Pharmacology – In the Face of Revisiting Flexner’s View of Medical Education

What are the sciences that constitute the foundation for medical practice?

Pharmacology is clearly one of the basic sciences that form the foundation for medical practice. Our understanding about how at the molecular, cellular, and tissue levels drugs elicit their effects on living organisms (pharmacodynamics) and how these organisms absorb, distribute, metabolize and eliminate (pharmacokinetics) drugs describes pharmacology as a hybrid science that borrows from other foundational sciences (e.g., genetics, molecular biology, cell biology, physiology, biochemistry).

The value of pharmacology is to ensure a scientific basis for therapeutic decisions, and the establishment of benefit versus risk estimates that are based on an understanding of the complex effects of medicines on the body, including how drugs affect living systems and how the body affects drugs.

What are the value and role of the foundational sciences in medical education?

Schmidt and colleagues suggest that student learning occurs through a series of phases.¹ For medical education the first phase includes the development of an extensive basic science knowledge base. In the second phase, students are immersed in clinical situations in which they begin to associate signs and symptoms with particular diseases constructing a coherent clinical knowledge base.

Through numerous patient encounters, physicians ultimately rely on pattern recognition against previously encountered cases in diagnosing disease. This is not to say that basic science knowledge is lost. On the contrary, the notion is that the basic science knowledge is encapsulated into the clinical knowledge.² Moreover, physicians revert to basic sciences knowledge when faced with an unfamiliar or challenging clinical problem.^3,4 Pharmacology is unique among the foundational sciences of medicine in that it follows students into their clinical years and beyond.

Pharmacology’s clinical role and value are self-evident. Indeed its value as an integrative science is also clear. Pharmacology bridges the foundational and clinical sciences. General foundational concepts of pharmacology such as pharmacokinetics, pharmacodynamics and toxicology are grounded in foundational sciences of biochemistry, physiology and anatomy. Such concepts are fundamental to the understanding of therapeutics and to understanding of why one drug might be picked over another in a specific pathophysiological circumstance. Pharmacological identification of how drugs interact with the specific targets (molecular targets within foreign cells such as microbes or within specific cells of organ systems) is foundational science. Using this information to provide a general nomenclature to the major classes of therapeutic agents provides a framework for clinical use of drugs. Finally, an understanding of the scientific methods of evaluating the benefits and risks of drugs is a core concept of pharmacology as a foundational science. Bridges into clinical science occurs under many circumstances, for example: 1) when discussions about individual drugs occur in the context of treating a specific pathology with currently recognized first choices of therapy; 2) when details of approaches of therapy (specific combination therapies that optimize treatment in specific circumstances for example) become the focus; 3) when adverse reactions of drugs emerge during therapy; 4) when drug metabolism affects treatment outcomes. The application of the principles of pharmacology becomes the foundation for therapeutics. Thus, when the discussion of drugs is directed toward selecting a specific drug to treat a specific patient and determining an appropriate dosing regimen, pharmacology evolves into therapeutics and therapeutic decision making.

When and how should these foundational sciences be incorporated into the medical education curriculum?

Pharmacology is a dynamic science [e.g., compared to anatomy]. Without a foundational understanding of the mechanisms by which drugs act, it is more difficult to integrate new information about novel and existing drugs, make informed therapeutic comparisons, safely prescribe complex therapeutic regimens to patients, and discover new therapeutic approaches for the prevention and treatment of diseases. Even so, there is no single best answer to this question of when and how to incorporate pharmacology into the medical education curriculum.

Some believe that for pedagogical reasons, it is important for pharmacology to maintain a unique identity in the curriculum and not be lost through a process of “integration”. Unfortunately, some faculty of pharmacology and other foundational sciences feel forced to attempt to maintain discipline identity and avoid integration not for pedagogical reasons but to avoid loss of autonomy, resources, and curricular time. An advantage to this approach is that the learning of the discipline is consolidated in time and effort. This potentially allows for continuity of learning. A disadvantage is that learning of fundamental concepts may be lessened since the student may have difficulty understanding concepts out of context. When science disciplines are somewhat isolated for introduction, use of examples of how the foundational concepts are important for clinical decision making is useful to students. This is relatively easily accomplished with pharmacology because of its natural bridging nature.

Other faculty feel that pharmacology can and should be taught throughout the medical education curriculum. They argue that an advantage of this approach is that fundamental concepts of pharmacology easily work into discussions of anatomy, physiology and biochemistry. For example, integration of pharmacological concepts of agonist and antagonist can easily coincide with discussions of natural ligands, neurotransmitters and hormones. Biochemical concepts of equilibrium and kinetics allow introduction of pharmacological concepts of potency, affinity, intrinsic activity, efficacy and half-life. Discussion of pathologies provides opportunity to begin introduction of potential treatment options with discussions of mechanisms of action of various drug classes. These two levels of introduction of pharmacology traditionally occur within the “preclinical” training. This allows students to begin a general understanding of why specific medications are used for specific circumstances. While pharmacology can be discussed in a more isolated manner, such as is done in a “traditional” curriculum, it can also be well integrated into system-based, organ-based and clinical presentation-based curriculum. A potential disadvantage of the more integrated approach is there is need for more coordination with other disciplines, which presents a considerable logistical challenge. This approach has the added disadvantage of fragmenting the discipline of pharmacology, sometimes to an extent that it is not prioritized by students.

Perhaps an optimal approach is to provide some dedicated focus to the learning of basic principles of pharmacology and to subsequently challenge students to apply these principles to the understanding of therapeutic agents that they will encounter subsequently in an integrated curriculum. Most pharmacologists agree that as a bridge discipline, pharmacology can be the central driving force for integration of curricula. The fact that several other foundational sciences contribute to the basis of pharmacology allows for help in directing what needs to be addressed in these other courses to facilitate learning of pharmacology as well as clinical science. A primary challenge in such an approach may be to continually monitor the pharmacology/therapeutics content and to continually assure that students are dedicating suitable time and energy toward pharmacology learning goals.

Regardless of opinions about the best pedagogical approach to use, pharmacology in the preclinical years can best serve preparing students for the clinic by ensuring that the concepts of drug action and how the body handles drugs are learned by the students in a manner that facilitates use and recall in the clinical years. Pharmacology being taught with a focus on clinical relevance can push pharmacologists out of their comfort zone. Moreover, pharmacologists are often concerned with venturing too far into therapeutics which is understandable since they most commonly have PhDs and, hence, lack the first-hand clinical experience to decide on appropriate choice of prescription for a patient. Still a student must understand how to transfer knowledge about drug action based on a good grasp of physiology, pathophysiology, and microbiology (in the case of antimicrobials) to how to treat patients. Rather than losing its place as a discipline pharmacology is in a unique position to encourage dialogue between basic and clinical scientists as a way to obtain the proper balance between important foundational concepts and clinical relevance.

During the pre-clerkship years, it is likely that assessment will help to drive the desired learning. During clerkship training, the motivation to learn therapeutic agents changes away from student assessment toward patient needs. Students are now helping to care for real people taking real drugs. Suddenly, it matters what drugs do and how they work. What may actually become less apparent during clinical training, however, is the relevance of recalling fundamental principles of pharmacology that were learned in the pre-clerkship years. Too often the approach to prescribing drugs becomes a technical exercise and the host of molecular underpinnings of the drug’s action on the body and the body’s action on the drugs become a distant memory from the past. This is the time when pharmacologists have an opportunity to re-engage students’ minds and help them to recall the importance of fundamental pharmacological principles.

Pharmacology, more than many of the foundational disciplines is unique in that this clinical relevance carries over into the clinical years and beyond. Since higher level learning takes place in context, clinical training settings provide excellent opportunities to discuss advanced concepts of Pharmacology. Working with clinical colleagues, pharmacologists can help with instruction regarding therapeutics. Students oftentimes appreciate more the pharmacology when it is presented in students’ clerkships.

What sciences could/should be pre-requisite components of the pre-medical (baccalaureate) requirements?

This question is daunting. The American Medical Association, the Howard Hughes Medical Institute and the American Association of Medical Colleges (AAMC) recently published commentaries on the recommendations for both pre-medical and undergraduate medical education in the areas of biological sciences.^5,6 A national committee of leading medical scientists and educators, formed by the AAMC, is actively reviewing the Medical College Admissions Test (MCAT).⁷ The committee’s work will take several years. The outcome of that work will not directly address the question of medical school pre¬requisites but will undoubtedly influence how pre-medical programs are designed and how undergraduate advisers council pre-medical students about their course of study while obtaining their baccalaureate degrees.

This question of pre-medical requirements has haunted the discipline of pharmacology for a long time (including that part of the discipline concerned with basic science graduate education). At the extreme, some feel that pharmacology could be addressed in pre-medical training and, in fact, this has been the topic of discussion at many conferences. Indeed, there are some college-level pharmacology curricula but many of their students go on to work in the pharmaceutical industry or go to graduate school to pursue pharmacological sciences. With the exception of few notable elective college courses/tracks, no one has figured out how to overcome the politics, economics and imperatives related to pre-medical requirements so that pharmacology could become a major component of the undergraduate science curriculum (at least to the same degree as physiology and biochemistry). Generally, pharmacology is considered a “bridge” discipline of medicine, almost as much as pathology, and is probably better taught in the medical (or professional) school environment rather than shifting it to the undergraduate curriculum.

Looking at the pre-requisites of other sciences for medical school, some pharmacologists in medical education feel the pressure to help “unload” some of the scientific content of the medical education curriculum into the undergraduate learning period. Others feel the need to maintain a relatively un-specified undergraduate education that focuses on helping a person learn how to learn.

On one hand we live in an age of vast understanding of disease and remedy of disease at a greater and greater genetic and molecular level and so it seems that more advanced knowledge of those sciences is essential as prerequisites to medical school. This has encouraged some pharmacology educators to recommend biochemistry, cellular and molecular biology and genetics as pre-requisites. Others feel that a strong understanding of statistics is necessary to improve the use of evidence-based medicine in clinical decision making, public health and treatment regime assessments. On the other hand, the US Institute of Medicine strongly recommends that reductions in medical error need to be considered in all levels of training. This discussion suggests that behavioral science issues such as psychology, teamwork and communication are skills that should be important to entry to medical school. For very integrated medical education curriculum where pharmacology is taught in the first year of medical school, general biochemistry, human physiology and human anatomy would be best required as pre-requisites. In this setting the concepts of statistics and behavioral sciences could be helpful as pre-requisites but not absolutely needed.

Other pharmacology medical educators feel that while a common set of pre-medical requirements that included a wish list of basic sciences plus biostatistics and psychology might make our jobs at the undergraduate medical education level easier, it is unreasonable and even undesirable that students should enter medical school as clones. While some understanding of biological and chemical sciences is desirable, the argument is that medical education should avoid dictating so many pre-med requirements so as to narrow the interests of our future applicants. The “bent arrow” who graduates from college, has a career, and then enters medical school is a valued commodity because what this individual may lack in the immediacy of biological and chemical background, is more than made up for in their motivation, commitment and perspective on life and a career in medicine. Perhaps the best preparation for medical school is the curriculum that teaches a student how to learn and how to question.

What are examples of the best practices for incorporating the foundational sciences into the medical education curriculum?

There is little consensus or pedagogical evidence for best practices on incorporating foundational sciences into medical education. The “strong foundation” approach is repudiated by adult learning theory.⁸ This has led to integration being the dominant approach currently. The effectiveness of this approach over others continues to be studied. Work by Novak et al looks at using a conceptual framework during medical learning and is not specific to pharmacology.⁹ The study looks at second year medical students’ ability to retain scientific knowledge regarding metabolic alkalosis in the year after it was introduced. Those authors found that use of diagnostic schema or conceptual framework improved retention of knowledge. This would support the notion that integration of foundational sciences may help transference of knowledge into the clinical setting.

Some specific teaching methods are beginning to accumulate data suggesting ways to incorporate foundational sciences effectively in the medical education curriculum. A good example of best practice is the use of simulation. Many computer-based programs allow for students to practice the use of medications in a safe setting. For instance, Szarek and Winston have described the use of computer-controlled mannequins in a PBL curriculum.¹⁰ They suggest that students are able to see the outcome or consequences of their drug choice in a safe environment with a preceptor. Simulation such as this offers a true integration of basic and clinical science at the “patients’” bedside. With respect to pharmacology specifically, recent publications suggested that students unanimously agree that learning through simulation is enjoyable.^11,12 Moreover, learning is facilitated and information is retained.¹³ Simulation use, however, is not limited to pharmacology. Other disciplines that have demonstrated effective use of simulation in teaching include physiology and biochemistry.^14-16 Methods on the horizon include sophisticated computer simulations for drug action, the use of avatars, and the use of a patient monitor in the classroom to see effects of drug treatment.

Another best practice has been the use of team-based learning (TBL).¹⁷ Using team-based learning to teach pharmacology compared to traditional methods to second year medical students improves student performance on a summative quiz.¹⁸ Other teaching methods such as problem-based learning (PBL) have their proponents but there is little data as to their effectiveness over other approaches. Indeed there is evidence that PBL-trained students perform less well than students trained in conventional curricula.¹⁹

The answer to the question of best practices with measured outcomes in pharmacology may best be answered by considering how to reinforce pharmacology using state-of¬the-art educational and cognitive psychology theories. For example Irby et al recently came out with recommendations on all medical education which included standardizing learning outcomes and individualizing the learning process, promoting multiple forms of integration, incorporating habits of inquiry, and improvement and progressive formation of professional identity.²⁰ Norman recently made helpful concrete recommendations on how to improve students’ ability to use a concept learned in one context to solve a problem in a different context (psychologists term this transfer).²¹ Briefly, he recommends initial teaching using analogy imbedded in a problem, multiple teaching examples so students can identify similar concepts, followed by students practicing with multiple dissimilar problems spread out over time. Pharmacology medical educators might be aided by a national dialogue of pharmacologists involved in pre-clerkship and clerkship initiatives and the creation of a repository of examples of effective design strategies. The authors are unaware of any such dialogue or repository that specifically addresses pharmacology. This is a subject that could be addressed by national or international pharmacology organizations such as the American Society for Pharmacology and Experimental Therapeutics, Division for Pharmacology Education or organizations whose primary mission is to provide professional development for all who teach the sciences fundamental to medical practice such as IAMSE.

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