Teaching phramacokinetics using a student-centered, modified mastery-based approach

American Journal of Pharmaceutical Education,  Fall 1999  by Brackett, Carolyn C,  Reuning, Richard H

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Evidence from clinical clerkships and pharmacy practice suggests that pharmacy students have great difficulty learning to apply pharmacokinetic principles to patient care. It is hypothesized that the problem is one of contextual transfer of learning. An undergraduate pharmacokinetics course was redesigned to teach the process of contextual transfer using active learning strategies. A modified mastery grading system was adopted to encourage consistent, long-term learning. Five years of course assessment data indicate that the instructional and assessment methods result in an enhanced process for learning application of pharmacokinetics. Evidence from student assessments and from the practice environment suggests that students who complete our course do begin to overcome the barriers of contextual transfer. Descriptions of specific instructional strategies and supporting data are presented.

INTRODUCTION

We have observed that most pharmacy students have considerable difficulty applying pharmacokinetics to patient care, and further, that this limitation is also prevalent among practicing pharmacists. In order to apply pharmacokinetics to patient care, the student or pharmacist must be able to transfer a learned process from one context to another; in other words, from the classroom to the patient-care setting. Angelo(l) states that "Research on learning to transfer generally is depressing. Most learning is highly context-bound, and few students become skilled at applying what they've learned in one context, to another similar context. In fact, many students cannot recognize things they've already learned if the context is shifted at all." The essential, transferable process in application of pharmacokinetics is the ability to reason and solve problems in a bidirectional fashion. By this we mean that the student must be able to work from an observed event, such as a dose-related adverse drug reaction, backward to the relevant pharmacokinetic principles in order to understand and solve the problem. Conversely, effective individualization of an effective dosing regimen necessitates that one begin with principles and reason forward to a solution.

We teach an elective third quarter of clinical pharmacokinetics to undergraduate pharmacy students. The course is taught annually and enrollment is usually 30-35 students. The apparent lack of learning to transfer we observed has occurred despite a history of more than 30 years of pharmacokinetics teaching experience, and a 15 year experience with the current course. One might ask then, whether the cause of this problem is: (i) not enough instruction; (ii) the wrong kind of instruction; (iii) student attitudes that inhibit learning to transfer; (iv) inadequate student ability, or (v) some combination of these explanations. Our own sense when we initiated this experiment was that reasons (ii) and (iii) above were the primary culprits. Pharmacokinetics is commonly perceived and taught as a mathematics- and physiology-based discipline. Our past instructional approach was quite traditional in most aspects, including an approach to problem solving which was directed primarily from principle to application. In other words, we taught the mathematical and physiologic principles, gave example applications, and expected that students would be able to use the principles when caring for patients. This is precisely the "instructional model" referred to by Barr and Tagg(2) wherein teachers teach the principles and the students are responsible for the transition to application. In order to add a dimension of reality to our teaching, we frequently tested students' "understanding" of our teaching with case-based examination questions. The difficulty of contextual transfer was evident even on these contrived examination questions and thus became the issue which prompted the introspection relative to our teaching efficacy. The subsequent discussions and analysis led us to embark on a path of radical and wholesale change. Although we did not benefit at the time from the cogent thinking of Barr and Tagg(2) in their recent article on the "learning paradigm". our conclusions were very similar. Even in the absence of their descriptions, we were attempting to shift from the "instruction paradigm" to the "learning paradigm."

The working hypothesis which emerged from our deliberations was that mastery and successful bidirectional problemsolving in pharmacokinetics could be accomplished only by the creation of a substantially different environment(3). Reflection on this hypothesis led to the emergence of three evaluable learning objectives which we feel encompass the mastery and bidirectional application of pharmacokinetics:

1. Students must identify drug-related problems which involve pharmacokinetic principles. Further, students must solve drug-related problems which involve pharmacokinetic principles by:

2. working from an observed outcome of drug therapy, for instance a side effect or therapeutic failure, back-ward from the outcome to the contributory principles, and/or