Japanese Journal of Pharmaceutical Education
Online ISSN : 2433-4774
Print ISSN : 2432-4124
ISSN-L : 2433-4774
Practical Article
Evidence-based medical education using team-based learning for mixed-grade pharmacy students
Mai AoeMasahiro UedaSeiji EsakiTadashi Shimizu
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Supplementary material

2022 Volume 6 Article ID: 2021-040

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抄録

本研究では,臨床事前実習を終えた4年生と臨床実習を終えた5年生を主な対象としたTBL法を用いたEBMワークショップの効果を測定した.学習成果は,ワークショップ開催時および2ヶ月後に実施した知識習得テストと,ワークショップ後のアンケートで評価した.参加者の文献評価能力は,ワークショップの2ヶ月後にも変化がなかった.臨床実習後の5年生は,臨床実習前の4年生に比べて,ワークショップ開催時および2ヶ月後のいずれにおいてもテストの平均点が高かった.アンケートの結果,5年生は4年生に比べてグループワークへの参加やEBMの必要性の認識を高く評価していた.この結果は,EBMに関するスキルの向上と,臨床実習中のEBMの必要性に対する意識の向上によるものと考えられる.臨床実習後にEBM講習会を実施することで,より強固なEBMスキルを身につけることができ,EBMの必要性に対する意識もさらに向上すると考えられた.

Abstract

In this study, an evidence-based medicine (EBM) workshop using the team-based learning (TBL) was conducted to verify the effectiveness of joint learning for fourth-year students who had completed their pre-clinical training and fifth-year students who had completed their clinical training. The learning outcomes were assessed with a knowledge acquisition test, administered at the time of the workshop and two months later, and a post-workshop questionnaire. The participants’ literature-based evaluation skills remained unchanged two months after the workshop. However, the fifth-year students had higher mean test scores than the fourth-year students, both at the time of the workshop and two months later. In addition, the questionnaire results revealed that fifth-year participants rated teamwork and the need for EBM higher than fourth-year participants, which may be due to increased awareness of the need for EBM during clinical practice. The workshop was effective in improving skills related to EBM and enhancing student awareness of the need for EBM.

Introduction

Evidence-based medicine (EBM) is utilized by healthcare professionals, including pharmacists, to evaluate and use medical information to make optimal patient care decisions in healthcare settings1). EBM integrates the best available evidence with the clinical expertise of individual healthcare providers to make clinical decisions regarding patient care, considering the values and circumstances of individual patients2). In the US Pharm D program, it is required to provide optimal medical care to individual patients by utilizing highly reliable medical information3). Therefore, the education program aims to teach the ability to practice EBM based on the ability to evaluate literatures4,5).

In Japan, the Model Core Curriculum for Pharmaceutical Education (2015 edition) listed the search and evaluation of medical literature and practical application of EBM as educational goals6). However, approximately 90% of pharmacy students in Japan feel that there is a lack of EBM practice and educational opportunities7). Therefore, education on making reliable, evidence-based decisions on drug treatment policies for patients remains insufficient.

Recently, there have been reports of EBM education that incorporates team-based learning in pharmacy education8,9). TBL is a well-established educational strategy that enables students apply conceptual knowledge through pre-class preparation, individual and team activities, and immediate feedback10). In Japan, the learning effects of the TBL method on literature evaluation for third- and fourth-year students prior to clinical practice have already been reported11,12). However, few reports have evaluated the effects of TBL-based EBM education for fourth-year students who have completed pre-clinical training and fifth-year students who have completed clinical training.

Additionally, it was reported that learning among residents in other fields is a conducive environment for team activities and collaboration13). Regarding the study of cross-grade joint learning in higher education institutions, cooperative learning effects in face-to-face environments and learning effects in medical education have been reported14). These reports suggest a mutual learning effect of joint learning between the upper and lower grades through cross-grade joint learning.

In this study, we conducted an EBM workshop using the TBL method for fourth-year students who had completed pre-clinical training and fifth-year students who had completed clinical training to verify the effects of joint learning for the students.

Methods

1.  Subjects

The workshop was held as a part of the advanced learning program mainly for fourth-year students who have completed their specialized courses except for clinical practice, and fifth-year students who have completed clinical practice. The recruitment was announced on the bulletin board and learning management system (LMS) (Moodle®). Moreover, students from the first to the third year were allowed to participate. Of the 52 students who attended the course, 51 agreed to participate in the study (two from the first year, three from the second year, three from the third year, 26 from the fourth year, and 17 from the fifth year) in the study. 51 took the iRAT administered during the workshop and responded to a survey questionnaire after the workshop. 24 of the study participants took the achievement test two months later (Supplementary Fig. S1).

2.  Workshop outline

The outline of the workshop is presented in Table 1. The workshop was held at the Faculty of Pharmacy, Osaka Ohtani University, in February 2020. The case scenario is shown in Supplementary Fig. S2. At the beginning of the workshop, participants were given a 30-minute lecture on the EBM concept. Subsequently, participants individually formulated the clinical questions pertaining to the case following the patient, intervention, comparison, and outcome (PICO) elements for 10 minutes, which were then shared with the team for 10 minutes. The TBL process followed existing methods, which included individual readiness assurance testing (30 min), team readiness assurance testing (45 min), and an instructor clarification review (30 min).

Table 1 Workshop schedule
Contents Learning Method Time (min)
Individual activity: Critical appraisal of RCT literature Self-learning
1. Introduction to EBM Lecture 30
2. Formulation of clinical questions (construction of PICO) Individual activity 10
Team activity 10
Presentation & feedback 20
3. Critical appraisal of RCT literature Individual test (iRAT) 30
Team test (tRAT) 45
Feedback 30
4. Decision-making regarding applying evidence to hypothetical cases Lecture 15
Individual activity 10
Team activity 10
Presentation & feedback 40

Notes: RCT = randomized controlled trial; EBM = evidence-based medicine; PICO = patient, intervention, comparison, and outcome; iRAT = individual readiness assurance test; tRAT = team readiness assurance test.

1)  Pre-assignment

We presented our assigned literatures before the workshop, along with a collection of literature evaluation points. The names of the drugs studied in this literature are drugs for hypertension (perindopril, trichlorothiazide, carvedilol, and amlodipine)15).

2)  Individual readiness assurance test (iRAT)

The iRAT data are presented in Supplementary Fig. S3. They consisted of 10 questions on a critical review of clinical research literatures (Q1–10) and two questions on basic pharmacological knowledge (Q11, 12).

3)  Team readiness assurance test (tRAT)

After the iRAT, the participants worked in mixed-grade teams of four or five participants to discuss the results. Each team was given 45 minutes to reach a consensus on the same questions as in the iRAT. The participants freely discussed each question based on their prior knowledge but were not allowed to search the Internet.

4)  Explanation by the instructor

After the team discussions, the participants submitted their answers. Following this, the instructor provided a 30-minute explanation of the test answers.

5)  Application task: Decision-making

The participants received a 15-minute lecture on decision support for patients regarding drug treatment plans. The lecture explicitly requested the participants to consider not only the evaluated literature information but also the chemical structure, pharmacology, and pharmacokinetics of the drug to determine the appropriate policy for each participant. Subsequently, the applicability of the results of the evaluated literatures to PICO, which was established at the beginning of the workshop, was discussed individually and then shared with the team. Note that the applied task also had the same 4–5 persons mixed grade teams as the tRAT.

3.  Evaluation

1)  Individual achievement test two months after the workshop

The achievement test (post-test) was changed to a 30-minute online examination on the LMS (Moodle®) due to the spread of COVID-19 infection. The literatures to be evaluated differed from those of iRAT, and the questions were the same as those of Q1–10 of iRAT16,17). The analysis targeted the participants who took both the iRAT and the achievement test. Test scores were compared overall and by grade level during the workshop and two months later. A statistical analysis was performed using the Wilcoxon signed-rank test. Comparisons before and after were not made for grades with fewer than four participants, because nonparametric tests showed no significant differences18). Fisher’s exact test was used to evaluate pre-and post-test changes in the scores for each question. A significance level of less than five percent was adopted.

2)  Survey questionnaire

The survey questionnaire was developed by the instructor and consisted of 27 questions related to the participants’ backgrounds and the EBM topics presented in the TBL workshop. The participants completed the questionnaire at the end of the workshop. The analysis of the questionnaire was based on a simple aggregation of the whole data and a comparison of the response trends of fourth- and fifth-graders. Fisher’s exact probability test was also used for comparison in the questionnaire.

All analyses were conducted using JMP Pro 15.

4.  Ethical considerations

This study was approved by the Ethical Review Committee of Hyogo University of Health Sciences (approval no.: 16045-3). Although the questionnaire was signed by the respondents, the participants were assured that no individual would be identified when the questionnaire was made public. Informed written consent was obtained from all participants.

Results

1.  Literature evaluation skills examination

24 participants (two from the first year, two from the third year, 12 from the fourth year, and eight from the fifth year) responded to both the pre- and post-tests, with a response rate of 47%. The mean iRAT and post-test scores were 5.33 ± 2.27 and 5.75 ± 1.70, respectively. There were no statistically significant differences between the pre- and post-test scores (p = 0.582, Table 2). Furthermore, the results indicated that first to third-year participants (n = 4, pre: 5.00 ± 2.58, post: 6.25 ± 1.50), fourth-year participants (n = 12, pre: 4.83 ± 2.40, post: 5.08 ± 1.62, p = 0.356) and fifth-year participants (n = 8, pre: 7.00 ± 1.41, post: 6.50 ± 1.69, p = 0.953) had similar post-test scores (Table 2).

Table 2 Results of pharmacy students’ literature evaluation skills examination before and after the two-month workshop
Characteristic N Score (Mean ± SD) p-Value*
Total 24 Pre 5.33 ± 2.27 0.582
Post 5.64 ± 1.75
1–3th degree 4 Pre 5.00 ± 2.58
Post 6.25 ± 1.5
4th degree 12 Pre 4.83 ± 2.40 0.356
Post 5.08 ± 1.62
5th degree 8 Pre 7.00 ± 1.41 0.953
Post 6.50 ± 1.69

* Wilcoxon signed-rank test

2.  Results of the post-workshop questionnaire

The results of the post-workshop questionnaire are presented in Table 3. The items in the questionnaire that received a high rating with a mean of four or higher were peer education for other participants during tRAT (Q6, mean = 4.14 ± 0.75), the importance of basic pharmacology in clinical practice (Q14, mean = 4.22 ± 0.67), and the need for pharmacists to have skills in reading clinical research literatures (Q18, mean = 4.24 ± 0.65). The iRAT questions were considered difficult by most respondents (Q1, mean = 1.69 ± 0.71).

Table 3 Post-workshop attitudinal survey
No Item Scorea
1 2 3 4 5 Mean (SD)
Q1 Did you find the individual test (iRAT) difficult? (1 = very difficult, 5 = very easy) 23 21 7 0 0 1.69 (0.71)
Q2 Did you speak up positively in the team test (tRAT)? 2 11 22 11 6 3.12 (0.99)
Q3 Did you explain questions that other students did not understand in the team test (tRAT)? 10 12 15 11 3 2.71 (1.19)
Q4 Did you receive explanations for questions that you did not understand in the team test (tRAT)? 1 4 13 17 14 3.84 (1.03)
Q5 Did one person’s opinion often guide your answers in the team test (tRAT)? 13 24 11 2 1 2.10 (0.90)
Q6 Did you often reach an answer by consensus among team members in the team test (tRAT)? 0 1 8 25 17 4.14 (0.75)
Q7 Did you actively participate in the discussion of PICO formulation of clinical questions about the case study patients? 1 2 22 20 6 3.55 (0.83)
Q8 Did you actively participate in the discussion of the application of evidence to the case study patients? 1 3 23 17 7 3.51 (0.88)
Q9 Did you find group work enjoyable in this workshop? 0 3 15 17 16 3.90 (0.92)
Q10 Did you tend to be (or were you often) a listener in group work in this workshop? 2 5 20 20 4 3.37 (0.92)
Q11 Did you speak up actively in the group work of this workshop? 1 6 30 11 3 3.18 (0.79)
Q12 Do you like to teach others how to study? 5 15 18 10 4 2.86 (1.10)
Q13 Do you think that studying should be done alone? 12 16 15 7 1 2.39 (1.06)
Q14 Do you think that using knowledge of basic science for learning is important for clinical practice? 0 0 7 26 18 4.22 (0.67)
Q15 Do you think you can put knowledge of basic science into clinical settings? 3 11 19 14 4 3.10 (1.02)
Q16 Are you able to formulate PICO to solve clinical problems? 1 7 29 10 4 3.18 (0.84)
Q17 Do you think that textbooks, approved drugs, and guidelines are sufficient to solve clinical problems? 20 28 2 1 0 1.69 (0.65)
Q18 Do you think that it is necessary for pharmacists to read clinically relevant medical literature? 0 0 6 27 18 4.24 (0.65)
Q19 Are you interested in reading clinically relevant medical literature? 0 4 19 21 7 3.61 (0.83)
Q20 Do you want to practice EBM to solve clinical problems? 0 0 16 26 9 3.86 (0.69)
Q21 Do you want to use clinically relevant medical literature after becoming a pharmacist? 1 7 26 15 2 3.20 (0.80)
Q22 Do you want to practice EBM to solve clinical problems? 0 1 13 26 11 3.92 (0.74)
Q23 Do you think you can practice EBM to solve clinical problems? 0 0 6 32 13 3.12 (0.64)
Q24 Do you have any difficulties with English? 1 7 8 13 22 3.94 (1.16)
Q25 Would you like to learn more about EBM? 0 2 14 26 9 3.82 (0.77)
Q26 Were you satisfied with this workshop? 0 3 8 23 17 4.06 (0.86)
Q27 Do you plan to work as a pharmacist at a medical facility in the future rather than in research and development or as a medical representative? (1 = yes, 2 = no) 47 3

a Answers were graded on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree).

Notes: EBM = evidence-based medicine; PICO = patient, intervention, comparison, and outcome; iRAT = individual readiness assurance test; tRAT = team readiness assurance test.

The results of examining the difference in attitudes between fourth and fifth-year participants in the post-lecture questionnaire showed statistically significant differences in the nine items shown in Table 4: proactiveness in tRAT and team discussion (Q2, 3, 8, 10), enjoyment of teaching others (Q12), possibility of using basic pharmaceutical knowledge in clinical practice (Q15), the need for pharmacists to have skills in reading clinical research literatures (Q18), willingness to practice EBM (Q22), and satisfaction with the workshop (Q26).

Table 4 Comparison of post-workshop attitudinal survey by grade level for items with statistically significant differences
No Grade N Scorea p-Valueb
1 2 3 4 5 Mean (SD)
Q2 4th 26 0 6 14 6 0 3.00 (0.69) 0.037
5th 17 0 4 4 5 4 3.53 (1.12)
Q3 4th 26 6 7 10 3 0 2.38 (0.98) 0.012
5th 17 1 3 3 8 2 3.41 (1.12)
Q8 4th 26 1 1 16 8 0 3.19 (0.69) 0.011
5th 17 0 1 5 7 4 3.82 (0.88)
Q10 4th 26 2 3 14 7 0 3.00 (0.85) 0.006
5th 17 0 1 3 9 4 3.94 (0.83)
Q12 4th 26 5 9 9 3 0 2.38 (0.94) 0.022
5th 17 0 3 5 7 2 3.47 (0.94)
Q15 4th 26 2 7 13 4 0 2.73 (0.83) 0.035
5th 17 1 2 4 8 2 3.47 (1.67)
Q18 4th 26 0 0 3 18 5 4.08 (0.56) 0.023
5th 17 0 0 3 5 9 4.35 (0.79)
Q22 4th 26 0 1 10 13 2 3.62 (0.70) 0.009
5th 17 0 0 1 9 7 4.35 (0.61)
Q26 4th 26 0 1 4 16 5 3.96 (0.72) 0.004
5th 17 0 2 3 2 10 4.18 (1.13)

a Answers were graded on a five-point Likert scale (1 = strongly disagree, 5 = strongly agree).

b Fisher’s exact test

Discussion

In this pilot study, EBM education through TBL was measured for fourth-year students before clinical practice and fifth-year students after the completion of clinical practice. The results showed that the participants maintained the literature evaluation skills they had acquired in their prior learning for the TBL-type workshop, even after two months. In addition, fifth-year student participants maintained higher abilities than those in their fourth year. A study on fourth-year pharmacy participants revealed that their scores improved on a post-test one week after the class11). Furthermore, a study on measuring the effectiveness of the TBL method for 12 Japanese pharmacists reported that they retained literature evaluation skills one month after the course11). It was suggested that the pharmacy student participants would be able to maintain the skills acquired in the prior study for several months.

Fifth-year participants indicated a higher awareness of proactivity in team discussions, need for pharmacists to have skills in reading clinical research literatures, and willingness to practice EBM than fourth-year participants. This could be attributed to the improvement of skills related to EBM and awareness of the necessity of EBM during clinical practice. Previous studies have shown that clinical practice in medical fields other than pharmacy deepened awareness of the field of specialization and that knowledge and experience promoted proactive behavior1922). This study shows that the EBM workshop using the TBL method can be expected to have a higher educational effect on fifth-year students after clinical practice.

Furthermore, the survey results suggested that the joint exercise with different grades had a positive impact on the fifth-graders, as they actively participated as upper graders, listened to the opinions of others, and taught the lower graders (Table 4, Q3, 10, and 12). A cross-tabulation of Q6 and Q26 indicated that the participants valued mutual education, such as tRAT and team work, and were highly satisfied with the workshop (Table 5). TBL utilizes team dynamics among learners and encompasses interpersonal team processes and task orientation12,23). Previous studies of EBM education reported that residents were satisfied with the team dynamics and problem-solving process in TBL sessions22). This is consistent with the present results, suggesting that the application of TBL in EBM education for medical participants and medical professionals could lead to satisfaction with learning.

Table 5 Cross tabulation of Q6 and Q26

Q6

Q26

1 2 3 4 5
1 0 0 0 0 0
2 0 0 1 1 1
3 0 1 0 5 2
4 0 0 5 11 7
5 0 0 2 8 8

Additionally, the students recognized the importance of basic science knowledge in clinical practice and pharmacists’ evaluation of clinical research literatures (Q14: 4.14 ± 0.67). Drug information based on clinical studies has priority over basic science considerations in EBM23). However, pharmaceutical information and knowledge based on basic science need to be integrated when considering a drug treatment strategy for individual patients2).

This workshop incorporated team work to examine the application of a drug for patients after literature evaluation, which likely helped raise awareness of the importance of using basic science knowledge as well as evidence obtained from clinical research. Conversely, the score of Q15 (3.10 ± 1.02) was lower than that of Q14, and the respondents tended to answer that it was difficult to apply basic pharmacology in clinical practice. Since this program was centered on EBM, the importance of the basics was first raised in their minds. However, it also became clear that it was difficult to apply the basics to clinical practice by itself. Therefore, it was thought that a separate program to apply the basics to clinical applications was necessary.

This study has several limitations. First, the test results may reflect only participants who were highly motivated to learn, as only half of the participants took the post-test. The breakdown of the dropouts was four in the first to third years, fourteen in the fourth year, and nine in the fifth year. The reason for the decrease in the number of participants was that the post-test was conducted online during spring break, which may have increased the psychological hurdle for the test. Second, the achievement test after two months was in a testing environment where participants could have referred to the material because it was administered online without teacher monitoring. Third, as participants were recruited through voluntary participation, the results may not reflect the trends of the entire population of participants or the academic year. Future studies should conduct large-scale investigations using follow-up surveys.

Acknowledgements

We would like to thank Editage (www.editage.com) for English language editing.

Conflict of interest

The authors declare no conflict of interest.

The electronic appendix (Supplementary materials) is included in the J-STAGE online journal version of this article.

References
 
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