Pharmacology for the 21st Century:

1. Pharmacology for the 21st Century: Thomas Lynch, Pharm.D. Julie Bridges, PhD Candidate Eastern Virginia Medical School Norfolk, VA The Successful Implementation of an Innovative, Integrative Pharmacotherapeutics Curriculum for Medical Students

2. EVMS Facts and Figures 2013 Located in Norfolk, Virginia Annual Budget 230.9 Million State Appropriations 24.1 Million Students in 2015 MD Class 145 Faculty, Residents and Staff Residents, Interns, Fellows 349 Foundational Science Faculty 46 Clinical Faculty 365

3. EVMS Doctor of Medicine Program

4. EVMS M3 and M4 Years

5. Pharmacology Curriculum Pre-2012 • Two semester curriculum starting later than other M2 courses • No synchronization with other courses • Little emphasis on clinical use of drugs • Out-of-date material • Didactic presentations by multiple faculty without standardized format • Five small group sessions using 6 pharmacology faculty members • Four exams using non-USMLE style questions plus final shelf exam

6. Overall Course Satisfaction

7. Concerns With Pharmacology Curriculum Pre-2012 • Consistently poor student evaluations • Low attendance (10-20%) • Material taught not relevant to current clinical practice • Students in 3rd & 4th years not able to evaluate and/or recommend medication regimens safely and effectively • Student prone to “hidden curriculum” • Pharmaceutical marketing, inaccurate advice from other students & residents

8. Some Drug Facts • Over 4 billion prescriptions dispensed with sales of $325 billion in U.S. in 2012 • Five brand drugs accounted for over $26 billion! • Nexium, Abilify, Crestor, Advair, Cymbalta • For every dollar spent on drugs, one dollar is spent on adverse events • Mortality secondary to drugs is unofficially estimated to be the 3rd leading cause of death in the U.S. • 11% of hospital admissions of older adults are due to adverse drug reactions • 42% of adults > 65 years old take more than 5 drugs • 13% take more than 10 drugs • At least 50% of patients are nonadherent to medications

9. Concern:Medical students are not receiving sufficient education and training in rational prescribing Panel:Academic and industry experts in drug therapy, pharmacology education, and pharmaceutical research and development Objectives:Based on six core competencies recommended by ACGME

10. Integrative Pharmacotherapeutics Curriculum Starting August, 2012 • Developed, directed, & taught by Pharm.D. • Board certified pharmacotherapy specialist • 25 years experience in hospital and ambulatory clinical practice • 15 years experience teaching physicians, residents, and students (medical, pharmacy, physician assistant, nursing) • Emphasis on preparation for Step 1 (20%) • Emphasis on the applied use of pharmacology principles (pharmacotherapeutics) to prepare medical students for clinical years (80% of content)

11. Integrative Pharmacotherapeutics – What Is It? • Merging of basic pharmacology with principles of therapeutic use of drugs • Goal: ensuring the safe, appropriate, and economical use of drugs in patient care by students and physicians • Incorporates current therapeutic reviews and guidelines published in peer journals, Medical letter, Prescribers Letter, DynaMed, etc • Focuses on benefits and risks of most common drugs used and abused in clinical practice • Be able to select the most appropriate medication for a patient based on pharmacodynamics, pharmacokinetics, clinical efficacy data, and individual patient characteristics • Be able to recognize inappropriate and dangerous drug regimens • Also incorporates pharmacoeconomics, marketing principles, print & TV advertisements, personal student experiences, clinical trial evaluations, techniques for evaluating biased vs unbiased information sources

12. Integrative Pharmacotherapeutics Curriculum Changes • Lengthened course by 1 month • New class schedule synchronized with topics in other basic science courses • New faculty • New course objectives and content • Standardized presentation format • New exam and grading system • Introduction of active learning methods

13. Course Structure • Nine modules each consisting of 5-7 topics, a modified team-based learning session, and exam • Modules synchronized with other courses • Nine exams using USMLE-style questions plus national Pharmacology Subject Exam for final • Quiz at start of class based on assigned reading and part of final grade • Attendance not mandatory except for TBL

15. Active Learning Methods • Two question quiz at start of most classes based on assigned reading in Brenner’s Pharmacology and part of final grade • Use of personal response system (PRS) to capture answers • Ensures attendance and familiarity with new terms and concepts • Use of clinical case examples during didactic • USMLE questions during didactic with use of PRS to evaluate answers, provide constructive feedback, and capture attendance • Modified team-based learning sessions

16. Modified Team-Based Learning Sessions Twenty two teams of 6-7 students in one room Mentored by two Pharm.D. faculty Two cases over 2 hour period based on module topics • Detailed history, presentation, physical exam, labs, and current medication list • Current therapeutic guidelines made available online for reference • Teams expected to prepare and present a therapeutic plan without prior knowledge of case within 1 hour • Teams chosen at random to answer set of questions Scheduled several days before exam No grading but attendance mandatory Last TBL session of year is series of realistic polypharmacy cases and teams must identify presumed drug indications, inappropriate dosing, contraindications, potential adverse effects, and drug interactions

17. Longitudinal Component of Curriculum During 3rd year by Pharm.D. Family Medicine clerkship • Review of drug treatment of diabetes, hypertension, heart failure, and hyperlipidemia • Journal club to review key clinical drug trials published in primary literature • Review of pharmaceutical marketing techniques – “the science of persuasion” • Inpatient rounds in hospital Geriatric Medicine clerkship • In depth review of Polypharmacy

18. Results Highest student evaluations of any of the basic sciences mid-year and end of year Mean scores for Pharmacology Subject Exam and Step 1 higher than previous years High attendance rates (80-95%) throughout year, although not mandatory Positive feedback from 3rd year clinical preceptors regarding students’ clinical drug knowledge

19. Student Evaluations at End of Year 2013 96% Satisfaction Overall

20. Integrative Pharmacotherapeutics 2013 Student Satisfaction Summary Report

21. EVMS Five Year Step 1 Exam: Mean Test Results Mean Score Year *Interim Results as of 10/28/2013 NOTE: Years 2011, 2012, 2013 EVMS scores were significantly higher than all test takers in the U.S. and Canada

22. EVMS Mean Scores on Step 1

23. Conclusions Today’s medical students must be able to manage a patient’s medications by the start of their 3rd year A clinically focused pharmacotherapeutics curriculum replacing a traditional pharmacology curriculum for 2nd year medical students resulted in high evaluation scores and attendance rates without negatively impacting Step 1 scores Modified team-based learning sessions of 145 students can be successfully managed by two clinical faculty