- Email: [email protected]
Pediatric pharmacotherapy in the PharmD curriculum: Course design and student self-assessment of learning outcomes achievement
Available online at www.sciencedirect.com
Currents in Pharmacy Teaching and Learning 6 (2014) 277–283
Short communication
http://www.pharmacyteaching.com
Pediatric pharmacotherapy in the PharmD curriculum: Course design and student self-assessment of learning outcomes achievement Evan R. Horton, PharmD*, Paul Belliveau, PharmD Department of Pharmacy Practice, MCPHS University, Worcester, MA
Abstract Background: The typical pharmacy school provides limited opportunities for focused pediatric pharmacotherapy discussions. This finding served as the impetus for development of an elective course on pediatric pharmacotherapy. The purpose of this study was to describe course design and evaluate students’ self-assessment of learning outcome achievement in a pediatric pharmacotherapy course. Methods: Thirty second-year pharmacy students were enrolled in a ten-week pediatric pharmacotherapy elective course. This course integrated numerous teaching strategies and provided several opportunities for formative and summative feedback. Students completed a pre- and post-course survey consisting of 20 items. Pre- and post-course surveys were compared to evaluate changes in student self-assessments of learning achievement following this course. Results: Twenty-nine and 27 students responded to the pre- and post-course survey, respectively. There was a significant improvement in post-survey results for all items that examined students’ self-assessment of competency in course learning outcomes (p r 0.036). Conclusions: Following completion of a pediatric pharmacotherapy course, significant improvements were observed in students’ self-assessment of learning outcome achievement. The course design appeared to have facilitated these improvements. Since this course was an elective offering, additional means of educating pharmacy students on the care of pediatric patients may need to be considered. r 2014 Elsevier Inc. All rights reserved. Keywords: Pediatric; Pharmacotherapy; Education; Outcomes
Introduction Advances in pediatric medicine, increasing complexities of childhood disease, and unique dosing and pharmacokinetic challenges all support a growing need for the education of pharmacists in basic pediatric competencies. Additionally, despite the difficulties in quantification, This research was originally presented in full at the 2009 American Association of Colleges of Pharmacy Annual Meeting, Boston, MA. * Corresponding author: Evan R. Horton, PharmD, Department of Pharmacy Practice, MCPHS University, 19 Foster Street, Worcester, MA 01608. E-mail: [email protected]
pediatric prescription medication usage is estimated to be substantial.1 According to the Centers for Disease Control 2007–2008 data, 14–20% of patients between the ages of zero and 19 years reported using at least one prescription drug in the month prior to being surveyed.2 In light of these findings, it is not an unrealistic expectation that pharmacy curricula should have some minimum level of pediatric pharmacotherapy emphasis. The 2004 Accreditation Council for Pharmacy Education (ACPE) guidelines and Center for Advancement of Pharmaceutical Education (CAPE) outcomes support the education of the pharmacist as a generalist.3,4 However, the ability of a pharmacist to provide ethical, professional, patient-centered, and evidence-based care for specific
1877-1297/14/$ – see front matter r 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cptl.2013.11.008
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E.R. Horton, P. Belliveau / Currents in Pharmacy Teaching and Learning 6 (2014) 277–283
patient populations is dependent upon familiarity with the unique characteristics of those populations. Although the ACPE guidelines address the need for pharmacists to be able to provide care for special populations (pediatric, geriatric, etc.) in its Appendix B, “Additional Guidance on the Science Foundation for the Curriculum,” surveys of pharmacy program curricula have revealed inadequacies and inconsistencies in pediatric care education.3,5 A survey of pediatric education in entry-level pharmacy programs demonstrated that the average number of hours dedicated to this subject matter was an average of 16.7 hours (range: 2.8–52.8 hours).5 In a 2004 position paper, Aucoin et al.6 asserted that time devoted to pediatric pharmacotherapy education within pharmacy programs is inadequate and recommended that pharmacy programs should have a minimum of 25 hours of pediatric contact time in the curriculum. Ideally such education should include a combination of didactic and experiential learning activities.7 The pharmacy program for which this course was designed is an accelerated PharmD program occurring in a lock-step fashion over 34 months (in contrast to the traditional 48-month PharmD program). Because of the accelerated nature of our program, achieving target numbers for pediatric-focused contact hours and introducing concurrent experiential learning in the curriculum is challenging. Initial surveys of our curriculum revealed that our students had approximately six contact hours of pediatric education (excluding specialty advanced pharmacy practice experiences). This finding was the impetus for developing an elective that focused on pediatric pharmacotherapy. The purpose of this report is to describe the structure of this course and report the results of the students’ self-assessment of learning outcome achievement. We hypothesized that students’ end-of-course self-assessments of competency would be significantly greater than their self-assessments at the start of the course. Methods Course design The pediatric pharmacotherapy elective course was designed to specifically address content that was either not presented in the core curriculum, or was presented but warranted advanced discussion. Specifically, course learning outcomes (Table 1) addressed strengthening general pediatric drug knowledge, relating principles of growth and development to pediatric disease states, formulating therapeutic plans, discussing pharmaceutics preparation and drug delivery, compounding aseptic products, applying evidence-based medicine, and utilizing active, team-based learning. The course content focused on providing functional approaches to thinking and understanding from the perspective of a pediatric pharmacist. Although few of these students are likely to become specialized pediatric pharmacists, such an approach is expected to give students a
Table 1 Course learning outcomes (1) Discuss pediatric drug therapy considerations for patients based upon age, pharmacokinetic issues, and concomitant issues. (2) Relate basic principles of pediatric growth and development to a variety of disease states. (3) Formulate therapeutic plans for pediatric and neonatal patients with a variety of disease states. (4) Identify methods for appropriate pediatric pharmaceutics preparation and drug delivery. (5) Discuss and apply pediatric literature towards the practice of evidence-based medicine. (6) Apply creative problem solving solutions to unique pharmaceutical and pharmacotherapeutic situations.
heightened sensitivity to pediatric issues potentially encountered in the professional setting. The course featured several unique elements, including multiple group projects and presentations, hands-on practical sessions, and expert guest speakers to facilitate learning. The ten-week course was module based, with topics ranging from basic elements of pediatric therapeutics to the in-depth management of specific disease states, such as pediatric diabetes and pain management (Fig. 1). Upon completion, this course provided an approximate 30 additional hours of pediatric education, accomplished by 10 three-hour classes conducted throughout the summer semester. Most topics were taught by faculty who were knowledgeable in pediatric therapeutics. Expert guest speakers were invited to discuss pediatric critical care, congenital heart disease, and pediatric medication safety. A variety of learning strategies were incorporated throughout didactic lectures to accommodate different learning styles. These strategies included guided notes, group discussions, debates, games, lectures, and student presentations. There were several assessments in the course including daily attendance, homework, quizzes, journal club, practical sessions, and a final case presentation. Students were assigned to small groups at the start of the course; these groups were utilized for the journal club and final case presentations.
Daily attendance Attendance was recorded for each class period and counted as 10% of the total course grade. Students received 0.5 points for attendance at each of the 20 classes. Attendance was stressed as a graded component of the course due to the emphasis on active and team-based learning.
Homework Four homework assignments, each worth 5% of the total grade, were given to facilitate class preparation and discussion. Homework activities consisted of the following:
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Introductory Activity (Homework 1) Module 1: Introduction Developmental Pharmacology Fluids and Electrolytes Module 2: Fluids/ Electrolytes/Nutrition
Pediatric TPN (Homework 2) Drug Delivery in Children (Homework 3)
Module 3: Pharmaceutics Drug Preparations (Practical Session)
R/O Sepsis Module 4: Medication Safety and Critical Care
Medication Safety in Children Adolescent Medicine
Module 5: General Pediatrics I
Anti-seizure Agents in Children
Diabetes in Children Module 6: General Pediatrics 2
Pediatric Pain Management (Homework 4)
Basics of Critical Care Module 7: Critical Care Neonatal Critical Care Fig. 1. Module and topic overview. TPN = total parenteral nutrition; R/O = rule out.
(1) Research an extemporaneously compounded recipe, summarize the compounding process and post on our institution’s learning management system. (2) Calculate components of a mock total parenteral nutrition (TPN) product when provided with a patient case. (3) Complete a pediatric dosage calculation as preparation for a practical session involving preparation of a standard concentration intravenous product. (4) Complete an activity that showed evidence of the pharmacist as a professional, by means of a creating a professional curriculum vitae (CV). The first three assignments focused on specialized preparation for pediatric dosage forms; they correlated with course learning outcomes 1, 4, and 6 (Table 1) and were used to prepare the students for aspects of modules 1, 2, and 3 of the course (Fig. 1). The assignments helped to achieve course learning outcomes by requiring students to
understand the pharmacokinetic complexities that involve care of pediatric patients. By understanding these complexities, students were able to gain a better understanding of how and why compounding pediatric dosage forms, unique from standard adult preparations, can be a difficult and specialized process. The fourth assignment was assessed via formative feedback utilizing grading rubrics and instructorwritten feedback. While the CV assignment was not specifically correlated to a defined course learning outcome in the syllabus, the CAPE outcomes address the importance of the development of a pharmacist as a professional practitioner. In future offerings of this course, this aspect will likely be incorporated into the course learning outcomes and more fully integrated into the structure of the course. In addition to assisting with defined course learning outcomes, these assignments also facilitated active, groupbased learning, allowed students to practice using technology to share information (specifically when conducted via our online learning management system), provided
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opportunities for students to utilize appropriate drug references, and heightened students’ appreciation for the unique challenges of drug delivery to pediatric patients. Formative assessment was further utilized through “minute paper” and “muddiest point” assignments that were done at the end of identified classes. These allowed the students and the instructors to gain a better understanding of how certain class days were received by the students. Quizzes Four unannounced quizzes, each worth 5% of the total grade, were administered during classes. Quiz content reflected basic knowledge and comprehension of concepts taught in the previous class period. Quizzes were specifically structured to cover general pediatric pharmacotherapy concepts as this course was not designed to produce proficient pediatric specialists, but to expose students to general concepts that drive pediatric pharmacotherapy decisions. Hence, quizzes were meant to provide a means of gauging how well students were retaining the overarching concepts taught within the course. Although the use of comprehensive examinations in this course was considered, the coordinators decided against this assessment method. Here, the coordinators’ rationale was that use of such a method could stifle active class discussions and cause the students to focus more on rote memorization for an examination. Journal club Between modules 4 and 5 (Fig. 1), students were asked to complete a journal club assignment worth 20% of their total course grade. Six published pediatric clinical trials were chosen by the course coordinators, with each one being assigned to a group of five students. Articles addressed specific therapeutic topics that were discussed within the course. Students were provided with the articles several weeks in advance of their assigned presentation date. Students worked within their groups, outside designated class time, to facilitate a journal club-style discussion with the class. Two class sessions were designated specifically for journal club presentations, with each group presenting for approximately 20 minutes. Student groups presented trial background, methodology, results, authors’ conclusions, and their own article critique. Each group was also required to apply their article to the current practice of pharmacy, and a portion of their grading rubric included recognition and application of clinical significance versus statistical significance. Each presentation was followed by an additional ten minutes designated for a question-andanswer session that was facilitated by the course coordinators and included questions from other students in the course, as well as instructors. One grade was given to each group using a pre-defined rubric, and a portion of each group’s evaluation included a non-graded peer-evaluation of
group members’ involvement in the project. Groups demonstrated this by having all group members participate in the delivery of content. This facilitated a team-based learning and teaching environment. Practical sessions Two practical sessions served to engage students in pediatric-related pharmaceutical calculations (including pediatric TPN calculations), intravenous medication preparation, and aseptic technique. In the more significant of these two sessions (worth 10% of the total course grade), students completed a series of pharmaceutical calculations relating to a pediatric patient case (Fig. 1, module 3). One week prior to this session, students received a one-hour, inclass lecture and demonstration on pediatric pharmaceutical calculations and standard concentration parenteral product preparation. During this class, students practiced these calculations and then received additional practice problems as homework (previously described) that was meant to serve as preparation for the practical session. Prior to the practical session, students were invited to optionally attend a review session to answer any remaining questions on the process of pharmaceutical calculations and standard concentration product calculations. On the day of the practical session, students were provided with a medication order for a parenteral medication, concentration-related guidelines for that specific medication, and the materials needed to prepare the product. Students were allowed ten minutes to perform the necessary calculations to create a continuous intravenous infusion in an appropriately sized solution; this time allotment represented an exaggeration of what may be expected if an urgent order for such a medication was to be prepared in a real-life situation. Once they had completed their calculations, students were allowed ten minutes to aseptically prepare the product in a laminar flow hood. In a second non-graded, in-class hands-on calculations session (Fig. 1, module 2), students utilized nutrition and calculation guides to create a TPN product specific to a patient case. Students were graded based on their ability to correctly complete these assignments and through instructor-written and verbal feedback. Final case presentation Following the conclusion of module 7, students completed a final case presentation that accounted for 20% of their total grade. Pre-specified pediatric disease states were assigned to each group for a final presentation. Students created a patient case that described their topic and developed an evidence-based therapeutic plan for this patient. Students formally presented cases to the class via the use of electronic slides. Grading focused on evidence of complete group participation, baseline knowledge of therapeutics, and an appropriate review of the primary literature. Each group was awarded one overall grade. Similar to the
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journal club, group evaluations included a non-graded peerevaluation of all group members’ involvement in the project as well as an instructor-completed rubric. Course survey Students were provided a 20-item survey that utilized a 5-point Likert scale, where 1 indicated complete disagreement, and 5 indicated complete agreement with the statement (Fig. 2). The survey contained questions related to two distinct areas. Four questions addressed the general course structure, and 15 questions addressed the students’ selfassessment of competency in course learning outcomes. One additional question focused on the students’ desire to
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pursue postgraduate education, given the specialized nature of this elective course. The self-assessment survey questions were loosely based on the 2004 CAPE Educational Outcomes and tailored to address learning outcomes relevant to this pediatric pharmacotherapy course.4 The student selfassessment portion of the survey included ten questions related to specific course content (survey items six through 15) and five questions related to professional and ethical considerations (items 16 through 20). Identical copies of the survey were provided on the first and last day of class. Students were instructed to remain anonymous in their responses and could opt-out of the survey at their own discretion. This study was approved by the institutional review board.
Item #
Response
Skill/Knowledge
1
1
2
3
4
5
2
1
2
3
4
5
3
1
2
3
4
5
4
1
2
3
4
5
This course is for students who want to practice in hospital pharmacy or pursue post-graduate education. Course timing is appropriate within the pharmacy curriculum.
5
1
2
3
4
5
I plan to pursue post-graduate pharmacy education.
6
1
2
3
4
5
I am able to use pediatric-specific drug references appropriately.
7
1
2
3
4
5
I am able to apply drug knowledge to various pediatric populations.
8
1
2
3
4
5
I am able to calculate pediatric fluid requirements.
9
1
2
3
4
5
10
1
2
3
4
5
I am equipped with necessary tools to provide introductory care to children with common disease states. I am able to calculate dosing for pediatric intravenous products.
11
1
2
3
4
5
I understand differences in pediatric and adult physiology/kinetics.
12
1
2
3
4
5
I am knowledgeable about drug administration in pediatric patients.
13
1
2
3
4
5
14
1
2
3
4
5
I am able to design/implement/monitor/evaluate pharmacotherapy care plans in pediatric patients. I am able to recognize/treat therapeutic issues in adolescents.
15
1
2
3
4
5
16
1
2
3
4
5
17
1
2
3
4
5
18
1
2
3
4
5
19
1
2
3
4
5
I am able to identify and correct situations that may result in medication errors in children. I am able to properly analyze and interpret professional pediatric pharmacotherapeutic literature. I am able to make pharmacotherapeutic recommendations in accordance with ethical guidelines. I am able to confidently communicate with other healthcare professionals in the pediatric profession. I am able to assume responsibility for my own learning.
20
1
2
3
4
5
I am able to identify situations that will foster my own learning.
Blackboard™ is the best way to distribute information for this course. Topics covered are repetitive in core curriculum.
Fig. 2. Survey to assess student learning perceptions: 1 ¼ disagree, 2 ¼ slightly disagree, 3 ¼ unknown, 4 ¼ slightly agree, 5 ¼ agree.
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Results Thirty students were enrolled in this elective course. Twenty-nine students (96.7%) completed the pre-course survey and 27 students (90%) completed the post-course survey. Values for each line item on the survey were expressed as median scores and analyzed using the Wilcoxon Rank Sum statistic (SPSS Version Inc Version 15.0, Chicago, IL). As expected, the initial four questions that related to the general course structure did not change between the pre- and post-survey comparison. However, they were included in both surveys to maintain consistency. These items related to the utility of the learning management system used within the course (median post-course survey score of 5, p ¼ 1.00), the lack of repetition of course topics from within the core curriculum (median post-course survey score of 2, p ¼ 0.791), the postgraduate applicability of course information (median post-course survey score of 3, p ¼ 0.429), and the appropriate timing of the course within the curriculum (median post-course survey score of 3, p ¼ 0.581). Comparisons of pre- and post-course questions related to learning outcome achievement revealed a statistically significant increase in the student self-assessment scores for 12 out of 15 items evaluated. Results of the self-assessment survey items are shown in Table 2. Of note, students’ desire to pursue postgraduate education or a career in hospital pharmacy did not change over the course of this elective (median preand post-course survey score of 5, p ¼ 0.153). Discussion The feasibility of the suggested 16–25 hours of pediatric content in the PharmD curriculum may be limited by faculty resources and curricular time restrictions.6 The latter limitation may be particularly problematic in accelerated pharmacy programs. Additionally, all curricular programming Table 2 Survey results related to course content items Survey question
Pre-course response
Post-course response
p-Value
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
4 3 3 2 4 2 2 3 2 3 3 4 3 5 5
5 5 5 5 5 5 4 4 5 5 4 5 4 5 5
0.36 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 0.317 0.739
should meet requirements outlined in ACPE guidelines as well as consider suggestions from the ACCP Pharmacotherapy Toolkit in regards to specific topics.8,9 Here, we were able to utilize goals outlined by ACPE to provide pediatricfocused education for students in a ten-week elective course. Unique features of this course included the use of a variety of teaching and learning strategies to help students meet course learning outcomes, as evidenced by students’ selfassessments. Several of the activities utilized in this course, such as the presentations and practical sessions, provided opportunities for learning about pediatric pharmacotherapy at higher levels of Bloom’s taxonomy.10 This approach was considered necessary to better prepare students for later experiences. For example, the case presentation demonstrated that students must properly understand and apply concepts of developmental pharmacology to make appropriate recommendations during advanced pharmacy practice experiences. Following completion of the practical sessions, a better understanding of practicalities related to pediatric calculations and compounding technique will likely help students better contribute to the care of their patients. Exposure to pediatric care information within the pharmacy curriculum should occur with all students, not just those interested in pediatric medicine. While it may not be practical to provide such intensive experiences to all, there may be room to increase exposure to more of the vital information related to the care of pediatric patients by requiring faculty to address some pediatric issues in individual class sessions related to drugs and disease-state pharmacotherapy. Although some students may also be reached through specialty advanced pharmacy practice experiences, exposures need not be limited to specialty pediatrics rotations. There are traditional pharmacy programs that offer pediatric concentrations within their curricula. Such programs require a certain number of elective hours and clerkship experiences be devoted to pediatric pharmacotherapy.11 These programs employ a multi-faceted approach to teaching and have showed improved student satisfaction with their own knowledge related to pediatric pharmacy domains. Pediatric pharmacy concepts could also be a component of elective experiences in subspecialty populations (i.e., surgical clinics, hematology/oncology clinics, and outpatient infusion sites). During community practice experiences, preceptors may encourage students to focus on developing pediatric-friendly clinic days, counseling materials, and disease prevention awareness activities. Pediatric human simulation may be another means to provide pediatric education and foster interest among students. One such program has been developed, and student-reported post-class surveys revealed an increase in clinical knowledge and appreciation of the realism of the material.12 The development of problem-based learning sessions involving students on a pediatric advanced pharmacy practice experience, as well as those who are on other rotations could also increase awareness of pediatric pharmacotherapeutic issues. Online
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education should also be considered as a medium for delivering pediatric pharmacy concepts. One institution was recently successful in offering a pediatric elective online that had previously been delivered live.13
3.
Limitations Limitations existed to this course and student survey. First, the scope of material covered in this course was restricted due to the short ten-week semester. Next, the preand post-course survey format is an inherent limitation, as one would anticipate an increase in student-perceived exposure following the completion of the course. Additionally, the use of a Likert scale for all survey items may not have been ideal, specifically for items such as planning to pursue postgraduate education or use of Blackboard could have simply been “yes” or “no” answers. Finally, the small class size and the use of data from one offering of this course may limit broader conclusions that may be drawn.
4.
5.
6.
7.
8.
Conclusion Following the completion of an elective in pediatric pharmacotherapy, there was an observed increase in the students’ self-measured achievement of learning outcomes related to the care of pediatric patients. This improvement was likely attributed to the integrated course design utilized to facilitate learning. The information provided by this course exceeded the quantity of contact time suggested for pharmacy programs. However, as this was an elective offering, other methods for supplementing pharmacy education on the care of pediatric patients still need to be considered.
9.
10.
11.
References 12. 1. Lasky T. Estimates of pediatric medication use in the United States: current abilities and limitations. Clin Ther. 2009;31(2): 436–445. 2. Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescribing drug data for 2007–2008. NCHS
13.
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Data Brief. 2010;42. 〈www.cdc.gov/nchs/data/databriefs/db42. pdf〉; Accessed November 22, 2013. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 〈http:// www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_ Adopted_Jan152006.pdf〉; Accessed November 22, 2013. Center for the Advancement of Pharmaceutical Education. American Association of Colleges of Pharmacy. Revised 2004. 〈http://www.aacp.org/resources/education/Documents/ CAPE2004.pdf〉; Accessed November 22, 2013. Low JK, Baldwin JN, Greiner GE. Pediatric pharmacy education for U.S. entry-level doctor of pharmacy programs. Am J Pharm Educ. 1999;63(3):323–327. Aucoin RG, Buck ML, Dupuis LL, Dominquez KD, Smith KP. Pediatric pharmacotherapeutic education: current status and recommendations to fill the growing need. Pharmacotherapy. 2005;25(9):1277–1282. Scott CS, Deloatch KH. Advanced pediatric pharmacotherapy: an elective course with service learning. Am J Pharm Educ. 1998;62(4):420–426. Slain D, Wong-Berringer A, Blake B, et al. Pharmacotherapy didactic curriculum toolkit 2009. 〈http://www.accp.com/docs/ positions/misc/pharmacotherapytoolkit.pdf〉; Accessed November 22, 2013. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 〈http://www. acpe-accredit.org/pdf/CPE_Standards_Final.pdf〉; Accessed November 22, 2013. Bloom BS. Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. New York: David McKay Co Inc; 1956. Elliot JP, Koerner PH, Heasley J, Kamal KM. The impact of elective active-learning courses in pregnancy/lactation and pediatric pharmacotherapy. Am J Pharm Educ. 2012;76(2): Article 26. Tofil NM, Benner KW, Worthington MA, Zinkan L, White NL. Use of simulation to enhance learning in a pediatric elective. Am J Pharm Educ. 2010;74(2):Article 21. Williams J, Motycka C. St, Onge E. Redesign of a pediatric pharmacotherapy elective course to accommodate budget reductions. Am J Pharm Educ. 2011;75(10):Article 206.
Currents in Pharmacy Teaching and Learning 6 (2014) 277–283
Short communication
http://www.pharmacyteaching.com
Pediatric pharmacotherapy in the PharmD curriculum: Course design and student self-assessment of learning outcomes achievement Evan R. Horton, PharmD*, Paul Belliveau, PharmD Department of Pharmacy Practice, MCPHS University, Worcester, MA
Abstract Background: The typical pharmacy school provides limited opportunities for focused pediatric pharmacotherapy discussions. This finding served as the impetus for development of an elective course on pediatric pharmacotherapy. The purpose of this study was to describe course design and evaluate students’ self-assessment of learning outcome achievement in a pediatric pharmacotherapy course. Methods: Thirty second-year pharmacy students were enrolled in a ten-week pediatric pharmacotherapy elective course. This course integrated numerous teaching strategies and provided several opportunities for formative and summative feedback. Students completed a pre- and post-course survey consisting of 20 items. Pre- and post-course surveys were compared to evaluate changes in student self-assessments of learning achievement following this course. Results: Twenty-nine and 27 students responded to the pre- and post-course survey, respectively. There was a significant improvement in post-survey results for all items that examined students’ self-assessment of competency in course learning outcomes (p r 0.036). Conclusions: Following completion of a pediatric pharmacotherapy course, significant improvements were observed in students’ self-assessment of learning outcome achievement. The course design appeared to have facilitated these improvements. Since this course was an elective offering, additional means of educating pharmacy students on the care of pediatric patients may need to be considered. r 2014 Elsevier Inc. All rights reserved. Keywords: Pediatric; Pharmacotherapy; Education; Outcomes
Introduction Advances in pediatric medicine, increasing complexities of childhood disease, and unique dosing and pharmacokinetic challenges all support a growing need for the education of pharmacists in basic pediatric competencies. Additionally, despite the difficulties in quantification, This research was originally presented in full at the 2009 American Association of Colleges of Pharmacy Annual Meeting, Boston, MA. * Corresponding author: Evan R. Horton, PharmD, Department of Pharmacy Practice, MCPHS University, 19 Foster Street, Worcester, MA 01608. E-mail: [email protected]
pediatric prescription medication usage is estimated to be substantial.1 According to the Centers for Disease Control 2007–2008 data, 14–20% of patients between the ages of zero and 19 years reported using at least one prescription drug in the month prior to being surveyed.2 In light of these findings, it is not an unrealistic expectation that pharmacy curricula should have some minimum level of pediatric pharmacotherapy emphasis. The 2004 Accreditation Council for Pharmacy Education (ACPE) guidelines and Center for Advancement of Pharmaceutical Education (CAPE) outcomes support the education of the pharmacist as a generalist.3,4 However, the ability of a pharmacist to provide ethical, professional, patient-centered, and evidence-based care for specific
1877-1297/14/$ – see front matter r 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cptl.2013.11.008
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E.R. Horton, P. Belliveau / Currents in Pharmacy Teaching and Learning 6 (2014) 277–283
patient populations is dependent upon familiarity with the unique characteristics of those populations. Although the ACPE guidelines address the need for pharmacists to be able to provide care for special populations (pediatric, geriatric, etc.) in its Appendix B, “Additional Guidance on the Science Foundation for the Curriculum,” surveys of pharmacy program curricula have revealed inadequacies and inconsistencies in pediatric care education.3,5 A survey of pediatric education in entry-level pharmacy programs demonstrated that the average number of hours dedicated to this subject matter was an average of 16.7 hours (range: 2.8–52.8 hours).5 In a 2004 position paper, Aucoin et al.6 asserted that time devoted to pediatric pharmacotherapy education within pharmacy programs is inadequate and recommended that pharmacy programs should have a minimum of 25 hours of pediatric contact time in the curriculum. Ideally such education should include a combination of didactic and experiential learning activities.7 The pharmacy program for which this course was designed is an accelerated PharmD program occurring in a lock-step fashion over 34 months (in contrast to the traditional 48-month PharmD program). Because of the accelerated nature of our program, achieving target numbers for pediatric-focused contact hours and introducing concurrent experiential learning in the curriculum is challenging. Initial surveys of our curriculum revealed that our students had approximately six contact hours of pediatric education (excluding specialty advanced pharmacy practice experiences). This finding was the impetus for developing an elective that focused on pediatric pharmacotherapy. The purpose of this report is to describe the structure of this course and report the results of the students’ self-assessment of learning outcome achievement. We hypothesized that students’ end-of-course self-assessments of competency would be significantly greater than their self-assessments at the start of the course. Methods Course design The pediatric pharmacotherapy elective course was designed to specifically address content that was either not presented in the core curriculum, or was presented but warranted advanced discussion. Specifically, course learning outcomes (Table 1) addressed strengthening general pediatric drug knowledge, relating principles of growth and development to pediatric disease states, formulating therapeutic plans, discussing pharmaceutics preparation and drug delivery, compounding aseptic products, applying evidence-based medicine, and utilizing active, team-based learning. The course content focused on providing functional approaches to thinking and understanding from the perspective of a pediatric pharmacist. Although few of these students are likely to become specialized pediatric pharmacists, such an approach is expected to give students a
Table 1 Course learning outcomes (1) Discuss pediatric drug therapy considerations for patients based upon age, pharmacokinetic issues, and concomitant issues. (2) Relate basic principles of pediatric growth and development to a variety of disease states. (3) Formulate therapeutic plans for pediatric and neonatal patients with a variety of disease states. (4) Identify methods for appropriate pediatric pharmaceutics preparation and drug delivery. (5) Discuss and apply pediatric literature towards the practice of evidence-based medicine. (6) Apply creative problem solving solutions to unique pharmaceutical and pharmacotherapeutic situations.
heightened sensitivity to pediatric issues potentially encountered in the professional setting. The course featured several unique elements, including multiple group projects and presentations, hands-on practical sessions, and expert guest speakers to facilitate learning. The ten-week course was module based, with topics ranging from basic elements of pediatric therapeutics to the in-depth management of specific disease states, such as pediatric diabetes and pain management (Fig. 1). Upon completion, this course provided an approximate 30 additional hours of pediatric education, accomplished by 10 three-hour classes conducted throughout the summer semester. Most topics were taught by faculty who were knowledgeable in pediatric therapeutics. Expert guest speakers were invited to discuss pediatric critical care, congenital heart disease, and pediatric medication safety. A variety of learning strategies were incorporated throughout didactic lectures to accommodate different learning styles. These strategies included guided notes, group discussions, debates, games, lectures, and student presentations. There were several assessments in the course including daily attendance, homework, quizzes, journal club, practical sessions, and a final case presentation. Students were assigned to small groups at the start of the course; these groups were utilized for the journal club and final case presentations.
Daily attendance Attendance was recorded for each class period and counted as 10% of the total course grade. Students received 0.5 points for attendance at each of the 20 classes. Attendance was stressed as a graded component of the course due to the emphasis on active and team-based learning.
Homework Four homework assignments, each worth 5% of the total grade, were given to facilitate class preparation and discussion. Homework activities consisted of the following:
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Introductory Activity (Homework 1) Module 1: Introduction Developmental Pharmacology Fluids and Electrolytes Module 2: Fluids/ Electrolytes/Nutrition
Pediatric TPN (Homework 2) Drug Delivery in Children (Homework 3)
Module 3: Pharmaceutics Drug Preparations (Practical Session)
R/O Sepsis Module 4: Medication Safety and Critical Care
Medication Safety in Children Adolescent Medicine
Module 5: General Pediatrics I
Anti-seizure Agents in Children
Diabetes in Children Module 6: General Pediatrics 2
Pediatric Pain Management (Homework 4)
Basics of Critical Care Module 7: Critical Care Neonatal Critical Care Fig. 1. Module and topic overview. TPN = total parenteral nutrition; R/O = rule out.
(1) Research an extemporaneously compounded recipe, summarize the compounding process and post on our institution’s learning management system. (2) Calculate components of a mock total parenteral nutrition (TPN) product when provided with a patient case. (3) Complete a pediatric dosage calculation as preparation for a practical session involving preparation of a standard concentration intravenous product. (4) Complete an activity that showed evidence of the pharmacist as a professional, by means of a creating a professional curriculum vitae (CV). The first three assignments focused on specialized preparation for pediatric dosage forms; they correlated with course learning outcomes 1, 4, and 6 (Table 1) and were used to prepare the students for aspects of modules 1, 2, and 3 of the course (Fig. 1). The assignments helped to achieve course learning outcomes by requiring students to
understand the pharmacokinetic complexities that involve care of pediatric patients. By understanding these complexities, students were able to gain a better understanding of how and why compounding pediatric dosage forms, unique from standard adult preparations, can be a difficult and specialized process. The fourth assignment was assessed via formative feedback utilizing grading rubrics and instructorwritten feedback. While the CV assignment was not specifically correlated to a defined course learning outcome in the syllabus, the CAPE outcomes address the importance of the development of a pharmacist as a professional practitioner. In future offerings of this course, this aspect will likely be incorporated into the course learning outcomes and more fully integrated into the structure of the course. In addition to assisting with defined course learning outcomes, these assignments also facilitated active, groupbased learning, allowed students to practice using technology to share information (specifically when conducted via our online learning management system), provided
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opportunities for students to utilize appropriate drug references, and heightened students’ appreciation for the unique challenges of drug delivery to pediatric patients. Formative assessment was further utilized through “minute paper” and “muddiest point” assignments that were done at the end of identified classes. These allowed the students and the instructors to gain a better understanding of how certain class days were received by the students. Quizzes Four unannounced quizzes, each worth 5% of the total grade, were administered during classes. Quiz content reflected basic knowledge and comprehension of concepts taught in the previous class period. Quizzes were specifically structured to cover general pediatric pharmacotherapy concepts as this course was not designed to produce proficient pediatric specialists, but to expose students to general concepts that drive pediatric pharmacotherapy decisions. Hence, quizzes were meant to provide a means of gauging how well students were retaining the overarching concepts taught within the course. Although the use of comprehensive examinations in this course was considered, the coordinators decided against this assessment method. Here, the coordinators’ rationale was that use of such a method could stifle active class discussions and cause the students to focus more on rote memorization for an examination. Journal club Between modules 4 and 5 (Fig. 1), students were asked to complete a journal club assignment worth 20% of their total course grade. Six published pediatric clinical trials were chosen by the course coordinators, with each one being assigned to a group of five students. Articles addressed specific therapeutic topics that were discussed within the course. Students were provided with the articles several weeks in advance of their assigned presentation date. Students worked within their groups, outside designated class time, to facilitate a journal club-style discussion with the class. Two class sessions were designated specifically for journal club presentations, with each group presenting for approximately 20 minutes. Student groups presented trial background, methodology, results, authors’ conclusions, and their own article critique. Each group was also required to apply their article to the current practice of pharmacy, and a portion of their grading rubric included recognition and application of clinical significance versus statistical significance. Each presentation was followed by an additional ten minutes designated for a question-andanswer session that was facilitated by the course coordinators and included questions from other students in the course, as well as instructors. One grade was given to each group using a pre-defined rubric, and a portion of each group’s evaluation included a non-graded peer-evaluation of
group members’ involvement in the project. Groups demonstrated this by having all group members participate in the delivery of content. This facilitated a team-based learning and teaching environment. Practical sessions Two practical sessions served to engage students in pediatric-related pharmaceutical calculations (including pediatric TPN calculations), intravenous medication preparation, and aseptic technique. In the more significant of these two sessions (worth 10% of the total course grade), students completed a series of pharmaceutical calculations relating to a pediatric patient case (Fig. 1, module 3). One week prior to this session, students received a one-hour, inclass lecture and demonstration on pediatric pharmaceutical calculations and standard concentration parenteral product preparation. During this class, students practiced these calculations and then received additional practice problems as homework (previously described) that was meant to serve as preparation for the practical session. Prior to the practical session, students were invited to optionally attend a review session to answer any remaining questions on the process of pharmaceutical calculations and standard concentration product calculations. On the day of the practical session, students were provided with a medication order for a parenteral medication, concentration-related guidelines for that specific medication, and the materials needed to prepare the product. Students were allowed ten minutes to perform the necessary calculations to create a continuous intravenous infusion in an appropriately sized solution; this time allotment represented an exaggeration of what may be expected if an urgent order for such a medication was to be prepared in a real-life situation. Once they had completed their calculations, students were allowed ten minutes to aseptically prepare the product in a laminar flow hood. In a second non-graded, in-class hands-on calculations session (Fig. 1, module 2), students utilized nutrition and calculation guides to create a TPN product specific to a patient case. Students were graded based on their ability to correctly complete these assignments and through instructor-written and verbal feedback. Final case presentation Following the conclusion of module 7, students completed a final case presentation that accounted for 20% of their total grade. Pre-specified pediatric disease states were assigned to each group for a final presentation. Students created a patient case that described their topic and developed an evidence-based therapeutic plan for this patient. Students formally presented cases to the class via the use of electronic slides. Grading focused on evidence of complete group participation, baseline knowledge of therapeutics, and an appropriate review of the primary literature. Each group was awarded one overall grade. Similar to the
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journal club, group evaluations included a non-graded peerevaluation of all group members’ involvement in the project as well as an instructor-completed rubric. Course survey Students were provided a 20-item survey that utilized a 5-point Likert scale, where 1 indicated complete disagreement, and 5 indicated complete agreement with the statement (Fig. 2). The survey contained questions related to two distinct areas. Four questions addressed the general course structure, and 15 questions addressed the students’ selfassessment of competency in course learning outcomes. One additional question focused on the students’ desire to
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pursue postgraduate education, given the specialized nature of this elective course. The self-assessment survey questions were loosely based on the 2004 CAPE Educational Outcomes and tailored to address learning outcomes relevant to this pediatric pharmacotherapy course.4 The student selfassessment portion of the survey included ten questions related to specific course content (survey items six through 15) and five questions related to professional and ethical considerations (items 16 through 20). Identical copies of the survey were provided on the first and last day of class. Students were instructed to remain anonymous in their responses and could opt-out of the survey at their own discretion. This study was approved by the institutional review board.
Item #
Response
Skill/Knowledge
1
1
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4
5
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5
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This course is for students who want to practice in hospital pharmacy or pursue post-graduate education. Course timing is appropriate within the pharmacy curriculum.
5
1
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3
4
5
I plan to pursue post-graduate pharmacy education.
6
1
2
3
4
5
I am able to use pediatric-specific drug references appropriately.
7
1
2
3
4
5
I am able to apply drug knowledge to various pediatric populations.
8
1
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4
5
I am able to calculate pediatric fluid requirements.
9
1
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4
5
10
1
2
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5
I am equipped with necessary tools to provide introductory care to children with common disease states. I am able to calculate dosing for pediatric intravenous products.
11
1
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4
5
I understand differences in pediatric and adult physiology/kinetics.
12
1
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4
5
I am knowledgeable about drug administration in pediatric patients.
13
1
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5
14
1
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5
I am able to design/implement/monitor/evaluate pharmacotherapy care plans in pediatric patients. I am able to recognize/treat therapeutic issues in adolescents.
15
1
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5
16
1
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5
17
1
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5
18
1
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19
1
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5
I am able to identify and correct situations that may result in medication errors in children. I am able to properly analyze and interpret professional pediatric pharmacotherapeutic literature. I am able to make pharmacotherapeutic recommendations in accordance with ethical guidelines. I am able to confidently communicate with other healthcare professionals in the pediatric profession. I am able to assume responsibility for my own learning.
20
1
2
3
4
5
I am able to identify situations that will foster my own learning.
Blackboard™ is the best way to distribute information for this course. Topics covered are repetitive in core curriculum.
Fig. 2. Survey to assess student learning perceptions: 1 ¼ disagree, 2 ¼ slightly disagree, 3 ¼ unknown, 4 ¼ slightly agree, 5 ¼ agree.
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Results Thirty students were enrolled in this elective course. Twenty-nine students (96.7%) completed the pre-course survey and 27 students (90%) completed the post-course survey. Values for each line item on the survey were expressed as median scores and analyzed using the Wilcoxon Rank Sum statistic (SPSS Version Inc Version 15.0, Chicago, IL). As expected, the initial four questions that related to the general course structure did not change between the pre- and post-survey comparison. However, they were included in both surveys to maintain consistency. These items related to the utility of the learning management system used within the course (median post-course survey score of 5, p ¼ 1.00), the lack of repetition of course topics from within the core curriculum (median post-course survey score of 2, p ¼ 0.791), the postgraduate applicability of course information (median post-course survey score of 3, p ¼ 0.429), and the appropriate timing of the course within the curriculum (median post-course survey score of 3, p ¼ 0.581). Comparisons of pre- and post-course questions related to learning outcome achievement revealed a statistically significant increase in the student self-assessment scores for 12 out of 15 items evaluated. Results of the self-assessment survey items are shown in Table 2. Of note, students’ desire to pursue postgraduate education or a career in hospital pharmacy did not change over the course of this elective (median preand post-course survey score of 5, p ¼ 0.153). Discussion The feasibility of the suggested 16–25 hours of pediatric content in the PharmD curriculum may be limited by faculty resources and curricular time restrictions.6 The latter limitation may be particularly problematic in accelerated pharmacy programs. Additionally, all curricular programming Table 2 Survey results related to course content items Survey question
Pre-course response
Post-course response
p-Value
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
4 3 3 2 4 2 2 3 2 3 3 4 3 5 5
5 5 5 5 5 5 4 4 5 5 4 5 4 5 5
0.36 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 o0.0005 0.317 0.739
should meet requirements outlined in ACPE guidelines as well as consider suggestions from the ACCP Pharmacotherapy Toolkit in regards to specific topics.8,9 Here, we were able to utilize goals outlined by ACPE to provide pediatricfocused education for students in a ten-week elective course. Unique features of this course included the use of a variety of teaching and learning strategies to help students meet course learning outcomes, as evidenced by students’ selfassessments. Several of the activities utilized in this course, such as the presentations and practical sessions, provided opportunities for learning about pediatric pharmacotherapy at higher levels of Bloom’s taxonomy.10 This approach was considered necessary to better prepare students for later experiences. For example, the case presentation demonstrated that students must properly understand and apply concepts of developmental pharmacology to make appropriate recommendations during advanced pharmacy practice experiences. Following completion of the practical sessions, a better understanding of practicalities related to pediatric calculations and compounding technique will likely help students better contribute to the care of their patients. Exposure to pediatric care information within the pharmacy curriculum should occur with all students, not just those interested in pediatric medicine. While it may not be practical to provide such intensive experiences to all, there may be room to increase exposure to more of the vital information related to the care of pediatric patients by requiring faculty to address some pediatric issues in individual class sessions related to drugs and disease-state pharmacotherapy. Although some students may also be reached through specialty advanced pharmacy practice experiences, exposures need not be limited to specialty pediatrics rotations. There are traditional pharmacy programs that offer pediatric concentrations within their curricula. Such programs require a certain number of elective hours and clerkship experiences be devoted to pediatric pharmacotherapy.11 These programs employ a multi-faceted approach to teaching and have showed improved student satisfaction with their own knowledge related to pediatric pharmacy domains. Pediatric pharmacy concepts could also be a component of elective experiences in subspecialty populations (i.e., surgical clinics, hematology/oncology clinics, and outpatient infusion sites). During community practice experiences, preceptors may encourage students to focus on developing pediatric-friendly clinic days, counseling materials, and disease prevention awareness activities. Pediatric human simulation may be another means to provide pediatric education and foster interest among students. One such program has been developed, and student-reported post-class surveys revealed an increase in clinical knowledge and appreciation of the realism of the material.12 The development of problem-based learning sessions involving students on a pediatric advanced pharmacy practice experience, as well as those who are on other rotations could also increase awareness of pediatric pharmacotherapeutic issues. Online
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education should also be considered as a medium for delivering pediatric pharmacy concepts. One institution was recently successful in offering a pediatric elective online that had previously been delivered live.13
3.
Limitations Limitations existed to this course and student survey. First, the scope of material covered in this course was restricted due to the short ten-week semester. Next, the preand post-course survey format is an inherent limitation, as one would anticipate an increase in student-perceived exposure following the completion of the course. Additionally, the use of a Likert scale for all survey items may not have been ideal, specifically for items such as planning to pursue postgraduate education or use of Blackboard could have simply been “yes” or “no” answers. Finally, the small class size and the use of data from one offering of this course may limit broader conclusions that may be drawn.
4.
5.
6.
7.
8.
Conclusion Following the completion of an elective in pediatric pharmacotherapy, there was an observed increase in the students’ self-measured achievement of learning outcomes related to the care of pediatric patients. This improvement was likely attributed to the integrated course design utilized to facilitate learning. The information provided by this course exceeded the quantity of contact time suggested for pharmacy programs. However, as this was an elective offering, other methods for supplementing pharmacy education on the care of pediatric patients still need to be considered.
9.
10.
11.
References 12. 1. Lasky T. Estimates of pediatric medication use in the United States: current abilities and limitations. Clin Ther. 2009;31(2): 436–445. 2. Gu Q, Dillon CF, Burt VL. Prescription drug use continues to increase: U.S. prescribing drug data for 2007–2008. NCHS
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Data Brief. 2010;42. 〈www.cdc.gov/nchs/data/databriefs/db42. pdf〉; Accessed November 22, 2013. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 〈http:// www.acpe-accredit.org/pdf/ACPE_Revised_PharmD_Standards_ Adopted_Jan152006.pdf〉; Accessed November 22, 2013. Center for the Advancement of Pharmaceutical Education. American Association of Colleges of Pharmacy. Revised 2004. 〈http://www.aacp.org/resources/education/Documents/ CAPE2004.pdf〉; Accessed November 22, 2013. Low JK, Baldwin JN, Greiner GE. Pediatric pharmacy education for U.S. entry-level doctor of pharmacy programs. Am J Pharm Educ. 1999;63(3):323–327. Aucoin RG, Buck ML, Dupuis LL, Dominquez KD, Smith KP. Pediatric pharmacotherapeutic education: current status and recommendations to fill the growing need. Pharmacotherapy. 2005;25(9):1277–1282. Scott CS, Deloatch KH. Advanced pediatric pharmacotherapy: an elective course with service learning. Am J Pharm Educ. 1998;62(4):420–426. Slain D, Wong-Berringer A, Blake B, et al. Pharmacotherapy didactic curriculum toolkit 2009. 〈http://www.accp.com/docs/ positions/misc/pharmacotherapytoolkit.pdf〉; Accessed November 22, 2013. Accreditation Council for Pharmacy Education. Accreditation standards and guidelines for the professional program in pharmacy leading to the doctor of pharmacy degree. 〈http://www. acpe-accredit.org/pdf/CPE_Standards_Final.pdf〉; Accessed November 22, 2013. Bloom BS. Taxonomy of Educational Objectives, Handbook I: The Cognitive Domain. New York: David McKay Co Inc; 1956. Elliot JP, Koerner PH, Heasley J, Kamal KM. The impact of elective active-learning courses in pregnancy/lactation and pediatric pharmacotherapy. Am J Pharm Educ. 2012;76(2): Article 26. Tofil NM, Benner KW, Worthington MA, Zinkan L, White NL. Use of simulation to enhance learning in a pediatric elective. Am J Pharm Educ. 2010;74(2):Article 21. Williams J, Motycka C. St, Onge E. Redesign of a pediatric pharmacotherapy elective course to accommodate budget reductions. Am J Pharm Educ. 2011;75(10):Article 206.