A Cross-Institutional Partnership for Teaching and Learning Pharmacology

INTRODUCTION

As increasingly recognized by the medical and applied sciences communities, for collaboration in patient care, research, and education to occur, it is key that some level of joint training occurs and that the importance and benefits of such collaborations be modeled and reinforced with students. The activities between different groups of professionals provide an increased understanding of each other’s knowledge and range of skills, enhanced teamwork skills which can be used to address patient problem-solving/management, and an increased understanding of roles and responsibilities. Given that literature in nursing and other health care fields notes that there has been a significant shift in the nature of health care work, the education of health care professionals has not shifted accordingly.¹ A continued delineation of roles between healthcare professionals² indicates the need to move toward a collaborative approach to healthcare education, such as the one presented in this paper. If members of the medical and pharmacy professions intend to work as peers, then that goal will be only be fully accomplished if joint training of the professionals becomes an integral part of professional development.³

To help respond to the need for a more collaborative approach between two professions that must work together in today’s health care system, we have developed an innovative multi-layered partnership intended to rejuvenate curricula, as well as faculty teaching and student learning, across and within two organizations; a school of medicine and a school of pharmacy. This paper provides a model for the development of a multi-layered teaching and learning partnership across and within these organizations. The model features the process of building an alliance between the medical school and school of pharmacy. This alliance includes the students, faculty and administrators of each organization as key participants. The paper highlights the value of building strategic relationships and institutional support. In doing so, we draw upon what we have found to be applicable and useful from the organizational change literature in the development of our partnership.

This paper further provides information about the challenges and successes for building new and valuable partnerships for courses and organizations, and provide an approach to developing partnerships that optimize teaching and learning in the basic sciences.

Interprofessional Trends in Healthcare Delivery: The assumption that educational partnerships lead to collaborative educational practices may not necessarily hold,¹ instead too often a disconnect between education and practice occurs. It is important that we draw upon the successes in multiprofessional education as we move to develop our own collaborations.¹

Although development of explicit knowledge is inherent to the continuing education within a specialization, there is a need for interprofessional learning.4 Providing students with learning opportunities within a multi-professional context can provide a foundation for developing effective communication and teamwork skills. Begun early in their professional education, inter-professional educational experiences may also help students with different professional backgrounds develop an increased understanding of each other’s knowledge and range of skills, enhanced teamwork skills toward patient problem-solving/management, and an increased understanding of roles and responsibilities.^4,5

An approach toward successfully incorporating interprofessional experiences into clinical practice is to incorporate an interprofessional approach to teaching at an early stage in the curricula of each profession.¹ Moreover, this approach is consistent with several benefits including early interprofessional socialization, and the ability to share knowledge, increase clinical skills and understand other healthcare professions.¹ Consistent with multiprofessional work, the primary focus of the clinical pharmacist continues to be that of an educator with medical residents and students, and pharmacy residents and students.⁶

The Role of Pharmacists in Medical School Education and Healthcare Delivery: The pharmacist has an important role in medical school education and healthcare, and it is important that these roles reflect each other. In pharmacy education in the United States, there is a paucity of compulsory interdisciplinary education. However, the importance of interdisciplinary approaches in education has been recognized by the American Council on Pharmaceutical Education (ACPE).⁷ In the recent accreditation guidelines developed by the ACPE for the Doctor of Pharmacy (PharmD), working in partnership with other health professionals is a professional proficiency objective that should be attained through the school of pharmacy curriculum.⁸ The pharmacists’ healthcare team role has evolved to include interdisciplinary teamwork as part of pharmaceutical care. Pharmacists are now expected to work with the patient and healthcare team when developing a therapeutic plan.⁸ In addition to patient care activities, many pharmacists also regularly present pharmacotherapy sessions for medical students and residents to learn about drug therapy.⁶

A study examining the state of clinical pharmacy practice in family practice residency programs reports that pharmacists have more than 60% of their time dedicated to the residency program. The study further notes that pharmacists are as likely to have academic appointments in a school of medicine as they are in a school of pharmacy.⁶

The importance of the pharmacist’s role in medical student education is reflected in a study of third-year medical students’ knowledge of clinical therapeutics. The study by Ward and Miloszewski⁹ notes that therapeutics tutorials led by pharmacists improved medical students’ understanding of drugs in clinical practice, and that the pharmacist was acknowledged by medical students as the appropriate person to lead their therapeutics tutorials.

The role of a clinical pharmacist in a residency program is reported by Ables and Baughman¹⁰ to be that helping of residents make decisions about drug therapy. That same article further notes that an observed increase in communication between the residents and clinical pharmacists may suggest a need for developing interprofessional collaboration and awareness of the need for pharmacotherapeutic information.

A report by the Institute of Medicine also recognizes the importance of interprofessional approaches to education to the quality of healthcare delivery.⁵

The primary purpose of this paper is to highlight the development of a multi-layered partnership between a school of medicine and school of pharmacy to introduce interprofessional teaching and learning in the medical school’s pharmacology course. This approach helped the partnership move forward and was key to facilitating effective change; many benefits occurred as a result of this multi-layered cross-institutional partnership.

MATERIALS AND METHODS

The impetus for building the partnership: With its transition to a new course director and redesign of specific portions of its curriculum, the medical school’s pharmacology course introduced case-based small group sessions with a focus on students’ problem-solving and critical thinking skills. A goal of the course was to address and model early in students’ professional lives, the importance of interprofessional collaboration between physicians and pharmacists in the care of patients. The decision was made by the medical school’s director of curriculum and faculty development, and the pharmacology course director, to approach a colleague at the school of pharmacy with an invitation to the pharmacy school to partner in this new initiative. Though located in the same city as the medical school, the school of pharmacy is a separate institution and located across town from the medical school. The initial formation of the inter-institutional partnership between the University of Massachusetts Medical School (UMMS) and Massachusetts College of Pharmacy and Health Sciences (MCPHS) began with preliminary conversations between UMMS’s Director of Curriculum and Faculty Development, UMMS’s Director of the medical school’s second year pharmacology course, and a Department of Pharmaceutical Sciences MCPHS faculty member (Figure 1, Tier II). The role of this group was to serve as what Duck11 refers to as the “Transition Management Team” (TMT), a key component of the change process. This began the development of the inter-institutional partnership.

It is important to note that the focus of a TMT is on managing, not leading, change. The purpose of the team is exclusively to manage and oversee the change effort. Via eight tasks noted by Duck, the team ensures that the various elements involved in the transition come together such that the change is realized. However, Duck points out that the TMT does not have sole responsibility for accomplishing each of the eight tasks. The tasks applicable to the transition involved in the pharmacology partnership closely paralleled those described by Duck11and were the responsibility of this cross-institutional TMT (Figure 1, Tier II). The eight tasks as managed by this partnership’s TMT are briefly described as follows.

Throughout the process of developing the intra-and inter-institutional partnership, the three members of the TMT (Figure 1, Tier II) provided faculty development sessions in order to align the work of the participating faculty and facilitators with the aim of the partnership, and thus established a context for change and provided guidance, the first of the tasks delineated by Duck.¹¹

Tasks 2-7 are as follows: stimulate [interprofessional] conversation; coordinate and align projects [and activities]; ensure congruence of messages, activities, policies and behaviors; provide opportunities for joint creation; anticipate, identify, and address people problems; and prepare the critical mass. These tasks were collectively addressed through faculty development sessions which further served to provide an arena for the interprofessional conversations necessary for modeling and reinforcing – a key component of the partnership. The faculty development sessions also served as a forum for those involved in various tiers of the partnership (Figure 1) to voice their ideas, and thus helped to facilitate empowerment as the partnership moved forward. Further, the sessions served to coordinate and align communication among individuals involved in the partnership and the activities of the partnership. The cross-institutional representation at the faculty development sessions further offered an opportunity for collecting and disseminating information pertaining to process and content as needed for the well-being of the partnership.

The eighth and last of the noted tasks is to provide appropriate resources.¹¹ The time and resources necessary to create and carry out the partnership were available because of the academic positions of each member of the transition team.

It was critical to have each of the three transition team members participate in moving forward in each of these eight task areas. The partnership and its activity would have been less effective without what the three members brought to the partnership table.

The initial request to partner was specifically intended to encourage pharmacy school faculty to co-facilitate the small group problem solving sessions with medical school faculty. Continued discussion with pharmacy school faculty and administration, and a formal presentation to the pharmacy school faculty and administration detailing what the partnership would consist of, led to an agreement to go forward with the partnership.

As the team began building its intra-institutional support and partnerships, it was vital to the inter-institutional partnership to have administrative support from each of the schools. Consequently, the team’s next step in moving forward with the inter-institutional partnership was to secure collaborative relationships with department administration, in our case this meant deans, vice deans, and department chairs and vice chairs (Figure 1, Tier III). These collaborative relationships with administration, and their agreement and identification with our goal, was key in having their support and involvement in the form of an alliance of medical and pharmacy school leaders who supported this new partnership. It was particularly important to have MCPHS administrative support, as well as their willingness to take a risk in trying a new relationship.¹² The medical school was taking less of a risk in that the effort was assisting their teaching efforts.

As the partnership evolved and was shaped, it was decided, in addition to pairing faculty from each of the schools as small group facilitators, to also pair fourth year students from each of the schools as small group facilitators. With this, the three initial change management team members brought a fourth year medical student into conversations for the purpose of informing its ongoing work with a student perspective.

At the Massachusetts College of Pharmacy and Health Sciences, faculty from two separate departments and fourth year pharmacy students, enrolled in the Doctor of Pharmacy program, participated as small group facilitators (Figure 1, Tier IV). The first step focused on acceptance of the cross-institutional partnership model “this required changes in attitudes of both students and faculty as to the benefits of becoming involved in model. Several barriers had to be surmounted before an effective dialogue between the Medical School and the School of Pharmacy occurred. First, a feasibility assessment and acceptance of the project had to be established. This was approached by presenting a mini-proposal outlining the concept and goals of the project to the Chairs of the School of Pharmacy’s Pharmaceutical Sciences and Pharmacy Practice Departments and the Dean of the Massachusetts College of Pharmacy & Health Sciences (MCPHS) (Figure 1, Tier III) to gather comments, suggestions and preliminary approval. Second, a working dialogue between the School of Pharmacy’s Pharmaceutical Sciences and Pharmacy Practice Departments was established to generate educational goals for the project. Third, formal contact between School of Pharmacy’s Pharmaceutical Sciences and Pharmacy Practice Departments faculty, and the Director of Curriculum and Faculty Development and the Department of Biochemistry & Molecular Pharmacology’s Director of Pharmacology Course at the Medical School, both involved in development of the collaborative partnership was established (Figure 1, Tiers II and III). This meeting was pivotal in determining whether the partnership would go forward. At the meeting, the Medical School programs directors (Figure 1, Tier II) presented their concepts and format involved in the implementation of the collaborative cross-institutional partnership to the School of Pharmacy faculty. This was followed by a question and answer session to discuss any issues and problems involved in the cross-institutional partnership. Finally, and importantly, a subsequent meeting was held between the faculty members of the School of Pharmacy’s Pharmacy Practice Department to determine how the partnership would impact individual programs and whether to accept the partnership.

In addition to pharmacy faculty, fourth year MCPHS students completing their professional electives were given a description of the project and its potential benefits and then asked whether they would participate as facilitators in cross-institutional partnership. Students at the fourth year level were chosen as facilitators for this cross-institutional partnership as they had completed their course work, and it was thought that they could also effectively contribute their professional viewpoint and insights to the small group discussions. Students were chosen based on their ability to problem-solve, and complete critical thinking quizzes and questions throughout their pharmacology courses.

At UMMS, deans, a division chief, division director, department chairs and vice chair, and faculty from several basic science and clinical departments, as well as a fourth year medical student were invited and participated in the partnership as small group facilitators (Figure 1, Tier IV). This group included a dean and basic science faculty from the University of Massachusetts – Worcester Graduate School of Biomedical Sciences (GSBS), which is located on the same campus as the University of Massachusetts Medical School. Acceptance and participation by the UMMS partners was achieved through one-on-one conversations regarding the benefits of partnering. The purposeful selection of facilitators was instrumental to the on-going institutional support, both in terms of resources and acceptance of change, of the cross-institutional aspect of the partnership. UMMS second year students, for whom the Pharmacology course is a required course, were participants in the small group sessions.

The timeline of building any partnership will differ from institution to institution, and depends on the type of the partnership being developed. However, we have provided an outline of the process and sequence of building this partnership, which took approximately six months.

Cross-Institutional Faculty Development: So as to inform all partners in this initiative, cross-institutional faculty development sessions were held to model and reinforce interprofessional communication and learning with respect to participants’ roles as co-facilitators of the case-based small group problem solving sessions. These sessions also served to inform faculty and student facilitators of the process (i.e., small group facilitation skills) and content (i.e., case topic and objectives) of each small group session. A faculty development session was held a week prior to each small group problem solving session for the three-fold purpose of 1) introducing the faculty and student facilitators to the case topic and objectives, 2) drawing on the expertise and strengths of each member, and stimulating the sharing of knowledge and perspectives between the professions, toward more informed small group sessions, and 3) enhancing small group facilitation skills. Consequently, each faculty development session focused on both the content of each session, as well as the process of small group facilitation, and was co-facilitated by the Pharmcology Course Director and the Director of Curriculum and Faculty Development.

RESULTS

Interprofessional approaches to education have the potential to benefit students in a number of ways. They help to provide students with an increased understanding of the roles and responsibilities of other health professionals. Without opportunities for students to interact with other health professionals, the barriers to successful collaboration and communication may be more difficult once they enter professional practice.^5,8,13 Interprofessional experiences require relevance and need to be appropriate to real life training.^8,14 Therefore, curricula designed to included such experiences, fosters students’ understanding of the roles and responsibilities of other health care professions, and makes the most effective use of healthcare team members.

Such approaches also help students to acquire an understanding of interprofessional knowledge and range of skills. Leininger notes that numerous problems among the different health care disciplines are connected to not only a lack of knowledge, but a decreased perception, of their actual and possible contributions.¹⁵ Developing a cross-institutional educational partnership model has the potential to foster among students an appreciation and increased awareness of skills contributed by different healthcare disciplines. These attributes can be carried into their professional careers and used to develop partnerships in the care of patients.⁵

Enhancing teamwork skills toward improving patient management is an additional benefit provided to students through interprofessional educational experiences. A number of interprofessional partnerships have led to improvement in health care. Adverse drug events (ADEs) are a common yet preventable phenomenon in today’s health care.¹⁶ Previous studies analyzing the frequency and degree of ADEs have shown that 42% of life-threatening and serious events were preventable.^16,17 Furthermore, during the same study almost 50% of avoidable ADEs were the result of mistakes in the prescribing procedure.^16,17 Subsequent studies have assessed the benefits of interprofessional health care participation in lowering the rates of adverse drug events. Specifically, when pharmacists are part of the health care team they positively impact ADEs, as evidenced by a significantly lower rate of ADEs caused by prescribing mistakes.^18,19

In light of the increasing recognition of the collaborative roles and work of healthcare team members, it is vitally important to begin to move toward an interprofessional approach to education.⁵

End of course student evaluation data for the Pharmacology course shows that 93% of students felt that the small group problem solving sessions enhanced their overall understanding of pharmacology. On the end of course evaluation, students commented that additional learning activities they would find helpful are “more small group problem solving sessions”, “more small group sessions on a regular basis”, and “more case-based learning.” Students also commented that the small group problem solving sessions cases “”were excellent tools in terms of overall understanding of course material and application to future clinical practice.”

Data from facilitators and students supports the statement that teamwork and interprofessional learning were two key benefits for students at both institutions. One hundred percent of both facilitators and students across all sessions agreed or strongly agreed that that their small “group worked as a team to help further its understanding of the underlying basic science issues of the case”; “each person contributed resources and knowledge to the group discussion”; and “the group came prepared with information to explain the issues under discussion.”

An average of 98 percent of medical student responses, across all small group sessions, agreed or strongly agreed that the sessions were “presented in a way that helped me integrate knowledge and ideas with others in my group”; and that “an effective communication process was established in the group.” One hundred percent of medical students across sessions responded agree or strongly agreed that the sessions “addressed my learning needs around this topic.” One of the students from the Pharmacy school who co-facilitated with a medical student commented that “pairing with 4th year medical student worked out very well in that the medical student] was able to answer some of the pathophysiology based questions much more thoroughly and on a higher level which the med students were more likely to understand,” and that she, as a pharmacy student, “was able to answer a number of the students’ questions’ that related more to her area of professional expertise.

Each small group session also had five content-based objectives pertaining to the case topic. One hundred percent of the students agreed or strongly agreed that “as a result of the case-based session, they had a better understanding of the the pharmacology content specific to each case. Examples of content objectives were “an understanding of some of the physiologic changes that occur with aging that may affect the pharmacokinetics and pharmacodynamics of drugs”, “issues involved in prescribing for the elderly”, and “the potential for adverse effects of herbal preparations including serious adverse affects.”

DISCUSSION

This partnership of the Medical School with the School of Pharmacy brought together different perspectives of the learning process and broadened the perspectives gained beyond a single institution. It required unique expertise of participants, strategic relationships, institutional support, and interconnected work, and it offered mutual benefit. Two key benefits of the interprofessional education provided by the partnership for the students of both institutions were the development of teamwork skills for patient problem-solving, and the modeling of interprofessional learning. Moreover, the partnership benefited both the School of Pharmacy and the Medical School as it achieved one of the ACPE professional proficiency objectives for the Doctor of Pharmacy, namely, working in partnership with other health professionals through its incorporation in the school of pharmacy curriculum,⁷ and the Medical School benefited from interprofessional teaching for its students and among its faculty, engendering a collaborative teaching and learning environment.

The significance of teaching and learning partnerships involving interprofessional experiences in education has been an area of focus in the Royal Pharmaceutical Society’s “Pharmacy in a New Age” initiative.²⁰ Subsequent studies related to this initiative have looked at the advantages of collaborative education among community pharmacists and physicians. The study by Parr and collegaues examines the implementation and evaluation of collaborative education among community pharmacists and medical practitioners. The authors conclude that the advantages of this approach to learning are a positive impact on the professionals.²¹ The data suggest that interprofessional approaches to education have the potential to increase professional development, advance reciprocal comprehension between health professionals, and increase professional communication.¹⁶

Similarly, a report by the Institute of Medicine advocates ‘providing more opportunities for interdisciplinary training’ as the healthcare delivery system works to redesign the education of its professionals.⁵

Continued development of the partnership during the next academic year will include faculty and students from the medical school’s Graduate School of Nursing, and a more structured inclusion of the Library.

CONCLUSIONS

Effective development of a multi-layered partnership requires interconnected work and mutual benefit. It is therefore important that in moving forward with the development process, the individuals designing and managing the change be aware of principles key to effective change and apply them strategically in order to optimize the goals of the partnership.

Institutional partnerships are more effective and sustainable when individuals within each institution are included and play a role in its development. The partnership brings together different perspectives and expertise from two institutions into a strategic alliance. Our experience has been that in bringing together the expertise of each professional in the teaching and learning partnership described in this paper, we have expanded the knowledge and skills of individuals at all layers of the partnership, both intra- and inter-institutional. As a result of this joint professional effort, we believe that we have also modeled interprofessional problem-solving and teamwork skills for the students of both institutions, skills which will ultimately benefit healthcare delivery. As Mundinger points out, the time is right for this promising idea to become part of our joint professional efforts.³

Future Plans to Enhance the Partnership: As development of the partnership continues during this next academic year, the transition management team (Figure 1, Tier II) intends to approach the Dean of the University of Massachusetts Worcester Graduate School of Nursing (GSN), which is located on the same campus as the University of Massachusetts Medical School, about becoming another partner in this multi-layered partnership (Figure 1, Tier IV). The GSN offers a pharmacotherapeutics course within their nurse practitioner curriculum and has been involved in other collaborative efforts with the medical school.

The change management team also has plans to increase the role the medical school’s library has played in the course (Figure 1, Tier IV). Though the library has served as a course resource for student and faculty, in the upcoming academic year it will be asked to take on an expanded role by providing students with formal sessions, with a focus on Pharmacology, on how to yield better results when searching the literature. An overview of the information given to student will be conveyed to small group facilitators by a representative from the library during faculty development sessions, so that facilitators can draw on the yield of the students’ literature searches during discussion of the literature during the case-based small group problem-solving sessions.

There are also discussions pertaining to the development of richer and more robust cases that would call for an increased use of problem-solving and critical thinking skills among students and facilitators, as well as develop in students skills that will benefit them as they begin practicing evidence-based medicine.

Focused attention on recognizing and creating opportunities to better utilize the expertise of the facilitators, who have been drawn from various specialties within each institution is on-going. In addition, we continue to nurture the partnership and stay open to opportunities to enhance the partnership in ways that benefit the teaching and learning of pharmacology within both institutions.

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