Teaching Pharmacology in an Innovative Medical Curriculum: Challenges of Integration, Technology, and Future Training

The Flexner report of 19101,2 set the stage for significant improvements in the growth and development of the individual subject disciplines that made up medicine. Aided by the chip technology in the latter half of the century, research grew without bounds and with it the individual disciplines and the body of knowledge required from each to produce the composite, fit-to-practice medical doctor. This posed serious challenges with regards to accommodating the ever-increasing knowledge base within the fixed timeframe for training the medical doctor.3,4 This scenario has been described by many medical educationalists in very impressionable terms. Guilbert5 describes “curriculopathy” as a syndrome that arises from the failure of the curriculum to catch up with factors that influence training, such as the increasing body of knowledge, lack of relevance, predominance of basic and biological sciences, faculty attitude to teaching, cost, and the organization of the delivery of medical education. These challenges largely constitute the forces that gave birth to innovative medical curricula,3 classical among which is the problem-based learning (PBL) paradigm that was developed in McMaster, Canada, in the mid-1960s. With increasing awareness in medical education, other curricular notions have since emerged, including the hybrid PBL curriculum, outcome-based curriculum, concept-based learning, case-based learning, and task-based learning. A critical analysis of these educational philosophies reveals a significant overlap of concepts with most (if not all) deriving largely from or are basically variants of the PBL philosophy, or what we choose to describe as the “metoo curriculum.” The undisputable common goal of innovative curricula is the training of a tomorrow's doctor who enters medical practice with a holistic mind-set achieved through a curriculum regimen that emphasizes the horizontal and vertical integration of the basic and clinical sciences, respectively, while promoting lifelong learning skills through self-directed learning.6 Innovative curricula also emphasize the application of information and communication technology (ICT) in the teaching-learning process, with ICT being, perhaps, the main engine that drives information growth and access. It is our experience, however, that the implementation of these essential elements (integration and use of ICT) of innovation paradoxically portends challenges to the teaching/learning of pharmacology and its growth/development. These are challenges that all teachers of pharmacology and curriculum managers should be aware of. In this editorial exploring these challenges in the innovative (PBL) curriculum, we focus on the challenges of integration in the teaching of pharmacology, the challenges of ICT in the teaching of pharmacology, and the challenges of training tomorrow's pharmacologist. The concept of the integrated curriculum arose from the perceived weakness of the traditional curriculum to adequately promote the application of the basic sciences in the clinical context because of its dichotomous (preclinical-clinical divide) curricular arrangement in which the medical student is taught the individual basic science disciplines in the early phase and is expected to apply the knowledge in the latter (clinical) phase of the curriculum. The reality of the holistic nature of man in health and disease is what integration essentially aims to capture, and perhaps the only meaningful way to deliver this in a curriculum is to learn the basic sciences in clinical context as exemplified by the PBL philosophy and its tutorial process. Pharmacology delivers special skills, knowledge, and attitudes as part of a multidisciplinary-input medical curriculum.1 Its proper delivery cannot be taken for granted even in a traditional discipline-based medical curriculum and perhaps much less so in innovative curricula without the traditional departmental structures that protect and advance the interests of the discipline. The possibility of inadequate delivery of pharmacology creates serious worries, especially so with reports of morbidity and mortality in clinical practice traceable to inappropriate uses of medication, a consequence of poor prescribing skills, which, given that the goal of the medical pharmacology curriculum is the rational use of drugs, is attributable to a defective pharmacology curriculum.7,8 We assert that there is an increasing need for the pharmacology component of any medical curriculum to be clearly defined in terms of the input and expected outcomes that must be reliably and validly assessed as a prerequisite for medical school graduation—a view affirmed by various professional bodies.9,10 The objectives of the PBL paradigm are well captured by the SPICES curriculum model—an acronym that stands for self-directed learning, problem based, integrated, community oriented, electives, and systematic.11 In addition, the PBL paradigm emphasizes professionalism, including team spirit and communication skills. It promotes early clinical exposure (to enhance integration), small group teaching (for the tutorial process), lifelong learning, and ICT competency. The educational qualities of these goals, especially in the context of lifelong learning, are clear indicators that the PBL paradigm and other similar curricular philosophies are here to stay. Compared to the traditional teacher-centered, discipline-based curriculum, it is our experience that the goals of integration (the central theme of all innovative curricula) are indeed better achieved through the PBL paradigm. Our students and others12 aver, and we concur, that team spirit and communication skills are much better acquired through the PBL than the traditional lecture-based curriculum. The following are sample (students') quotes from our study in response to a question on perceived advantages of PBL over lecture-based curriculum:13 Makes me speak more. Brings out the best in a student (leadership qualities). Learning new knowledge from friend at “student level.” From the perspective of the discipline (pharmacology), however, the following questions always agitate the mind of the teacher: Where is pharmacology in the (PBL) curriculum? Who teaches it and by what delivery tool? How is it assessed? How are we growing the discipline? The rest of this editorial attempts to address these concerns. At the end of the day, the essence of any curriculum is that the learner learns (to acquire knowledge, skills, and attitudes required for prescribed outcomes/competencies). It follows, therefore, that resolving the challenge of where pharmacology is in the curriculum comes down to evaluating the factors/issues that may specifically affect the learning of pharmacology. These would include the following: How much of pharmacology objectives/outcomes have been prescribed for the students (the learning contract/syllabus)? How much of the syllabus has been delivered and how? How much of the delivered (and prescribed) have been learned with appropriate outcomes? This is perhaps the most important question, given (as stated above) that the essence of the curriculum is learning. How much of the delivered (and prescribed) have been validly and reliably assessed? The answers to these fundamental curricular questions begin with the provision of a detailed curriculum map that only few curricula can boast of. A curriculum map provides details of learning objectives, the teaching-learning activities, the sequence of their delivery, and the learning outcomes. It is an information base for all stakeholders, including students, teachers, and assessors/evaluators of the curriculum. It provides the much-needed guide to depth and scope that has remained a major worry of students in PBL curricula.14 It does not, however, guarantee delivery, which depends on such factors as the curriculum management culture of the organization, nor does it guarantee learning that is influenced by such factors as the hidden curriculum.15 Of the prescribed/written curriculum (syllabus), the taught (delivered) curriculum, and the assessed curriculum, the assessed is the most correlated with what is learnt—the learnt curriculum.16 In effect, assessment drives learning, thus making proper assessment (of pharmacology) a major issue in the integrated PBL curriculum, where it may be difficult to decipher the pharmacology component of an assessment instrument. In many medical schools, integrating the curriculum has meant tearing down the physical and administrative walls that separated the traditional basic medical sciences (of anatomy, physiology, biochemistry, pathology, etc), thus promoting horizontal integration, and also bringing down the structures that promoted the traditional preclinical-clinical divide, thus enhancing vertical integration. Although these arrangements have the huge potential advantage of interdisciplinary interaction and intellectual development, including collaborative research, all of which may rub off positively on students through a faculty with a broader and holistic perspective, the challenges are equally enormous. One of the major challenges in these so-called umbrella/interdisciplinary curricula17 is the lack of the authoritative presence of the discipline-based departments with the potential consequence of sidelining disciplines that may have politically weak champions (advocates) or indeed no champions at all within the curriculum. This was the case with pharmacology in one medical school where, repeatedly, external examiners gave feedback on the paucity of pharmacology questions in the various exams. This scenario arose partly because there was no one (pharmacologist) officially charged with overseeing pharmacology input in that curriculum. In addition, the few pharmacologists on board were medically qualified and were, therefore, required to double as teachers of clinical skills in the early clinical exposure (ECE) component of the curriculum. The requirement to multitask further diverted the attention of the few pharmacologists from ensuring adequate penetrance of the discipline in the PBL curriculum. Thus, nobody seriously promoted the learning of pharmacology by the students, not to mention training pharmacologists for the future. This scenario is one that can easily and inadvertently creep into a medical curriculum with devastating consequences of gaps in students' pharmacology knowledge—a pointer perhaps to the need for nonmedically qualified pharmacologists as previously identified,18 although integrated curricula, rightly so in our opinion, tend to prefer the medically qualified. The challenge, as in the example given above, is in curriculum management. Any curriculum, traditional or innovative (integrated), requires a curriculum manager with knowledge and skills and the authority to ensure that the curricular philosophy blossoms. This manager, it has been strongly recommended, must be a senior faculty appointment at the deputy dean level.19 This requirement is perhaps most apt in the integrated curriculum, where the interest of individual subject disciplines is easily subsumed in the overwhelming uncharted sea of integration. Such an experienced manager will ensure the adequate representation of each subject discipline in the curriculum and will best perform such function through the active involvement of discipline champions. It is our view that the appointment of discipline champions/advocates is a sine qua non of success in an integrated curriculum. To do otherwise is to encourage a scenario where individual disciplines feature in the curriculum only to the extent that practitioners of the discipline are powerful in the curriculum. This is unacceptable. Pharmacology became more or less an orphan subject in the medical school example referred to above. This development, on the other hand, is a pointer to the usefulness of regular external evaluation of any curriculum, especially so in the integrated (PBL) medical curriculum and wherever the management style is hierarchical and/or political.20 In the PBL curriculum, the delivery tool is the problem/case/scenario/trigger, and the “teacher” facilitates learning basically through the PBL tutorials. Knowledge of how much pharmacology has been delivered could be derived from the learning objectives of the triggers. The challenge to pharmacology lies in whether or not pharmacology objectives feature adequately (as prescribed in the syllabus) in the designing of the triggers and whether the PBL tutorial facilitation process ensures the emergence of these objectives. There is also the issue of whether the students actually attain the outcomes stated in the syllabus, the answer of which lies in the validity and reliability of the formative and summative assessments in the curriculum. Closely aligned to this is the challenge of constructing integrated exam questions that ensure adequate representation of the disciplines (including pharmacology). There is also the issue of who marks these integrated questions. In effect, the challenge is that of moving from setting questions that are purely pharmacology (as in the traditional curriculum) to setting and evaluating questions that are integrated across medical disciplines. Developing such questions will generally require multidisciplinary input and, preferably, examiners with a broad medical background (and therefore usually medically qualified) who have a working knowledge of the various contributing disciplines, thus enhancing the question development process. The temptation that must be avoided is the tendency to set questions based on individual disciplines, put them together in a single exam paper, and assume integration. This tends to occur but is not necessarily restricted to curricula that still retain the traditional discipline-based administrative structures. A truly integrated assessment is one with questions that cover various themes of the curriculum with interdependent, overlapping, and multidisciplinary concepts. Such questions will necessarily require multidisciplinary input and, if well integrated, will pose challenges when it comes to the marking of the students' answer scripts. It is our experience that quite often, the so-called model/specimen answers are provided for the guidance of the examiner who may not be a content expert. Indeed, a content expert becomes difficult to define in the context of a properly integrated question that focuses on basic sciences and application of the same across clinical disciplines. We have observed the marking of pharmacology questions in which apparently top students were marked down for offering correct answers because they used terminologies different from those offered in the so-called model answers. The more integrated the questions, the more desirable, yet more challenging, including the challenge of the right persons to mark the scripts. The following provocative words are intended as food for thought: Leaving pharmacology (basic and clinical) entirely in the hands of today's clinical pharmacologist is perhaps a sure way to kill (the basic science component of and ultimately) the discipline. Leaving it entirely in the hands of a nonmedically qualified pharmacologist is a sure way to defeat the highly desirable objectives of vertical and horizontal integration of the medical curriculum. Defining a balance is essential. In summary, the integrated curriculum is founded on sound pedagogic principles and is perhaps here to stay, despite its huge but surmountable challenges. Integration is so fundamental to the philosophy of innovative medical curriculum and is perceived to be so threatened by the traditional discipline-based departments that these administrative structures are dissolved in several PBL curricula. Desirable as this practice may be, it creates the potential danger of loss of adequate penetrance of individual disciplines in the curriculum, especially so in schools where there is no clearly identifiable curriculum manager or one where the manager runs an integrated curriculum with a mind-set still frozen in the ways of the traditional curriculum. It is recommended that all integrated curricula appoint clearly identifiable curriculum managers and discipline champions. These should be senior-level appointees with demonstrable knowledge, skills, and experience in curriculum matters. These managers should work with the discipline champions to ensure proper balance in the horizontal and vertical integration of the disciplines, their delivery, and reliable and valid assessment to ensure that products of the curriculum meet prescribed curricular outcomes. The importance of regular internal and external reviews cannot be overemphasized. An awareness of these issues is perhaps the beginning of curricular wisdom for all who manage integrated curricula. Other challenges of the integrated (PBL) curriculum include those of computer-aided learning, which constitutes the focus of the next section. When in the late 1970s, computers were introduced into teaching/learning, the idea was greeted with skepticism, with some believing that, like radio and television in education before it, this was going to be another passing phenomenon. By the mid-80s, however, it became clear that computer-based ICT was here to stay and would revolutionize education. Thus, from skepticism arose immense optimism with an early observer claiming that, “The space left for practitioners in Higher Education is either to embrace the new media enthusiastically or to stand aside and watch its inevitable unfolding.”21 ICT in education has since moved from just classes in computer literacy to broader roles in the delivery of educational material, promoting research and education management information systems, which lower administrative costs. From a global perspective, however, major challenges exist, especially with regards to accessing this invaluable educational tool. The so-called digital divide is a phenomenon ordinarily interpreted as the dichotomy of access- nonaccess to ICT facilities, often simplistically construed on the basis of the North-South economic divide of the rich versus poor nations. However, it has been recognized that the challenges of the digital divide go beyond just economic geography; individuals who have overcome the access barrier dimension of the digital divide may be trapped in the literacy barrier facet22—a phenomenon in which people with access to ICT facilities may lack the literacy to put such facilities to optimal benefit (see Camoy23 for further reading). The challenge, therefore, is in providing global access to ICT facilities and, equally important, providing literacy training for the effective utilization of the facilities (the so-called digital democracy).22 From the perspective of an integrated (PBL) curriculum, the importance of ICT cannot be overemphasized. It is required for achieving the major goals of the PBL paradigm, including serving as a source of information for self-directed learning and, it is hoped, lifelong learning. It is also a means of communication and a sharing of information/consultation among peers that promotes team spirit and the curriculum delivery of learning materials, including the PBL cases/scenario, especially its newfound use in distributed learning, which involves large PBL groups across time zones using synchronous and asynchronous media.24 Among the major challenges are those of access, literacy, and ability to evaluate information. From the perspective of pharmacology and as observed above, the challenges are twofold. The first is the challenge of promoting a worldwide access to ICT facilities in medical schools to minimize regional differences in pharmacology standards, particularly now that there is an increasing call (due to the forces of globalization) for minimal global medical education standards.25,26 The second is to promote computer literacy among staff (and students) so that available ICT facilities are put to maximum benefit, facilitating a worldwide growth and development of the discipline and thus the rational use of drugs—a major goal of the apical professional body, the International Union of Pharmacologists (IUPHAR). The goal of the rational use of drugs is strongly challenged by the forces of ICT as students (and teachers) have access to a multiplicity of sources of drug information and, therefore, face the challenge of making decisions on the validity/reliability of such information, some of which can be confusing and/or conflicting. This is a major challenge to any pharmacology curriculum, perhaps more so to those (like the PBL) that promote student-centered, self-directed learning. This is perhaps the essence of teaching evidence-based medicine (EBM) in any modern pharmacology curriculum. The advent of chip technology is a contributing factor to the high turnover of knowledge, its ease of dissemination, and the changes in medical paradigms consequent upon new knowledge. Not surprising, therefore, ICT skills are seen as essential for tomorrow's doctor and an essential feature of all innovative curricula.27–29 In addition to serving as a means of obtaining information, including the promotion of EBM,27,28 ICT in medical education serves so many other functions in the delivery of the curriculum, and that its usefulness cannot be overemphasized. 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