抄録
多くの薬学部が6年制に移行し，実務実習の重要性が増している．実務実習は，薬剤師の視点で行なわれることが多い．今回，和歌山県立医科大学サテライト診療所と隣接する和歌山県薬剤師会営薬局を利用している患者に同行し，診療現場から薬局に至る過程を体験する実習を実施した．学生は医師の処方意図，処方内容の説明，病状の理解の重要性および実習の有効性について高く評価した．多職種連携についてのアンケートでは実習後4つの領域で改善がみられた．職業アイデンティティのアンケートでは実習後5つの領域で改善がみられた．質的解析では，実習の有用性，処方意図，患者情報，多職種連携，処方指導・監査がカテゴリーとして抽出された．診療所・薬局連携実務実習により，学生は従来の実務実習では経験できなかった異なった視点での体験をすることができ，職業アイデンティティと多職種連携の意識，処方意図と患者説明への理解が向上した．
Abstract
In Japan, almost all clinical pharmacy departments moved to a six-year practical training program in 2006. The student training took place at the pharmacy schools and did not expose students to the medical process from the clinic to the pharmacy. In this study’s clinical training, the students accompanied patients from the Wakayama Medical University satellite clinic to the neighboring prefectural pharmacist association pharmacy to experience the process. The students learned about the doctor’s prescribing intent, the prescription explanation to the patient, more about the patient’s condition, and the effectiveness of interprofessional practice. Following the training program, a questionnaire was given to the students on the multidisciplinary collaboration and training. A qualitative analysis of the questionnaire comments extracted categories in the usefulness of practical training, prescription intention, patient information, interdisciplinary cooperation, and prescription guidance and audit. The clinic to pharmacy training allowed students to take on develop their professional identity within the interprofessional collaboration, understand prescription intentions, and hear doctor explanations of the prescriptions to patients.
Introduction
In Japan, the School Education Act 2006 revision of pharmacy education extended the undergraduate training period from four to six years. The aims were to train pharmacists with high qualifications and to match the advancement of medical technology and the progress of the division of labor. Transitioning to a six-year system increased the importance of practical training and multi-professional collaborative education among medical, nursing, and pharmacist students, including multi-professional collaborative work in the medical field. Besides, university pharmacy departments point out drug doses and contraindicated drugs based on information such as blood chemical examination from doctors and increase opportunities to participate in conferences on specific patients in the university hospital. However, outpatient clinics giving prescriptions to many patients transmit some blood chemical test data to pharmacies, but not sufficient information on pathophysiology and prescription intentions1).
Most practical training is from the pharmacist’s point of view, students barely experience the doctor’s perspective on the medical condition and the numerous factors driving the prescription such as cost and insurance. Therefore, since October 2019, the Wakayama Medical University satellite clinic and the neighboring prefectural pharmacist-operated pharmacy collaborate and carry out practical training where students accompany the patient and experience the processes from medical examination drug reception at the pharmacy. In this training program, students witness the scene where the doctor explains the condition and its changes to the patient, prescribes the medicine, gets it from the pharmacy, and gives it to the patient. They experience dosage choices made to match the prescription and what pharmacists look out for when dispensing a drug. Since the prescription lacks most of this information, it is a good opportunity to experience the patient’s understanding of the prescription and the difference in perception between the clinic and pharmacy.
Furthermore, it will allow the students inferring the doctor’s prescribing intentions, and this will develop the doctor’s ability to judge whether information sharing is necessary. Besides, it allows the students to experience the delay from the medical examination to the drug reception from the patient’s point of view. It may provide an unprecedented practical training experience, and help doctors understand how prescriptions and dispensing should be done in payment and insurance medical care systems.
Therefore, this study aimed to clarify the educational effects of this training based on a questionnaire survey regarding the understanding of occupational identity and multi-professional cooperation, and a questionnaire and free description evaluating the training itself.
Methods
We conducted a one-day training at a satellite clinic of the Wakayama Medical University, located in a commercial building of the Wakayama city center, targeting students following practical training at the Wakayama Medical University hospital. The training period was from October 2019 to November 2020. Total of thirteen 5th grade students of other universities (one male and twelve females) participated 2nd to 4th term of pharmacy practical training in our hospital. During the training period, two same doctors (one cardiologist and one diabetes specialist) supervised the students. Before participating, students answered a questionnaire about their occupational identity2) and IEPS (Interdisciplinary Education Perception Scale) about thirteen students who consented to use these questionnaires for research3). We enrolled patients of the cardiovascular/geriatric department and diabetes department who used the neighboring prefectural pharmacist-operated pharmacy and obtained their written consent to participate in the practical training.
Students were present during the medical interview and clinical examination, filled out a worksheet about the prescription content of each patient regarding changes in the medical condition, and accompanied the patient from the clinic to the pharmacy on the same floor. Students listened to the explanations about the drugs with patients, filled in the worksheets, and went back to the clinic. They repeated this process all day long. At the end of the day, the attending physician, supervising pharmacist, and pharmacist at the dispensing pharmacy reviewed all experienced cases based on the worksheet. They identified treatments and problems and discussed new findings. Finally, we conducted a questionnaire on this training program. Besides, we asked them to freely describe what they noticed about the training program and used their responses for qualitative analysis. Participants answered the questionnaire about occupational identity and IEPS before and after the training to analyze changes of understanding of the occupational identity and the interprofessional education.
Statistical analysis
In the questionnaire on occupational identity and IEPS, we calculated the average of 6-point scores for each item and evaluated the values before and after the practice using Wilcoxon signed rank test. A significant difference was defined as p < 0.05.
We performed open-ended, qualitative studies with MAXQDA and extracted categories and subcategories.
Results
The questionnaire on this training program showed a score over 5.5 points in items 2 (doctor’s prescription content), 3 (Explanation of prescription contents by the doctor), 10 (Importance of collaboration between medicine and medicine), and 11 (training benefits) (Table 1).
Table 1
Questionnaire for training program
|
Did you deepen your understanding of the following points? |
Average of Scores (6-points rating) mean ± SD |
| 1 |
Clinic/Pharmacy cooperation |
5.00 ± 1.00 |
| 2 |
Doctor’s prescription content |
5.62 ± 0.65 |
| 3 |
Explanation of prescription contents by doctor |
5.77 ± 0.44 |
| 4 |
Legal restrictions on drug prescriptions |
4.54 ± 1.05 |
| 5 |
Description of the drug at the pharmacy |
5.15 ± 0.69 |
| 6 |
Differences in explanations between clinics and pharmacies |
4.92 ± 0.95 |
| 7 |
Patient’s understanding of prescription |
4.92 ± 0.64 |
| 8 |
Understanding differences between patients |
4.92 ± 0.64 |
| 9 |
Differences in understanding by disease |
4.69 ± 0.95 |
| 10 |
Importance of collaboration between medicine and medicine |
5.62 ± 0.65 |
| 11 |
Training benefits |
5.85 ± 0.38 |
Values are expressed as the mean ± SD.
In the questionnaire on IEPS, practical training significantly increased the scores of items 4 (Pharmacists respect the work of my profession), 8 (Pharmacists should rely on other professionals to do their job), 17 (Pharmacists can work together smoothly within the profession), and 18 (Pharmacists often seek the advice of people in the same profession as me) (Table 2). The survey on occupational identity showed that practical training significantly increased the score of items 2 (I can’t think of anything other than a pharmacist), 4 (I think pharmacist is my way of life), 11 (I’m sure I want to work as a pharmacist), 12 (I think I can be my own pharmacist), and 21 (I am needed by patients as a pharmacist) (Table 3).
Table 2
Interdisciplinary education perception scale
|
Average of Scores (6-points rating) |
p value |
| mean ± SD |
| before |
after |
| 1 |
Pharmacists are well educated. |
4.85 ± 0.69 |
4.85 ± 0.38 |
1 |
| 2 |
Pharmacists can work closely with other professionals. |
4.31 ± 0.75 |
4.54 ± 0.52 |
0.317 |
| 3 |
Pharmacists can act autonomously. |
4.23 ± 0.83 |
4.54 ± 0.66 |
0.102 |
| 4 |
Pharmacists respect the work of my profession. |
4.38 ± 0.65 |
4.92 ± 0.64 |
0.020* |
| 5 |
Pharmacists are very positive about their goals and goals. |
4.69 ± 0.95 |
4.85 ± 0.80 |
0.527 |
| 6 |
Pharmacists respect the work of my profession. |
5.38 ± 0.77 |
5.69 ± 0.63 |
0.157 |
| 7 |
Pharmacists are confident about their contribution to medical care and their achievements. |
4.15 ± 0.69 |
4.38 ± 0.87 |
0.257 |
| 8 |
Pharmacists should rely on other professionals to do their job. |
3.77 ± 1.17 |
4.15 ± 1.28 |
0.025* |
| 9 |
Pharmacists appreciate people in the same profession as me. |
4.92 ± 0.86 |
4.92 ± 0.76 |
1 |
| 10 |
Pharmacists respect each other’s judgments as specialists. |
5.00 ± 0.91 |
5.38 ± 0.65 |
0.096 |
| 11 |
Pharmacists have a higher status than other professions. |
2.62 ± 1.04 |
3.08 ± 1.12 |
0.107 |
| 12 |
Pharmacists strive to understand the abilities and contributions of other professionals. |
5.08 ± 0.76 |
5.00 ± 0.91 |
0.705 |
| 13 |
Pharmacists are very capable. |
4.23 ± 0.60 |
4.54 ± 0.78 |
0.157 |
| 14 |
Pharmacists actively seek to share information and resources with other professionals. |
4.62 ± 0.96 |
5.00 ± 0.71 |
0.129 |
| 15 |
Pharmacists have good relationships with other professions. |
4.62 ± 0.96 |
5.00 ± 0.58 |
0.129 |
| 16 |
Pharmacists value people in other professions. |
5.08 ± 0.86 |
5.46 ± 0.52 |
0.129 |
| 17 |
Pharmacists can work together smoothly within the profession. |
4.77 ± 0.73 |
5.23 ± 0.60 |
0.014* |
| 18 |
Pharmacists often seek the advice of people in the same profession as me. |
4.62 ± 1.04 |
5.15 ± 1.07 |
0.035* |
Values are expressed as the mean ± SD. The values before and after clinical training were evaluated using Wilcoxon signed rank test. A significant difference shown as * was defined as p < 0.05.
Table 3
The questionnaire about occupational identity
|
Average of Scores (6-points rating) |
p value |
| before |
after |
| 1 |
I think it was good that I chose a pharmacist. |
5.08 ± 0.49 |
5.08 ± 0.49 |
1 |
| 2 |
I can’t think of anything other than a pharmacist. |
3.15 ± 1.52 |
3.62 ± 1.66 |
0.034* |
| 3 |
I’m going to be a pharmacist for life. |
4.23 ± 1.09 |
4.31 ± 1.11 |
0.665 |
| 4 |
I think pharmacist is my way of life. |
3.69 ± 1.03 |
4.00 ± 0.91 |
0.046* |
| 5 |
I can proudly tell others that I am a pharmacist student. |
4.46 ± 0.97 |
4.54 ± 0.88 |
0.705 |
| 6 |
I am proud to be a pharmacist. |
4.54 ± 0.78 |
4.69 ± 0.75 |
0.480 |
| 7 |
I can grow as a human through the work of a pharmacist. |
4.77 ± 0.73 |
4.62 ± 0.65 |
0.414 |
| 8 |
As a pharmacist, I think I will be able to live my own way in the real world. |
3.92 ± 0.64 |
4.08 ± 0.95 |
0.480 |
| 9 |
I think pharmacists are suitable for me. |
3.85 ± 0.80 |
4.00 ± 0.91 |
0.317 |
| 10 |
I feel that I can continue to grow as a pharmacist. |
4.46 ± 0.78 |
4.31 ± 0.75 |
0.317 |
| 11 |
I’m sure I want to work as a pharmacist. |
3.08 ± 0.76 |
3.77 ± 1.09 |
0.034* |
| 12 |
I think I can be my own pharmacist. |
3.31 ± 0.63 |
3.77 ± 0.83 |
0.014* |
| 13 |
I know what kind of pharmacist I want to be. |
3.69 ± 0.95 |
3.77 ± 0.83 |
0.739 |
| 14 |
I think I will be able to create my own pharmacist in the future. |
3.38 ± 0.65 |
3.69 ± 0.85 |
0.206 |
| 15 |
I have my own thoughts on how a pharmacist should be. |
3.46 ± 0.97 |
3.62 ± 1.04 |
0.414 |
| 16 |
As a pharmacist, I want to be able to demonstrate my uniqueness in relationships with doctors. |
4.08 ± 0.95 |
4.23 ± 0.93 |
0.627 |
| 17 |
As a pharmacist, I always feel I can work. |
3.31 ± 0.95 |
3.69 ± 0.95 |
0.190 |
| 18 |
As a pharmacist, I will be able to realize my full potential in the real world. |
3.54 ± 0.78 |
3.77 ± 0.83 |
0.257 |
| 19 |
As a pharmacist, I consider myself an integral part of the medical world. |
4.00 ± 1.22 |
4.08 ± 0.95 |
0.748 |
| 20 |
As a pharmacist, I think that it has been and will be needed by many people. |
3.62 ± 1.04 |
4.00 ± 1.08 |
0.096 |
| 21 |
I think that as a pharmacist the patient needs. |
3.62 ± 1.04 |
4.08 ± 0.95 |
0.034* |
| 22 |
As a pharmacist, as a member of the medical team, I think there will be more and more needs. |
3.92 ± 0.76 |
4.31 ± 0.95 |
0.129 |
| 23 |
As a pharmacist, I have a unique academic background. |
3.62 ± 1.19 |
3.54 ± 1.39 |
0.803 |
| 24 |
As a pharmacist, I think I can make a unique contribution as a member of the medical team. |
3.77 ± 0.83 |
4.08 ± 1.12 |
0.271 |
| 25 |
I think I can support patients as a pharmacist. |
4.23 ± 0.83 |
4.23 ± 1.01 |
1 |
| 26 |
In the process of studying pharmacy, I feel that I have emerged as a pharmacist. |
3.38 ± 0.65 |
3.77 ± 0.93 |
0.096 |
| 27 |
As a pharmacist, I want to contribute to patients. |
5.08 ± 0.86 |
5.15 ± 0.90 |
0.705 |
| 28 |
As a pharmacist, I want to meet the wishes of patients. |
5.23 ± 0.73 |
5.23 ± 0.83 |
1 |
| 29 |
As a pharmacist, I want to contribute to society. |
5.23 ± 0.60 |
5.00 ± 0.91 |
0.317 |
| 30 |
As a pharmacist, I want to contribute to the development of medical care. |
5.00 ± 0.71 |
4.69 ± 0.95 |
0.102 |
| 31 |
As a pharmacist, I would like to contribute to the development of the world of pharmacy. |
4.77 ± 0.93 |
4.62 ± 1.04 |
0.157 |
| 32 |
As a pharmacist, I want to achieve unique results that no one else can. |
3.69 ± 1.03 |
3.85 ± 1.14 |
0.577 |
Values are expressed as the mean ± SD. The values before and after clinical training were evaluated using Wilcoxon signed rank test. A significant difference shown as * was defined as p < 0.05.
In the qualitative analysis of the free description, we extracted five categories: (1) usefulness of practical training, (2) prescription intention, (3) patient information, (4) multidisciplinary cooperation, and (5) prescription guidance/prescription audit. The subcategories of each category were as follows. Category (1): understanding prescribing intent; observation of outpatient clinic; experience from the perspective of a doctor and pharmacist; cooperation between prescription intention and medication guidance; understanding the medical fee system. Category (2): prescription according to the patient’s condition and background; consensus building with patients about prescription; dispensing with awareness of prescription intention. Category (3): the importance of sharing disease names, pathological conditions, and blood test values between doctors and pharmacists; differences in what patients say between medicines between doctors and pharmacists. Category (4): importance of understanding the roles of other occupations; coordination of patient information between occupations; importance of dispensing based on prescribing intent; differences in information from patients between occupations; seamless cooperation from the examination room to the pharmacy. Category (5): importance of medication guidance based on patient information from doctors; patient understanding of prescription; prescription audit based on information about the patient’s condition; importance of medication guidance based on clinical practice guidelines; building a clear image of medication instruction (Table 4).
Table 4
Categories and subcategories
|
Categories |
Subcategories |
| 1 |
Usefulness of practical training |
Understanding prescribing intent |
| Observation of outpatient clinic |
| Experience from the perspective of a doctor and pharmacist |
| Cooperation between prescription intention and medication guidance |
| Understanding of medical fee system |
| 2 |
Prescription intention |
Prescription according to the patient’s condition and background |
| Consensus building with patients about prescription |
| Dispensing with awareness of prescription intention |
| 3 |
Patient information |
The importance of sharing disease names, pathological conditions, and blood test values between doctors and pharmacists |
| Differences in what patients say between medicines between doctors and pharmacists |
| 4 |
Multidisciplinary cooperation |
Importance of understanding the roles of other occupations |
| Coordination of patient information between occupations |
| Importance of dispensing based on prescribing intent |
| Differences in information from patients between occupations |
| Seamless cooperation from the examination room to the pharmacy |
| 5 |
Prescription guidance/prescription audit |
Importance of medication guidance based on patient information from doctors |
| Patient understanding of prescription |
| Prescription audit based on information about the patient’s condition |
| Importance of medication guidance based on clinical practice guidelines |
| Building a clear image of medication instruction |
Qualitative analysis performed with MAXQDA and extracted categories and subcategories.
Examples of the intention of prescribing in (1) include “I have never had a chance to hear from a doctor about my prescribing intentions”, “I had never seen it in a series of steps from the doctor’s examination to the pharmacy, so it was a very valuable experience”, “Looking at the work of doctors and pharmacists from a different perspective. I was very impressed and was able to find points to which I would like to pay more attention”, and “Looking at the site of the examination, I could imagine why the patient was taking this medicine”. Samples regarding the prescription intention in (2) include “I felt that I was prescribing the drug considering the patient’s progress”, “today’s symptoms and blood test values”, “When deciding on a prescription at the clinic, I did not find that patients talked too much about it”. Those in (3) regarding patient information include “as pharmacists, receiving information from doctors, would allow us to provide better feedback and prevent unlikely contraindicated drug prescription”, and “I thought I needed more information about the underlying illness to do a prescription audit”. Samples of (4) regarding multidisciplinary cooperation include “Doctors and pharmacists rarely talk directly to each other outside hospitals, but I hope that such opportunities will increase”, “Sharing information such as blood pressure and blood test values at the time of medication guidance reduces the burden, and it would make even the first medication guidance easier”, and “I learned that patients give different stories and explanations at the clinic and the pharmacy”. In (5) regarding prescription guidance/prescription audit, “Even if I knew the disease, I could not give proper medication guidance because I did not know the patient’s background. I learned that patients have different levels of understanding of prescriptions and diseases”.
Discussion and Conclusions
Since the transition to a six-year system, pharmacy training at the Faculty of Pharmacy in Japan is a combination of hospital training and pharmacy training. In the United States, students in all clinical settings spend 69% of their time on activities such as compounding, dispensing, and distributing drug products in their advanced pharmacy practice experiences1).
Higher education health programs can achieve professional identity formation through hands-on experience during this transition and through student involvement and interaction with qualified professionals4). Besides, pharmacists with a short career can be less motivated to work because of the pressure to perform their daily work and the lack of time to provide new pharmaceutical services. If pharmacists get the opportunity to participate in clinical practice, job satisfaction improves, and active participation in clinical practice is desired even in practical training5).
In the field of practical training in Japan, it is rare to experience the overall medical flow from the doctor examination to the medicine delivery, and the training focuses on pharmacist work. Furthermore, although multi-professional collaboration meetings occur, professionals have few opportunities to experience the work of other occupations. Doctors are particularly unlikely to accompany patients to the prescription site.
On the path to becoming pharmacists, students often encounter difficulties. They need to reconcile their professional aspirations and theoretical knowledge with the realities of practice. Their inability to enact the role they have envisaged or unmet expectations can hamper a smooth transition. These challenges relate to professional identity. A key challenge for pharmacy educators is figuring out how best to support the professional identity formation of pharmacy students6). The development of professional identity involves a focus on who the student is becoming, as well as what they know or can do, and requires authentic learning experiences such as practice exposure and interaction with pharmacist role models7).
Fujii showed the improvement of occupational identities by analyzing the developmental aspects of students’ professional identities in multidisciplinary classes of the faculties of nursing, physiotherapy, occupational therapy, and radio science at medical colleges2).
Ino submitted a questionnaire to pharmacy students in a joint class of three medical universities and increased their score in several statements such as “Individuals in other occupations highly value my occupation”. They also found that interprofessional education improved self-assessment, social skills, learning preparation/orientation, and awareness of interdisciplinary medical team education among pharmacy students8).
Our program allowed clinics and pharmacies to work together so that students experienced a range of medical practices from the perspective of doctors, pharmacists, and patients. This study aimed to clarify whether this training would improve students’ professional identity and raise their awareness of collaboration with multiple occupations.
The increased growth of interdisciplinary education programs in the allied health professions has presented the need for alternate forms of assessment that go beyond basic performance indicators. IEPS would gauge professionally oriented perceptions and related affective domains for participants in such programs3).
In the post-training questionnaire, all students gave high evaluation scores to this medical cooperation training. In particular, they recognized the doctor’s intention to prescribe, explanation to the patient, and the importance of cooperation between the doctor and the pharmacist. This study also showed that clinic-pharmacy collaboration raises the evaluation of the four areas of IEPS and raises interdisciplinary collaboration awareness.
Five items emerged from the qualitative analysis of the free description of the questionnaire for the entire training: (1) usefulness of the training, (2) prescription intention, (3) patient information, (4) interdisciplinary cooperation, and (5) prescription guidance/prescription audit. These results indicate that the students recognize the viewpoints of doctors and patients, which conventional training could not achieve. In a study where pharmacy and physical therapy students collaborated to analyze the fall risk in elderly persons, a descriptive qualitative analysis extracted values and ethics, communication, team and teamwork, and roles and responsibilities, and revealed the importance for students to consistently evaluate other professions, understand each other’s roles, deepen communication between professionals, and work within the medical team9).
Besides, in an interprofessional education providing home visit care with doctors, the interprofessional education medication program included the identification of students’ self-awareness and medication-related issues in skills and abilities related to team-based care between specialists. Focused home visits improved awareness, demonstrating the usefulness of clinical experience in patient care among professionals10). Calattelli showed that collaboration among three medical professionals (dentist, kinesiologist, and pharmacist whose coursework included four on-site visits at two regional clinics for hands-on training between specialists and four site visits) improved the core domain (communication between experts, values and ethics, roles and responsibilities, teams and teamwork)11).
Various multidisciplinary education including doctors improved student consciousness even in qualitative research12). Our initiative improved the students’ awareness of prescribing intentions, patient explanations, sharing of patient information by doctors, and of contents that were rarely taken up in the past.
In Japan, clinical practice lacked information exchange between doctors and pharmacists, but it is becoming more important in situations including primary care13). Our educational collaboration program between doctors and pharmacists was effective in helping students recognize some important points in clinical training.
In conclusion, this collaborative training between clinic and pharmacy allowed students to experience the actual situation of pharmaceutical cooperation that cannot be learned through lectures. Besides, this collaborative training has helped improve students’ identity, raise their awareness of multidisciplinary collaboration, and develop an important perspective in prescribing intent, explaining prescriptions to patients, and prescribing audits.
Limitation
This study was conducted while students from other universities were practicing at our facility, and could not be compared with other educational indicators such as descriptive test results and research evaluations.
Conflicts of interest
There are no conflicts of interest to disclose in relation to the contents of this paper.
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