|Year : 2012 | Volume
| Issue : 5 | Page : 634-638
Introduction of case based teaching to impart rational pharmacotherapy skills in undergraduate medical students
Sandhya K Kamat, Padmaja A Marathe, Tejal C Patel, Yashashri C Shetty, Nirmala N Rege
Department of Pharmacology and Therapeutics, Seth G. S. Medical College and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra, India
|Date of Submission||07-Jan-2012|
|Date of Decision||08-Mar-2012|
|Date of Acceptance||01-Jul-2012|
|Date of Web Publication||31-Aug-2012|
Nirmala N Rege
Department of Pharmacology and Therapeutics, Seth G. S. Medical College and KEM Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: The aim of this study is to assess the impact of case based teaching (CBT) on learning rational prescribing and to compare CBT with the traditional method of teaching (TRD).
Materials and Methods: Second year Bachelor of Medicine and Bachelor of Surgery (MBBS) students (n = 179) were administered a pre-test and randomly divided into groups to receive CBT (n = 96) and TRD (n = 83). CBT group was further sub-divided into CBT1 and CBT2. Both these groups were taught two topics each by CBT and TRD during tutorials; however, the topics were switched with respect to method of teaching. The post-test comprised of three therapeutic problems of which two were related, and one was not related to the tutorial topics. Marks obtained in the post-test were graded and analysed using Fischer's exact test.
Results: In the post-test, the therapeutic problems on diabetes mellitus and peptic ulcer were attempted by 85.41% students from CBT and 73.49% from TRD group. CBT group obtained more marks for these problems (4.23 ± 0.94; P < 0.001) than the TRD (3.32 ± 0.92) group. Also, more students in the CBT obtained grade 3 (P < 0.001) and fewer obtained grade 1 (P < 0.01), compared to the TRD group. When the grades of the two CBT groups were compared, it was found that fewer students in CBT 2 had obtained grade 1 and those scoring higher grades were comparable between the two groups. For the therapeutic problem on malaria, 7.29% students from CBT and 18.07% from TRD received 0 grade (P < 0.05). More students received ≥ 2 grade in CBT group (P < 0.05).
Conclusion: Use of CBT during tutorials is better than TRD and facilitates learning of rational pharmacotherapy.
Keywords: Case based teaching, medical students, teaching methods, tutorials
|How to cite this article:|
Kamat SK, Marathe PA, Patel TC, Shetty YC, Rege NN. Introduction of case based teaching to impart rational pharmacotherapy skills in undergraduate medical students. Indian J Pharmacol 2012;44:634-8
|How to cite this URL:|
Kamat SK, Marathe PA, Patel TC, Shetty YC, Rege NN. Introduction of case based teaching to impart rational pharmacotherapy skills in undergraduate medical students. Indian J Pharmacol [serial online] 2012 [cited 2020 May 30];44:634-8. Available from: http://www.ijp-online.com/text.asp?2012/44/5/634/100400
| » Introduction|| |
Irrational use of medicines is a major problem worldwide, and one of the factors responsible is the lack of of prescribing skills among doctors.  The World Health Organization (WHO) Guide to Good Prescribing is the most widely used model that is used to prepare students for the challenges of prescribing. Although the guide is based on sound therapeutic principles and has shown some beneficial effects, there is a need for further development in teaching and assessment of the prescribing methodology.  In fact, several studies have emphasized the need for an increase in the training of medical students and junior doctors in the rational use of medicines. ,, The National Health Policy (2002) of the Government of India has emphasized that a need-based, skill-oriented syllabus, with a more significant component of practical training, would be useful to fresh doctors to serve the society immediately after graduation.  Despite these recommendations, in many institutes, pharmacology is taught using the traditional approach which focuses more on acquiring information about drugs and lays less emphasis on imparting the skills required to put this knowledge into practice. In view of the lack of proper training in pharmacotherapeutics, a well-designed educational intervention in the form of teaching rational prescribing using case simulations is the need of the time.
Case based teaching (CBT) enhances students' ability to synthesize, evaluate, and apply information and concepts learned in lectures and texts. The teachers in turn can assess these abilities during the discussions. Working in groups on case-studies also helps students develop interpersonal skills and the capacity to work in a team.  In our institute, pharmacotherapy is taught to undergraduate students in their second year of medical school through lectures, practicals and tutorials. For the tutorials, students are expected to prepare for specific topics which have been taught earlier in the lectures. The discussion is built up on theme lectures taken earlier. However, important aspects of pharmacotherapy such as how to select a drug, write a prescription, inform and instruct the patient and monitor drug therapy are rarely discussed. The present study was therefore undertaken to assess the impact of tutorials conducted using CBT on learning rational prescribing and to compare it with traditional method of conducting tutorials among second year medical students.
| » Materials and Methods|| |
The institutional ethics committee permission was taken prior to initiation of the study. It was felt that the knowledge of exposure to a new teaching methodology would result in an introduction of bias amongst students. Hence to avoid it, a waiver of written informed consent was obtained from the ethics committee. Four tutorial topics, viz. treatment of constipation, treatment of diabetes mellitus, uses and dangers of steroids in clinical practice and treatment of peptic ulcer were selected for teaching through both, the traditional and CBT approaches. Before starting the tutorials, theme lectures on the above- mentioned topics as well as on concept of P-drug and rational use of medicines were conducted. The students also attended two practical sessions on rational drug prescribing which were carried out as a part of the routine teaching programme of the department. A meeting of all the teachers participating in the study was called to discuss the conduct of the study, including the salient teaching points for the two teaching approaches. All the teachers were actively involved in formulation of cases which were reviewed by the clinicians and were suitably modified as per the comments received. It was decided to discuss case studies with respect to the six step approach of rational use of medicines. 
In all, 179 students were administered a pre-test which included multiple choice questions (MCQ's), short answer questions (SAQ's) and long answer questions (LAQs). The scores obtained in the pre-test served as the baseline data. The students were divided in alphabetical order into 15 groups of 12 students each, and the groups were randomized so that 8 groups received case based teaching (CBT), and 7 groups received traditional teaching (TRD). The eight CBT groups (96 students) were further randomly sub-divided into 2 groups of 48 students each namely CBT 1 and CBT 2. The CBT 1 group was taught 'treatment of diabetes mellitus' and 'treatment of peptic ulcer' using CBT and 'treatment of constipation' and 'uses and dangers of steroids' in the traditional way. On the other hand, the CBT 2 group was taught 'treatment of diabetes mellitus' and 'treatment of peptic ulcer' using the traditional approach and 'treatment of constipation' and 'uses and dangers of steroids', using CBT. The seven TRD groups (83 students) were taught all the four topics in the traditional way and served as the control group.
In the group taught through CBT, the students were initially apprised about the case, following which they discussed the case amongst themselves and specified the diagnosis, defined therapeutic objectives and prepared a P-drug list for the given condition. They were encouraged to select the dose, dosage form and regime for the given condition. They also learnt to write down prescriptions, give relevant information/instructions and advice about monitoring. The teachers facilitated the discussion. In the TRD group, the students were expected to answer questions asked by teachers on the topic under discussion. The important aspects to be covered through the questions were decided during pre-intervention meetings to minimize variability in the content and level of knowledge delivered. Each session was conducted for one and half hour which was the standard time allotted by the department for taking tutorials on a particular day.
One month after the end of the study, a post-test was administered to both, the test as well as control group to evaluate the impact of the teaching methodology. The pattern of the post- test was similar to pre-test with respect to MCQs and SAQs. However instead of framing LAQs in the traditional manner which only tests recall, the LAQs were structured as therapeutic problems. In all, 3 therapeutic problems were asked, of which 2 problems were on diabetes and peptic ulcer. One problem pertained to malaria, which was taught in the theme lectures but was not covered by case simulation for either the CBT or the TRD group. The students were expected to attempt any two of the three case study problems each of which was allotted 6 marks. The marks obtained for the therapeutic problems on diabetes and peptic ulcer were added and the mean marks were considered, whereas for problem on malaria, individual marks were considered. The marks were graded as follows: Grade 0 : 0 to < 1.5 marks, Grade 1:1.5 to < 3 marks, Grade 2: 3 to < 4.5 marks, Grade 3: 4.5 to 6. The answer sheets were coded and randomly distributed to the teachers who assessed them using pre-formulated model answers. For analysis of the study data, Fischer's exact test was performed using GraphPad InStat version 3.06. Level of significance was set at P<0.05.
| » Results|| |
The average marks obtained in the pre-test by the CBT group and the TRD group were 30.77 ± 3.95 (61.54%) and 29.42 ± 4.73 (58.84%), respectively. When the average marks obtained by both groups for a set of MCQs and SAQs in the post-test were compared, there was no significant difference between the average marks obtained by the CBT group (32.69 ± 6.75) and TRD group (30.07 ± 6.82). It was observed that 82/96 (85.41%) students from the CBT group attempted both the therapeutic problems on diabetes mellitus and peptic ulcer, whereas only 61/83 (73.49%) students from the TRD group attempted these problems. The mean marks obtained by CBT group (4.23 ± 0.94) for these problems were significantly more (P < 0.001) than the mean marks obtained by the TRD group (3.32 ± 0.92). In addition, more number of students in the CBT group obtained grade 3 (P < 0.001) and significantly fewer students obtained grade 1 (P < 0.01) as compared to the TRD group [Table 1].
|Table 1: Grades obtained by students in the case based teaching and traditional method of teaching groups who attempted therapeutic problems on Diabetes mellitus and Peptic ulcer|
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On further analysis of the CBT group, it was observed that 44/48 (91.67%) students in the CBT 1 group (taught diabetes and peptic ulcer using CBT) attempted both the therapeutic problems pertaining to these topics. On the other hand, only 38/48 students (79.17%) in the CBT 2 group (taught diabetes and peptic ulcer using traditional method) attempted both the questions. The differences in the average marks obtained CBT 1 (8.03 ± 1.83) and CBT 2 (8.88 ± 1.70) groups was statistically significant (P < 0.05). When the individual grades were compared between CBT 1 and CBT 2 groups, it was observed that fewer students had obtained grade 1 in the CBT 2 group as compared to CBT 1, and those scoring higher grades (grade 2 and 3) were comparable between the two groups [Table 2].
|Table 2: Grades obtained by students in the case based teaching groups who attempted therapeutic problems on diabetes and peptic ulcer|
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It was found that the question on malaria was attempted by 76 of 96 students (79.17%) in the CBT group. Of the 83 students from the TRD group, 63 attempted the question on malaria (75.90%). The mean marks of the students in the CBT group (3.68 ± 1.34) were also significantly higher (P < 0.05) than that of the TRD group (3.01 ± 1.40). When the grades were compared, it was found that only 7/76 students from CBT group received 0 grade (9.21%), whereas 15/63 students from the TRD group received 0 grade (23.81%; P< 0.05)). Also the number of students getting ≥ 2 grade was higher in the CBT group (P< 0.05) [Table 3].
|Table 3: Grades obtained by students in the case based teaching and traditional method of teaching groups who attempted therapeutic problem on malaria|
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| » Discussion|| |
The average marks obtained in the pre-test by the CBT group and the TRD group were similar indicating that both the groups were comparable with respect to the baseline knowledge. Further, the comparison of MCQs and SAQs marks in the post-test of these two groups demonstrated that acquisition of knowledge for factual data was similar irrespective of the teaching methods. The CBT group performed better than the TRD group in the therapeutic problem on diabetes and peptic ulcer. This was expected as the CBT group had received more training than the TRD group in the skills of rational prescribing. Further analysis of the CBT group revealed that the CBT 2 group had performed better than CBT 1 group. This difference was marginal and can be attributed to the fact that the CBT 2 students had also been exposed to case based teaching, albeit for different topics. Hence, they were aware of the approach to be followed and as seen from the results they could use it to logically solve other therapeutic problems which were not taught to them using case simulations. The poor performance of CBT 1 group as compared to CBT2 could be because some students from CBT 1 group did not benefit by case based teaching. The learning performance of such students can be improved by repeatedly exposing them to case based discussions.
The performance of the CBT group as a whole was then compared with the TRD group for the question on malaria, (the topic taught only in the theme lectures) to find out whether the students who were taught the concepts of rational pharmacotherapy through CBT, could apply these concepts to solve other therapeutic problems. The results indicate that the higher scores achieved by the CBT group were not due to a difference in the knowledge of the subject, but due to the skill of rational prescribing that had been inculcated in the students in the tutorial class. In other words, though both the groups had a common exposure to the principles of rational pharmacotherapy during the lecture and practicals, use of CBT in tutorials improved the skill of rational prescribing.
A good case discussion can be exciting and involving for learners. In a study conducted by Garg et al., 81% of the students opted for case studies and treatment protocols to be added as a part of regular teaching in pharmacology.  Further, a case discussion is interactive and it leads to synergistic learning, in which the learning outcome of the group is more than the sum of learners' individual contributions.  Studies have also shown that CBT is an effective modality of imparting medical education.  CBT creates a learning environment which is non-threatening and introduces students to clinical skills in a way that builds up their confidence for future patient encounters.  Chan et al., have reported in their study that 60.9% of students who were taught through case-based integrated teaching showed an improvement in their communication and discussion with teachers, and 56.6% of students felt that it improved communication and discussion among the students as well.  It is possible that the higher scores obtained by the students in the CBT group was as a result of the lively discussions on cases which helped them to learn the concepts of rational pharmacotherapy and prescribing skills better than the other group.
Efforts since as early as 1985 have been taken by teachers in Indian medical colleges to train interns in rational prescribing,  and currently, CBT and rational prescribing have been incorporated to some extent in the undergraduate pharmacology curriculum.  Few systematic studies have also been conducted in India to evaluate the effect of CBT in comparison to conventional teaching.  One study has shown that when conventional pharmacology teaching was supplemented with patient oriented problem solving (POPS) method, it improved learning outcomes.  Another study that compared the usefulness of the POPS method of teaching pharmacology to the audiovisual aided lecture methods, concluded that audiovisual aided lectures were comparable with the POPS method.  Nevertheless, no Indian study has evaluated CBT as a teaching method to impart rational prescribing skills, as was done in the present study.
Most studies intending to improve prescribing skills by medical students have been conducted in undergraduate setting due to which it has not been possible to show long term improvement in prescribing outcomes.  Even our study looked at the short term effect on prescribing skills of undergraduate medical students. Another limitation was that the design of our study was quasi-experimental. The students were grouped in alphabetical order in order to avoid any disruption of the standard teaching programme planned by the department. However as stated in the methods, allocation of groups to different teaching interventions was done in a random manner. Discussion amongst students from different groups about the teaching methodologies adopted by different teachers for the same topic is also a possibility. In addition, the teachers were involved in both, in conducting the small group discussion as well as the assessment. Consequently, even though the answer papers were coded and randomly distributed to teachers for correction, the assessors were not independent of the study and the chances of bias creeping in cannot be overlooked.
Despite the methodological strengths of randomised controlled trials (RCTs), randomisation, although useful in some education studies, is not the gold standard for medical education research given the highly complex system of education.  Some limitations of RCTs for studying educational interventions are as follows: randomisation of students to different groups is often not feasible, variables such as teacher and student motivation and individual expectations cannot be controlled, and choosing the appropriate therapeutic outcome for the intervention is a major challenge.  Moreover, in educational research it is often difficult to 'blind' the students to their assigned group. Thus, students can react to the knowledge that they are being studied or assigned to a particular group. Interaction among students also results in contamination effects that further compromise randomisation.  Additionally, students will usually adapt quantity and quality of studying to meet testing requirements, and in doing so, they may compensate for any shortfalls in teaching.  The scarcity of resources in terms of funding as well institutional support for both faculty time and structured evaluative strategies also restricts educators' ability to conduct rigorous studies. Finally, the ethics of randomly assigning learners to receive or not to receive an intervention is an issue that educators continue to debate upon. 
| » Conclusion|| |
The present study demonstrated that use of CBT during tutorials is better than the traditional method, and facilitated learning of rational pharmacotherapy. The study revealed that not only did CBT improve the ability of students to solve problems in a logical manner, but also that the skills of rational prescribing once learnt can be applied to solve new problems. With sufficient practice, these skills can be mastered by students, which will help to promote rational prescribing amongst future practitioners. However, in order to assess whether CBT leads to long term improvement in prescribing outcomes, further studies to evaluate the prescribing skills of junior doctors need to be conducted during internship and residency.
| » Acknowledgments|| |
The authors acknowledge with gratitude the contribution of Dr. Ashwini Karve, Dr. Rajani Rokade and Dr. Amrapali Patil in the collection of data for the study.
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[Table 1], [Table 2], [Table 3]