to work to a timetable that is different from that in a traditional approach to topics. Such new challenges can only be met by planning involving scientists and clinicians from all contributing disciplines.

Few accounts explain how to incorporate disciplinary content into such an integrated curriculum. One of the few by Sivan, Iatridis and Vaughn reported on the integration of pharmacology into a problem-based learning course at the Indiana School of Medicine^[12]. These authors concluded that it is possible to successfully integrate core pharmacological knowledge into a PBL curriculum, although the course they describe concentrates blocks of pharmacology teaching into one section known as `Systemic Function and Drug Action'. In the more common body systems approach adopted by the University of Melbourne, each learning block has a theme of one or two major body systems. In such a framework, pharmacology cannot stand as something to be taught on its own. It must be taught within the synthesized whole system.

At Melbourne, a broadly-based introductory subject known as `Principles of Biomedical Science' is followed by four `body system' subjects: nutrition, digestion and metabolism is the first block, followed by cardio-respiratory and musculoskeletal, neuroscience and endocrine, and the final subject is organized around microbiology and pathology. Pharmacology must find its place as one discipline represented in the analysis of each of these body systems, but as a discipline that informs and is informed by all the other disciplines (eg, physiology, biochemistry and pathology).

CHALLENGES FOR TEACHING PHARMA-COLOGY IN AN INTEGRATED CURRICULUM

The challenges involved in teaching pharmacology in an integrated curriculum include the need to ensure that a core disciplinary curriculum can be identified and mapped to the new structure, and that students are introduced to key scientific concepts and information in an order that builds from a sound scientific base to the more clinically applied knowledge. Even more importantly, foundational concepts must be given sufficient emphasis in students' self-directed learning to allow them to construct a knowledge-base that can be available to them as a resource when they are engaged with clinical problems.

Identifying the curriculum The clinical pharmacology and therapeutics over-arching objectives within our course are to understand mechanisms of action of specific therapeutic agents and to apply these into clinical settings. This approach seeks to provide a practical and rational prescribing skill base by the end of the final semester of the course. This hopes to enable the future prescriber to define the patient's problem, define the therapeutic objectives, to check the effectiveness and safety or appropriateness of the preferred agent for that individual patient, to provide the patient with information, instructions and warnings and to initiate and monitor treatment, in line with WHO prescribing guidelines. In addition, the course aims to provide skills to access information sources (print-based and in electronic format) for new and emerging therapeutic agents. The media used for these aims include incorporation of therapeutic and prescribing issues in the PBL cases/tutorials and in electronic prescribing modules, developed by the Australian National Prescribing Service. Identifiable therapeutic areas include hypertension and cardiac failure, drugs in disease and therapeutic drug monitoring, peptic ulcer disease/reflux and bowel disturbance, diabetes, Parkinson's disease including drug-induced movement disorders, metabolic bone disease, COAD and asthma, pain, headache and vomiting, ischaemic heart disease, dermatologic drugs and anti-rheumatic drugs.

The British Pharmacological Society (BPS)^[13] has identified generic core objectives applicable to most areas of therapeutics, and has constructed a list of "core drugs and therapeutic problems for the medical curriculum". For these drugs graduates are expected to have an understanding of mechanism of action, contra-indications and side effects.

The general mechanisms of action of drugs at a molecular, cellular and organ level are considered as drugs acting on the different body systems. This is readily dealt with in a systems based curriculum, and we have identified systems and related drugs appropriate for the pre-clinical years. Appendix 1 maps our curriculum to the BPS drug list and identifies the number of PBL tutorials, and accompanying lectures or practical classes where those drugs are discussed.

Appendix 1. Frequency with which selected drugs are included in different teaching formats (The drugs are listed as they appear on the BPS website. http://www.bps.ac.uk/)

Commonly used drugs	Drugs	Lectures (n)	PBL	PBL	Practical
			Tutorial 1 (n)	Tutorial 2 (n)	Classes (n)
System	Drugs
Gastrointestinal system	antacids		1
	alginates
	H2-antagonists			1	1
	proton pump inhibitors			1
	misoprostol	1
	codeine
	loperamide
	sulphasalasine
	corticosteroids
	laxatives
	antispasmodics
	spironolactone
	metreonidazole
Cardiovascular system	thiazide diuretics	2		2
	loop diuretics	1		3
	potassium-sparing diuretics	1
	b-adrenoceptor antagonists	4		2	2
	calcium channel blockers	4	2	1
	ACE inhibitors	1	2	1
	AT1-antagonists	1
	a-adrenoceptor antagonists	1			1
	methyldopa	1
	nitrates	1	1	1	1
	digoxin	1		1
	adenosine
	amiodarone	1	1
	lignocaine	1
	aspirin	1		1
	clopidogrel	1
	thrombolytics	1		1
	heparins	1		3
	warfarin	1		3
	statins		1	1
Respiratory system	oxygen		3	1
	b-adrenoceptor agonists	1	4	3	1
	cromoglycate	1
	ipratropium	1	1	1
	theophylline	1			1
	corticosteroids	1	3	4
Nervous system	L-dopa	1
	Dopa decarboxylase inhibitors	1
	bromocriptine	1
	anti-muscarinic drugs	1	1
	anti-convulsant therapy		1