Abstract
The knowledge and application of pharmacology is essential for safe prescribing and administration of drugs. In this narrative review, the challenges to pharmacology education in the medical curricula were broadly identified to include issues around content and pedagogies. The increasing number of approved drugs and drug targets, expanding field of pharmacology and the often‐changing treatment guidelines and board‐defined competencies can make pharmacology education in the medical curriculum daunting. There has been a consensus around the deployment of innovative medical curricula with emphasis on vertical and horizontal integration. This strategy, effective as it has been, presents new challenges to pharmacology education. As a discipline often perceived by students to be hard‐to‐learn, the future of pharmacology education must include heavy reliance on active learning strategies. The continuing utilization of problem‐based, team‐based and case‐based learning can be complemented with personalized learning which aims to identify the learning gaps in individual students. Technology‐inspired student engagement can foster pharmacology learning and retention. Early exposure to pharmacology from premedical preparation through an enduring across‐the‐level integration can be an effective way to enhance pharmacology learning in the medical curricula.
Keywords: active learning, case‐based learning, medical education, personalized learning, pharmacology education, problem‐based learning, team‐based learning
Abbreviations
- AMEE
Association for Medical Education in Europe
- ARS
Audience Response System
- CBL
Case‐Based Learning
- CME
Continuing Medical Education
- IRAT
Individual Readiness Assessment Test
- LBL
Lecture‐Based Learning
- PBL
Problem‐Based Learning
- TBL
Team‐Based Learning
- USMLE
United States Medical Licensure Examination
1. INTRODUCTION
Pharmacology education is an integral component of health sciences where its application is essential to improve pharmacotherapy outcomes and quality of life. In health professions, the knowledge of pharmacology is necessary to enhance drug safety, avoid medication errors, and prevent adverse drug interactions. Data from the US Center for Disease Control and Prevention (CDC) indicates that about half of the US adult population (and 85% of those that are 60‐year and older) takes prescription medicines. 1 The US FDA receives more than 100 000 reports of suspected medication errors each year while studies have suggested that medication errors may be responsible for up to 250 000 deaths (up to 10% of all deaths) annually in the US alone. 2 This figure, according to a study that analyzed death rate data, has placed medication errors as the third leading cause of death after heart diseases and cancer. 3 Of all medication errors that could potentially lead to adverse effects, prescription errors have been estimated to account for 70%. 4 , 5 Although the causes of prescription and medication errors are multifactorial, the knowledge of pharmacology is arguably the most important. 6 , 7 A significant number of junior doctors often demonstrate inadequate knowledge of pharmacology required at their levels for effective drug prescribing. 8 Thus, effective learning of pharmacology has been a concern for medical educators and other stakeholders in the training of the health professionals.
The required core‐concepts to be taught and learned in pharmacology are generally discipline‐based. While mechanistic concepts are emphasized in graduate research‐focused programs, the focus is generally on practice‐relevant pharmacotherapy in the health professions of medicine, pharmacy, nursing, dentistry, and optometry. For physicians, the centrality of pharmacology to the various specialties underscores the importance of attaining competencies in pharmacology education.
Published in 1910, Flexner's report of the Carnegie Foundation for the Advancement of teaching formed the bedrock of the traditional medical curriculum. The report recommended the teaching/learning of basic medical sciences in the first 2 years (often referred to as the preclinical years) to be followed by 2 years of clinical training. In the past decades, changes to this model have been adopted to include curricular designs that enhance the integration of basic and clinical sciences, promoting earlier clinical exposure. Innovative designs of these changes have emphasized active learning pedagogies. The organ system‐based curricular integration in undergraduate medical education has unarguably enhanced longitudinal learning that blurs the preclinical‐clinical dichotomy. Pharmacology, like other basic sciences, has been integrated in this way in most medical curricular prompting new challenges that are still being recognized.
2. CHALLENGES IN PHARMACOLOGY EDUCATION
Teaching and learning pharmacology can be an arduous task. Based on the discipline and the content to be taught, pharmacology can be abstract. The core mechanistic principles of drug actions often appear theoretical and complex. Biomolecular signaling pathways, second messengers and mathematical concepts of drug disposition and pharmacokinetics, for example, require strong interest and motivation to learn. When learning is patient‐focused, where learners can deduce applicability (as in pharmacotherapy), pharmacology becomes more relatable for students. 9 , 10 Thus, unlike other courses in the medical curriculum, pharmacology can be perceived as unexciting in content, and stressful to learners who approach its learning by rote memorization. The challenges in pharmacology education can therefore be broadly grouped into those that relate to either content or teaching/learning. Identifying these challenges, along with innovations in teaching can improve pharmacology education in the medical curriculum.
2.1. Challenges relating to content
The pharmacology content that is to be taught in the medical curriculum is often influenced by the information provided by licensing agencies, time allocation, and instructor preference.
2.1.1. Expansion in current pharmacology knowledge
In the past few decades, the rate of discovery of new drug targets and the development of new drugs has been astounding. For example, the US FDA approved an average of four drugs per year before the 1950s, increasing to about 10 per year up to the 1980s. In the past decade, new drug approvals have averaged 50 per year. 11 As new high‐throughput technologies continue to emerge, the trend of new drug discoveries is expected to continue over the next decades. Alongside new discoveries is the expansion in approved indication of old drugs. These are expected to change the dynamics of teaching and learning pharmacology. For example, the pharmacology of type 2 diabetes mellitus a decade ago, would have covered three classes of drugs, compared to the current content of over 10 pharmacological classes. Furthermore, several of these classes have additional labeled and unlabeled indications. This rate of knowledge expansion is a challenge for educators, students, examiners, and curricula developers.
2.1.2. Expanding pharmacology field
There has been expansion of pharmacology as a field and subject of study. For example, until recent years, pharmacology curricula did not include significant content in the areas of pharmacogenomics and herbal products. With great strides in the field of genomic medicine there is a clearer understanding of the interplay between genetics and drug action. According to the Clinical Pharmacogenomics Implementation Consortium (CPIC), there are currently 26 published actionable clinical guidelines affecting the use of over 120 drugs based on drug‐gene interaction. 12 The implementation of these guidelines at the level of medical practice includes actions such as required/recommended genetic screening with the attendant change in drug dosing or the disclosure of an absolute contraindication. While these are generally instrumental in driving personalized medicine, the teaching and the learning of the content is an added challenge to an already condensed medical curricula.
While herbal products are seldom prescribed in medical practice, the increasing popularity of herbal supplements has often raised the question of herb‐drug interactions. This has thus expanded the teaching/learning content of drug interactions to include such herbal interaction‐inducing products like St John's wort, ginkgo biloba, garlic, and ginseng.
Other areas of pharmacology that are gaining relevance in medical education include environmental and forensic toxicology, pharmacology of addiction, and regulatory pharmacology. These expansions project a future where prioritization of taught content becomes more challenging since there is a limitation of time allocation to one subject in the medical curricula.
2.1.3. Changes in treatment guidelines and board‐defined competencies
Pharmacology in the undergraduate medical education naturally places emphasis on first‐line drugs based on clinical guidelines. This also aligns with the priorities of the medical licensure agencies. The United States Medical Licensure Examination (USMLE) states in its content description that it is designed to provide a “flexible structure for test construction that can readily accommodate new topics, emerging content domains, and shifts in emphasis.”. 13 Frequent changes in treatment guidelines thus often imply changes in priorities. Pharmacology content pertaining to the treatment of chronic diseases including asthma, hypertension, diabetes, depression, and other psychiatric disorders often has to undergo revision based on these often‐changing treatment guidelines. Thus, for effective pharmacology teaching, pharmacology educators must adapt their content to reflect current medical examination competency statements, as well as drug preferences in pharmacotherapy treatment guidelines.
2.2. Challenges relating to teaching and learning
Unlike the previously used traditional curriculum where subject courses are taught independent of others, the integrated medical curriculum is largely organ‐system based enhancing learning across subjects while integrating basic and clinical sciences in the process. The design of traditional medical curricula is believed to be weak in promoting holistic learning that centralizes the patient. It promoted the basic‐clinical sciences dichotomy and leaves most of the learning to the assimilating capacities of the individual learners. To enhance learning and overcome the challenges in the traditional medical curriculum, innovative curriculum, and teaching methodologies have evolved to include problem‐based, task‐based, and team‐based learning. 14 , 15
The innovative integrated medical curriculum is intended to teach the basic medical science courses within clinical contexts, accompanied by early clinical exposure in the previously called preclinical years of medical education. This principle is followed up in the clinical years of medical education where the basic science basis of clinical medicine is still emphasized. The design of the innovative curricular deemphasizes contact lecture hours, includes self‐directed and team learning activities, and makes allowance for interprofessional education. This has put limitations of time allocation for pharmacology. This is also without regard for the expanding field of pharmacology, increasing number of new drugs and drug targets.
2.2.1. Pharmacology educator question
There has also been the pharmacology educator question. Pharmacology educators come from diverse background. There is currently a less clearly defined path to becoming a pharmacologist than in years past. There are no universally accepted/defined core concepts and competencies on which graduates should be assessed in order to qualify to teach pharmacology. 16 , 17 In recognition of this challenge, the Core‐Concept in Pharmacology Expert Group (CC‐PEG) was set up by the pharmacology educators in Australia and New Zealand to identify a set of core concepts and reliable assessment tools to guide the development of new curricula and evaluate existing curricula. 18 The absence of uniformity in competency requirements for pharmacologists can translate into varying instructor‐based outcomes in pharmacology in the medical education curriculum. It has led to the suggestions of clinician‐pharmacologist and scientist pharmacologist distinction where the clinician‐pharmacologists may, for example, tend to focus more on pharmacotherapy principles compared to scientist‐pharmacologists, who may teach more of biomolecular pharmacology. 19
2.2.2. Challenges of integration
Integrative medical curricula are innovative and is rooted in pedagogic principles that aim to achieve holistic learning, blending basic sciences and clinical applications in real‐time. To achieve integration, emphasis is laid on teaching models that employ active learning including problem‐based, team‐based, task‐based, and case‐based learning. Pharmacology by its nature of encompassing both basic and clinical components, integrates physiology, pathology, and therapeutics. The integrated medical curriculum with emphasis on team‐based and self‐learning has reduced time allocation to individual subjects. The reality has also involved weakened discipline‐based departmental structures in many institutions in favor of combined basic science departmental structures. The competition for subject matter relevance in such arrangements will depend on the influence of the individual pharmacology educators, and the course director's perceived importance of pharmacology relative to other disciples represented in the integrated module. This often leads to the interest of individual subjects being subsumed in the overbearing interest of integration.
Several years into the integrated medical curriculum system, reference readings and recommended textbooks are still largely subject‐based. Integrated materials would arguably enhance the integrated learning experience and ensure balanced contents that minimize the influence of individual course directors or what subject areas are prioritized.
3. IMPROVING PHARMACOLOGY TEACHING/EDUCATION
With the current heavy‐content load of medical curriculum, the feasibility of any significant increase in the time allocation for pharmacology is remote. With increasing scope and content, pharmacology will continue to be relevant in medical education. Thus, teaching/learning strategies need to be carefully considered to improve pharmacology education. Modern innovative teaching/learning models involve strategies that are learner‐centered, deemphasizing the role of the educator from an instructor to a facilitator of learning. This student‐centered and often, student‐directed curricula enable lifelong learning. Rather than diminish the role of the teacher, these modern curricular designs expand the roles of the educator to provide inspiration, information, direction and guidance to learners. It thus requires pharmacology educators to not just to be knowledgeable in the subject matter, but to possess expertise in pedagogy.
In the past decades, several new teaching and learning methods have been developed and promoted in order to maximize the benefits of innovative medical curriculum. Some of these are particularly applicable in overcoming the challenges of pharmacology education in integrated medical curriculum.
3.1. Team‐based learning
Team‐based learning (TBL) has generated significant interest as an effective learning and teaching method since it was first designed by Dr. Larry Michaelsen for use in the University of Oklahoma business school. 20 , 21 It is an instructional method that consists of repeating sequences implemented in at least three phases. 22 The first phase of TBL involves individual student preparation that requires the students to familiarize themselves with the content of the subject through instructor‐provided reading assignments, literature articles, handouts and/or other materials. This is followed by readiness assurance, a critical phase that ensures that the understanding of the core concepts is reinforced. In many settings, each student is required to take a graded individual readiness assessment test (IRAT) as part of the readiness assurance. This is followed by an interactive discussion among the team members to select the best answers for the quiz questions, and some feedback from the facilitator. The third phase of TBL involves the application of the key concepts in solving problems in the small‐group settings. It involves team activities that require a deeper understanding of the contents, enhancing discussions and critical thinking. The teams are often presented with multiple plausible solutions from where they choose and defend their resolutions, ensuring accountability and teamwork. The student engagement in this phase facilitates higher‐level learning and active connection with the subject content. TBL, through these phases, provides additional benefits including peer‐level teaching, communication skills, critical thinking, and team building.
In pharmacology, TBL has been applied and adjudged an effective learning methodology in health professions including pharmacy, 23 nursing, 24 and physician assistant programs. 25 When used in undergraduate medical pharmacology, TBL has been reported to elicit positive feedback from students and improved test performance. 26 It appears to be more beneficial to low‐performing students as it may assist these students to organize their independent study time more efficiently. 27 , 28 Because of the voluminous nature of pharmacology TBL also provides the environment whereby team members can exchange strategies for memorizing drug names, mechanisms and side effects that may be otherwise hard to individually achieve. Through several studies, TBL has been shown to be as effective, and sometimes, better that the traditional lecture‐based approach of teaching pharmacology (Table 1).
TABLE 1.
Studies evaluating the effectiveness of team‐based learning in pharmacology education.
Author | Study design and description | Major outcomes |
---|---|---|
El‐Banna et al. 24 | Use of differences in test scores to compare the effectiveness of TBL to lecture‐based pharmacology teaching in a nursing program | TBL approach resulted in significantly higher test scores |
Nguyen et al. 25 | In a clinical pharmacology course in a physician assistant program, half of the course was taught using TBL approach, and the other LBL | Although more students preferred TBL approach, and believed it helped them learn, there was no significant differences in test scores from both approaches |
Zgheib et al. 26 | Two case‐based sections of pharmacology were taught with the TBL approach to second year pharmacy students | Better group performance during TBL, significant improvement in quiz performance in selected areas, unchanged in others |
Kim et al. 27 | An integrated clinical pharmacology course was designed and taught using TBL approach to first year medical students | More positive perception in post‐course survey, and significant improvement in test performance for otherwise low‐achieving students |
Carrasco et al. 28 | A long‐term study to determine the effect of implementing a single TBL iRAT exercise in a pharmacology for medical students | The final examination scores for low‐achieving students correlates moderately with their iRAT scores |
Dunaway 29 | TBL was implemented in a graduate pharmacology course and used to assess | Both students and instructors had positive perceptions. Students perceived TBL to enhance participation, learning, retention |
Nguyen et al. 25 | A clinical p1harmacology was offered to physician assistant students using TBL for half of the course and the other half was lecture‐based | Student perceptions varied but there was no significant difference in test performance |
Sabra et al. 30 | TBL used in two case‐based sessions in a medical pharmacology class to teach drug metabolism and pharmacogenomics (less challenging) and pharmacokinetics (more challenging) | More positive feedback for drug metabolism and pharmacogenomics session. TBL was not as successful an approach to teach more challenging topics like pharmacokinetics |
Hashilkar & Gelula 31 | Students taking medical pharmacology course were randomized into TBL or LBL group | TBL is associated with higher student performance in the individual sessions as well as in the overall module |
Prabha et al. 32 | Randomized crossover study to compare perception and test outcomes of medical students who took pharmacology by either virtual TBL approach or online lectures. | TBL approach led to significantly higher test performance, and better perception measures |
Mehnaatamai & Zhong 33 | The perception of students on an ongoing TBL‐based medical pharmacology was assessed | Students have a more positive experience and perception of TBL approach of learning pharmacology |
Study randomized medical students into 2 groups to receive pharmacology through either the traditional LBL or the TBL approach | Test results were significantly higher for the TBL group, accompanied with more positive qualitative feedback | |
Singh et al. 34 | Students were surveyed to assess their perception TBL approach after its use in a second‐year medical pharmacology | Assessment scores were higher after TBL compared to lecture‐based approach. Overwhelming majority showed preference for, and satisfaction with TBL. |
Rao & Shenoy 35 | Authors adopted TBL teaching format in a medical pharmacology and assessed students' perceptions | TBL was rated high on helping to acquire the content knowledge, better understanding of material, and reduction in time required for self‐study |
Chen et al. 36 | The teaching and learning experience in a dental pharmacology through TBL was assessed | TBL enhanced teamwork and enhanced quicker learning of pharmacology. Instructors perceived that TBL enhanced student performance |
Attia & Mandour 37 | The impact of TBL in the learning of pharmacology in a pharmacy school was evaluated through problem‐solving and post‐course survey | TBL enhanced students' satisfaction, content understanding and participation |
Gorman 38 | Authors incorporated TBL in a medical pharmacology curriculum and assessed the impact in multiple ways | TBL was more effective for learning, yielding higher test scores, and positive feedback and perception |
Abbreviations: LBL, lecture‐based learning; TBL, team‐based learning.
3.2. Problem‐based learning
Problem‐based learning (PBL), like TBL, is a student‐centered active learning/teaching method where pedagogic emphasis is on the application of knowledge to solve real‐world problems. The learners are exposed to the “problem” where they can utilize constructive reasoning and enquiry, problem identification, self‐realization of knowledge gap, self‐directed learning and the application of knowledge, and skills to solve problems. PBL is designed to be learner‐centered and teacher‐facilitated. At least five features characterize PBL. The first is the “problem” content which facilitates the beginning of the learning process. Like TBL, the problem discussion and learning facilitation are usually done in small groups, which enhance student‐directed collaborative learning. Another characteristic of PBL is the student‐centered design of the pedagogy, emphasizing learning over teaching. Fourthly, PBL modifies the role of the teacher to a facilitator of learning. And lastly, there is generous provision for self‐study time in the curricular design. The major distinguishing feature of PBL from other active learning methodologies is the opportunities for learners to identify their knowledge deficiency while also applying prior knowledge in problem solving.
The utilization of PBL in pharmacology education can be beneficial to both learners and teachers. The design of PBL curriculum is more nuanced than TBL. According to Kwan, 39 PBL is not the mere inclusion of “PBL activities” in the curriculum. It is an entire design of student‐centered learning methodologies with focus on the learning objectives, and with learning sessions facilitated by teachers who are not necessarily content experts. Thus, PBL is not just the learning that occurs through clinical case studies, but a broader application of problem‐solving skills to real or simulated problems (including clinical cases). When adopted in pharmacology education, PBL has been reported to improve student performance and competencies. 40 , 41 For example, a meta‐analysis of 37 controlled studies demonstrated a more positive student perception of PBL over traditional pedagogies in pharmacology education. 42 PBL, according to the studies enhanced interest in learning pharmacology, bolstered team spirit, inspired effective communication, and improved the students' skills in problem analysis and problem‐solving. 42 Some of the major outcomes of utilizing PBL in pharmacology education are summarized in Table 2.
TABLE 2.
Studies demonstrating the application of problem‐based learning in pharmacology and the largely positive outcomes.
Authors | Study design and description | Major outcomes |
---|---|---|
Gregson et al. 40 | Anonymous survey was used to assess student perception of the use of PBL in a dental pharmacology curriculum | Students perceived PBL to enhance better understanding of the concepts; and to improve confidence in pharmacology knowledge |
Brinkman et al. 41 | Using a structured questionnaire, authors investigated if a change from traditional LBL to PBL improved the prescribing competencies of medical trainees | Students in PBL had higher knowledge scores, fewer prescription errors and fewer inappropriate therapy choices |
Antepohl & Herzig 43 | Use of a randomized controlled prospective study to determine if the use of PBL leads to less pharmacology knowledge acquisition among medical students | No significant difference in knowledge level among students who use either PBL or lecture‐based classes. PBL is perceived as a more effective learning method by the students |
Bratt 44 | The PBL experiences of pharmacy students for pharmacology learning were evaluated and compared with the traditional LBL format | PBL was ranked higher in aiding overall learning and knowledge retention |
Mustafa et al. 45 | Cross‐sectional study to evaluate pharmacology knowledge recall among medical students who studied in PBL or traditional LBL systems | Between the two learning formats, there was no statistically significant differences in recalling pharmacology |
Miller 46 | Use of test scores and level of satisfaction to compare PBL and traditional lecture format for a graduate pharmacology | No significant differences in the outcomes measured |
Michel et al. 47 | Medical students randomly assigned to two groups to receive pharmacology lecture by PBL or traditional LBL. Effectiveness of the methods were assessed | PBL enhanced more interest, knowledge acquisition and understand of pharmacology. PBL students performed similarly to lecture‐based students in national exam |
Distlehorst & Robbs 48 | A 3‐year retrospective analysis of the academic performance in pharmacology of students taught through PBL or traditional LBL format | PBL students did perform at least as well as the traditional lecture‐based students, and much better in some instances |
Sushama et al. 49 | Cross‐over study comparing the effectiveness of PBL with LBL in pharmacology learning | No statistically significant difference in test scores. Perception for PBL was higher |
Imran et al. 50 | A crossover study to compare medical student test performance after pharmacology learning via PBL and LBL | Students in the PBL group had higher mean score |
Laveesh et al. 51 | Two groups of medical students were taught pharmacology using comparative PBL and structured group discussion in a crossover design | The mean test score was higher for PBL. Knowledge acquisition was similar through both methods |
Sivam et al. 52 | An integrated medical curriculum of basic sciences including pharmacology was designed and implemented. Test scores in national board exams were used for comparison | Students who learned through PBL performed as well or better that those who learned through the traditional LBL methodology |
Abbreviations: LBL, lecture‐based learning; PBL, problem‐based learning.
3.3. Personalized learning
Personalized learning uses adaptive learning (with or without software applications) to tailor the learning experience to individual students based on their progress and understanding of the material. The traditional class structure employs uniformity, with the inherent assumption that every learner will fit in. This approach does not address the learning deficiencies in the learner population nor take into consideration the levels of prior knowledge, personal motivation, and readiness for new knowledge acquisition. Personalized learning, as a concept, promotes self‐paced learning that emphasizes the roles of the learner and learning. It streamlines education and tailors learning based on the individual needs of the student. As a result of the potential of personalized learning in addressing the diversity of the learner population, it has been popularized and adopted in national education policies. 53 , 54
The integration of technology in pharmacology education, including simulation and guided real‐time assessment has been a useful tool in medical education. Combined with integrated technology, PL can be very effective in gauging the level of knowledge acquisition and enhance progression through the learning process. 55
PL has been utilized extensively in graduate/specialty medical education and has enhanced the development and delivery of continuing medical education (CME). AMEE Medical Education Guide provides templates for planning PL across the disciplines in medical education. Pharmacology, PL allows learners to develop and adopt strategies including mnemonics, shorthand, vocalizations, small groups etc. with time and location flexibility, which facilitates learning drug names, mechanism of action, clinical applications etc. Thus, structured PL can be a veritable tool for improving pharmacology education in the medical curriculum.
3.4. Integrative technology
The use of video clips, interactive e‐books, game‐like interactions, online quizzes are some of the ways technology integration is being used to enhance learning experience. Perhaps, one of the most popular interactive technologies is the audience response system (ARS) which is being utilized in several institutions of learning. The ARS is effective in student engagement with a relatively simple operationalization. Typically, the computer being used by the instructor/facilitator serves as the central unit to which handheld devices are connected. These student‐held devices, with wireless receiver systems, are programmed for classroom participation with the options for anonymity. This system enhances student engagement and active learning, provides real‐time data on participation and learning progress. The ARS can enhance pharmacology learning primarily because of its ability to enhance attention and participation. Other options that integrate gaming and other active participation tools into the pharmacology learning experiences including kahoot, jeopardy, etc. have been reported to enhance attendance, participation and learning. 56 , 57
3.5. Case‐based learning
Case‐based learning (CBL) involves the application of knowledge to real world scenarios. In pharmacology education, clinical cases are utilized, and learners are required to analyze the scenario, recognize the issues in the case and develop treatment plans, including pharmacotherapy. This high‐level learning is effective in medical education because of its capability for simultaneous multidisciplinary application. It allows learners, for example, to learn pathophysiology and disease symptoms, while also enabling the identification of the potential sites of drug action. While CBL can be used in both the traditional and integrative medical curriculum, it is more effective in the latter. The simultaneous learning of other basic sciences not only enhanced pharmacology learning, but it also facilitates problem‐solving and holistic pharmacology education. To be effective, CBL may be utilized in combination with other teaching methodologies. In multiple studies, students reported positively on the influence of CBL on the ability to grasp difficult concepts in pharmacology, and to integrate the contents in clinical problem‐solving. 58 , 59 , 60 , 61 , 62 Table 3 highlights studies evaluating the effectiveness of utilizing CBL in pharmacology education.
TABLE 3.
Studies evaluating the utilization and outcome of case‐based learning in pharmacology.
Authors | Study design and description | Major outcomes |
---|---|---|
Hasamnis et al. 58 | CBL sessions were developed for second year medical students to teach clinical pharmacology. Responses were measured through a questionnaire | Majority of the students have positive perception of CBL to enhance their understanding of pharmacology |
Tayem 59 | After the use of LBL for a medical pharmacology curriculum, CBL was used for a second part and student perceptions were assessed | Most students considered CBL to be a more effective learning tool, better at improving their analytical skills and prepared them for exams |
Kaur et al. 60 | Medical students were divided into two groups to have 2‐h pharmacology learning through CBL and LBL in a crossover design | No significant difference in test scores. Majority of the students considered CBL as a better method |
Baheti et al. 61 | A crossover study to assess the perception and effectiveness of CBL to teach pharmacology to third‐year medical students | Post test scores and perception measures were significantly higher with CBL than LBL |
Chiranjeevi et al. 62 | Randomized controlled study of the effectiveness of CBL compared to LBL in medical pharmacology teaching | Perception, and scores in both knowledge‐based and application‐based assessments were higher with the CBL group |
Gupta et al. 63 | CBL was developed and used to teach an integrated topic of disease and drug use. Students were assessed though an anonymous questionnaire | CBL enhanced learning and is preferred to LBL by most of the students |
Kumar et al. 64 | CBL was studied in a rural medical school as an alternative way to LBL for teaching pharmacology | Test scores showed significant improvement, and students considered CBL as a better tool |
Jain et al. 65 | Controlled crossover study to compare CBL and TBL for pharmacology learning among second year medical students | CBL was associated with statistically significant higher test scores, better understanding and improved learning |
Meira et al. 66 | Pharmacy students were recruited to participate in a CBL of pharmacology to assess perception and effectiveness | CBL enhanced knowledge acquisition, with a positive perception by the majority of the participants |
Taesotikul et al. 67 | CBL was used to teach cardiovascular pharmacology to pharmacy students. Students were assessed for performance and perception | Average test score was considered high with CBL. Students had high satisfaction with CBL in enhancing knowledge acquisition. |
Özdener et al. 68 | CBL was integrated into the third‐year medical curriculum. Students evaluated CBL through questionnaire | Students found CBL useful for learning |
Jalgaonkar et al. 69 | The perception of medical students was assessed on the use of CBL, and role play method as teaching techniques for pharmacology | Majority of the students perceived the 2 approaches to enhance their learning and understanding, with high level satisfaction |
Kantar & Sailian 70 | Comparable study of CBL and LBL in nursing pharmacology for knowledge retention and judgment skills | No statistically significant difference in knowledge retention measured by test scores but CBL was associated with better judgment skill |
Picard et al. 71 | Use of CBL to integrate pharmacology and microbiology in a fifth‐year veterinary course. Written and oral reports/discussions were used to assess learning | Consistently high means scores over three successive years. Students indicated that CBL facilitated knowledge/skill acquisition, and confidence development |
Vora & and Shah 72 | Same pharmacology topics were taught to two set of randomized medical students using either CBL or LBL | CBL was associated with significantly higher test scores, and critical thinking. CBL has higher students' perceptions for enhancing learning and understanding concepts |
Rajasekaran 73 | Controlled study comparing students' performance after being taught medical pharmacology using either CBL or LBL | Students taught using CBL had better performance scores. Students rated CBL better for enhanced learning and integration |
Abbreviations: CBL, case‐based learning; LBL, lecture‐based learning.
4. DISCUSSION
As an integral part of the medical curricula, pharmacology will continue to be relevant in medical education and practice. Its learning and application are essential for safe prescription and utilization of drugs. While there are identified challenges in pharmacology education relating to content and teaching, there are also opportunities for improvement. The future of pharmacology in medical education depends on pragmatic approaches that take into consideration the expanding content of pharmacology and the limited time for undergraduate medical education.
The overriding objective of active learning is the participation of learners in knowledge acquisition to enhance retention and application. Learning pharmacology has to move up the ladder of Bloom's taxonomy. While “remembering” drug names will continue to be essential, the learning that emphasizes the need to “apply” and “analyze” the pharmacology of each drug class in relation to the mechanism of action, indication and side effects, will enhance retention. To achieve this, a deeper and broader integration of pharmacology in the medical curriculum will be required. For example, while the innovative integrated curriculum has achieved early clinical exposure in the medical curriculum, similar level of engagement with the basic sciences is not present in the later years of undergraduate medical curricula. For pharmacology, which is considered an applied science, an across‐the‐level integration has the potential of enhancing retention and application that will reflect in safer drug prescription and pharmacotherapy.
Closely related to an enduring pharmacology content throughout the undergraduate medical curricula is pre‐medical pharmacology knowledge. Unlike physiology and biochemistry, pharmacology is generally not a prerequisite for medical admissions. While there are no published data to show the benefit of prior pharmacology knowledge before medical admission on success in medical school and beyond, it can be expected that premedical exposure to basic pharmacology can prepare students for success in medical pharmacology and safe drug use. The adoption of some pharmacology competencies as a prerequisite for medical admission, along with across‐the‐level pharmacology integration in the medical curricula will entrench and deepen the knowledge of drugs and enhance safe and effective pharmacotherapy.
Within the current curricular realities, immediate and sustainable improvement in pharmacology education can be achieved only through improved pedagogies. Specifically, emphasis has to shift from teaching‐centered pedagogies to learner‐focused andragogy and heutagogy. While andragogy enhances the facilitation of learning that is self‐directed, heutagogy emphasizes group work towards a common goal. 74 Emphasis on andragogy, specifically, through personalized self‐directed learning of pharmacology can be a veritable means for enhanced pharmacology education. This active learning method takes into consideration, the individual's learning gap and incorporates self‐paced knowledge acquisition and assimilation. Peer teaching and participatory group work, as espoused by heutagogy, can facilitate pharmacology learning as it allows free exchange of ideas and study techniques among peers. These approaches can aid the students in identifying their individual areas of strengths and weaknesses, and self‐directed focus on areas of need.
Finally, pharmacology education can benefit enormously from the technology‐inspired student engagement and active participation. The availability of the audience response system (like Kahoot, Poll Everywhere, Clica), and gaming applications (jeopardy, memorang) can be leveraged upon to enhance the learning experience. The utilization of virtual environment (canvas, blackboard, Google classroom) and other online resources can enhance individualized pharmacology education through self‐paced learning free of in‐person distractions.
5. CONCLUSION
Despite the challenges of expanding content of pharmacology and the limited time for its teaching, there are opportunities for innovative strategies to enhance pharmacology education in the medical curricula. In the immediate, continuing focus on active learning, and the technology‐inspired student engagement can boost learning and retention. In the long‐term, strategies that introduce learners to pharmacology early (through prerequisites) and prolong its learning and applications through sustained curricular integration (in the later years of undergraduate medical training) may have positive effect on safe drug prescribing practices and pharmacotherapy.
AUTHOR CONTRIBUTIONS
Both authors conceptualized the research. PSF conducted literature search and drafted the manuscript. TWW critically reviewed and revised the manuscript draft. Both authors agreed on the final version of the manuscript.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
ETHICS STATEMENT
No ethics approval was required for the review.
ACKNOWLEDGMENTS
Both authors are supported by departmental grants from the Department of Pharmacology and Toxicology, The Heersink School of Medicine, University of Alabama at Birmingham.
Fasinu PS, Wilborn TW. Pharmacology education in the medical curriculum: Challenges and opportunities for improvement. Pharmacol Res Perspect. 2024;12:e1178. doi: 10.1002/prp2.1178
DATA AVAILABILITY STATEMENT
All data discussed in the manuscript are publicly available in the articles cited.
REFERENCES
- 1. Martin CB, Hales CM, Gu Q, Ogden CL. Prescription drug use in the United States, 2015–2016. NCHS Data Brief, no 334. National Center for Health Statistics; 2019. [PubMed] [Google Scholar]
- 2. Anderson JG, Abrahamson K. Your health care may kill you: medical errors. In: Lau F, et al. eds. Building Capacity for Health Informatics in the Future. 2017;13‐17. 10.3233/978-1-61499-742-9-13 [DOI] [PubMed] [Google Scholar]
- 3. Makary MA, Daniel M. Medical error ‐ the third leading cause of death in the US. BMJ. 2016;353:i2139. [DOI] [PubMed] [Google Scholar]
- 4. Kuo GM, Phillips RL, Graham D, Hickner JM. Medication errors reported by US family physicians and their office staff. Qual Saf Health Care. 2008;17:286‐290. [DOI] [PubMed] [Google Scholar]
- 5. Ross S, Bond C, Rothnie H, Thomas S, Macleod MJ. What is the scale of prescribing errors committed by junior doctors? A systematic review. Br J Clin Pharmacol. 2009;67:629‐640. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Gwee MC. Teaching of medical pharmacology: the need to nurture the early development of desired attitudes for safe and rational drug prescribing. Med Teach. 2009;31(9):847‐854. [DOI] [PubMed] [Google Scholar]
- 7. Fialová D, Onder G. Medication errors in elderly people: contributing factors and future perspectives. Br J Clin Pharmacol. 2009;67(6):641‐645. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Harding S, Britten N, Bristow D. The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardized clinical cases. Br J Clin Pharmacol. 2010;69(6):598‐606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Ahmed MW, Dass P, Gulabani M, Ahmed R, Javedar P, Mishra R. Undergraduate MBBS and BDS students' opinion‐based survey on current teaching practices in pharmacology and changes recommended for betterment of the same. J Evol Med Dent Sci. 2014;3(70):14923‐14929. [Google Scholar]
- 10. Mauldin B. Bringing clinical context to the classroom in nursing pharmacology: a case study. Nurs Educ Perspect. 2023;44(1):57‐58. [DOI] [PubMed] [Google Scholar]
- 11. Kinch MS, Haynesworth A, Kinch SL, Hoyer D. An overview of FDA‐approved new molecular entities: 1827–2013. Drug Discov Today. 2014;19(8):1033‐1039. [DOI] [PubMed] [Google Scholar]
- 12. Clinical Pharmacogenetics Implementation Consortium. Accessed November 10, 2023. https://cpicpgx.org/
- 13. United States Medical Licensing Examination (USMLE, 2023). Accessed November 10, 2023. https://www.usmle.org/prepare‐your‐exam/step‐3‐materials/step‐3‐content‐outline‐and‐specifications
- 14. Papa FJ, Harasym PH. Medical curriculum reform in North America, 1765 to the present: a cognitive science perspective. Acad Med. 1999;74:154‐164. [DOI] [PubMed] [Google Scholar]
- 15. Harden RM, Crosby J, Davis MH, Howie PW, Struthers AD. Task‐based learning: the answer to integration and problem‐based learning in the clinical years. Med Educ. 2000;34:391‐397. [DOI] [PubMed] [Google Scholar]
- 16. White PJ, Davis EA, Santiago M, et al. Identifying the core concepts of pharmacology education. Pharmacol Res Perspect. 2021;9(4):e00836. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. White PJ, Guilding C, Angelo T, et al. Identifying the core concepts of pharmacology education: a global initiative. Br J Pharmacol. 2023;180(9):1197‐1209. [DOI] [PubMed] [Google Scholar]
- 18. Santiago M, Davis EA, Hinton T, et al. Defining and unpacking the core concepts of pharmacology education. Pharmacol Res Perspect. 2021;9(6):e00894. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Achike FI. Teaching pharmacology in an innovative medical curriculum: challenges of integration, technology, and future training. J Clin Pharmacol. 2010;50(1):6‐16. [DOI] [PubMed] [Google Scholar]
- 20. Michaelsen LK. Getting started with team‐based learning. Team‐Based Learning. Routledge; 2004:27‐50. [Google Scholar]
- 21. Michaelsen LK, Sweet M, Parmelee DX, eds. Team‐Based Learning: Small Group Learning's Next Big Step: New Directions for Teaching and Learning, Number 116. John Wiley & Sons; 2011. [Google Scholar]
- 22. Parmelee DX, Hudes P. Team‐based learning: a relevant strategy in health professionals' education. Med Teach. 2012;34(5):411‐413. [DOI] [PubMed] [Google Scholar]
- 23. Silberman D, Carpenter R, Takemoto JK, Coyne L. The impact of team‐based learning on the critical thinking skills of pharmacy students. Curr Pharm Teach Learn. 2021;13(2):116‐121. [DOI] [PubMed] [Google Scholar]
- 24. El‐Banna MM, Whitlow M, McNelis AM. Improving pharmacology standardized test and final examination scores through team‐based learning. Nurse Educ. 2020;45(1):47‐50. [DOI] [PubMed] [Google Scholar]
- 25. Nguyen T, Wong E, Pham A. Incorporating team‐based learning into a physician assistant clinical pharmacology course. J Physician Assist Educ. 2016;27(1):28‐31. [DOI] [PubMed] [Google Scholar]
- 26. Zgheib NK, Simaan JA, Sabra R. Using team‐based learning to teach pharmacology to second year medical students improves student performance. Med Teach. 2010;32(2):130‐135. [DOI] [PubMed] [Google Scholar]
- 27. Kim DH, Lee JH, Kim SA. The pharmacology course for preclinical students using team‐based learning. Korean J Med Educ. 2020;32(1):35‐46. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Carrasco GA, Behling KC, Gentile M, Fischer BD, Ferraro TN. Effectiveness of a Team‐Based Learning exercise in the learning outcomes of a medical pharmacology course: insight from struggling students. Naunyn‐Schmiedeberg Arch Pharmacol. 2021;394(9):1941‐1948. [DOI] [PubMed] [Google Scholar]
- 29. Dunaway GA. Developments: adaption of team learning to an introductory graduate pharmacology course. Teach Learn Med. 2005;17(1):56‐62. [DOI] [PubMed] [Google Scholar]
- 30. Sabra R, Simaan JA, Zgheib NK. Using team based learning (TBL) to teach pharmacology to second year medical students. FASEB J. 2009;23:LB407. [DOI] [PubMed] [Google Scholar]
- 31. Hashilkar NK, Getula M, Ameen A. Effectiveness of team based learning to teach pharmacology for phase‐II MBBS students. J Med Sci. 2014;7:181‐187. [Google Scholar]
- 32. Prabha ML, Rani AG, Maheswari YN, Ramya JE. Impact and perception of virtual team‐based learning in comparison to online lectures in pharmacology‐ a randomised crossover interventional study. J Clin Diagn Res. 2022;16(12):FC09‐FC13. [Google Scholar]
- 33. Mehnaatamai Mohanram A, Zhong Q. Assessing team‐based learning method's effectiveness in medical pharmacology teaching (719.8). FASEB J. 2014;28:718‐719. [Google Scholar]
- 34. Singh H, Jain A, Bala R, Verma K, Modak S. The implementation of team‐based learning in MBBS pharmacology teaching: a student's perception. Chrismed J Health Res. 2018;5(4):281. [Google Scholar]
- 35. Rao YK, Shenoy GK. Introducing team based learning in undergraduate pharmacology. Indian J Pharm. 2013;45(1):102‐103. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Chen D, Yue H, Liu S, Meng L, Yin W. The introduction of team‐based learning into the clinical pharmacology section of the endodontics clinical course. Clin Exp Pharmacol Physiol. 2022;49(9):998‐1001. [DOI] [PubMed] [Google Scholar]
- 37. Attia RT, Mandour AA. Team‐based learning‐adopted strategy in pharmacy education: pharmacology and medicinal chemistry students' perceptions. Future J Pharm Sci. 2023;9(1):1‐6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38. Gorman L. Promoting the active learning of pharmacology and clinical therapeutics utilizing team‐based learning (TBL) methods in second year systems modules. FASEB J. 2017;31:660‐662. [Google Scholar]
- 39. Kwan CY. Problem‐based learning and teaching of medical pharmacology. Naunyn Schmiedeberg's Arch Pharmacol. 2002;366:10‐17. [DOI] [PubMed] [Google Scholar]
- 40. Gregson K, Romito LM, Garetto LP. Students' attitudes toward integrating problem‐based learning into a DDS pharmacology curriculum. J Dent Educ. 2010;74(5):489‐498. [PubMed] [Google Scholar]
- 41. Brinkman DJ, Monteiro T, Monteiro EC, Richir MC, van Agtmael MA, Tichelaar J. Switching from a traditional undergraduate programme in (clinical) pharmacology and therapeutics to a problem‐based learning programme. Eur J Clin Pharmacol. 2021;77:421‐429. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Liu L, Du X, Zhang Z, Zhou J. Effect of problem‐based learning in pharmacology education: a meta‐analysis. Stud Educ Eval. 2019;60:43‐58. [Google Scholar]
- 43. Antepohl W, Herzig S. Problem‐based learning versus lecture‐based learning in a course of basic pharmacology: a controlled, randomized study. Med Educ. 1999;33(2):106‐113. [DOI] [PubMed] [Google Scholar]
- 44. Bratt AM. A large group hybrid lecture and problem‐based learning approach to teach central nervous system pharmacology within the third year of an integrated masters level pharmacy degree course. Pharm Educ. 2003;3(1):35‐52. [Google Scholar]
- 45. Mustafa AA, Alassiry HA, Al‐Turki A, Alamri N, Alhamdan NA, Saeed A. Recall of theoretical pharmacology knowledge by 6th year medical students and interns of three medical schools in Riyadh. Saudi Arabia Edu Res Int. 2016;2016:5374653. [Google Scholar]
- 46. Miller SK. A comparison of student outcomes following problem‐based learning instruction versus traditional lecture learning in a graduate pharmacology course. J Am Acad Nurse Pract. 2003;15(12):550‐556. [DOI] [PubMed] [Google Scholar]
- 47. Michel MC, Bischoff A, zu Heringdorf D, Neumann D, Jakobs KH. Problem‐vs. lecture‐based pharmacology teaching in a German medical school. Naunyn Schmiedeberg's Arch Pharmacol. 2002;366:64‐68. [DOI] [PubMed] [Google Scholar]
- 48. Distlehorst LH, Robbs RS. A comparison of problem‐based learning and standard curriculum students: three years of retrospective data. Teach Learn Med. 1998;10(3):131‐137. [Google Scholar]
- 49. Sushama J, Palappallil DS, Thomas SP. Comparison of the effectiveness between problem‐based learning and lecture class in pharmacology for medical undergraduates. J Evid Based Med Healthc. 2022;9(11):48. [Google Scholar]
- 50. Imran M, Shamsi S, Singh A, Goel S, Sharma P, Panesar S. Problem‐based learning versus lecture‐based learning in pharmacology in a junior doctor teaching program: a crossover study from northern India. Int J Res Med Sci. 2015;3(11):3296‐3299. [Google Scholar]
- 51. Laveesh MR, Vishwaprakash MK, Somashekara SC. Comparative study of problem based learning versus structured group discussion in teaching pharmacology. Int J Basic Clin Pharmacol. 2016;5(5):1877‐1880. [Google Scholar]
- 52. Sivam SP, Iatridis PG, Vaughn S. Integration of pharmacology into a problem–based learning curriculum for medical students. Med Educ. 1995;29(4):289‐296. [DOI] [PubMed] [Google Scholar]
- 53. US Department of Education. Accessed November 11, 2023. https://www.ed.gov/essa
- 54. UK Department of Education. Accessed November 11, 2023. https://dera.ioe.ac.uk/id/eprint/8447/7/00844‐2008DOM‐EN_Redacted.pdf
- 55. Fidalgo‐Neto AA, Alberto AV, Bonavita AG, et al. PHARMAVIRTUA: educational software for teaching and learning basic pharmacology. Adv Physiol Educ. 2014;38(4):368‐371. [DOI] [PubMed] [Google Scholar]
- 56. Bryant SG, Correll JM, Clarke BM. Fun with pharmacology: winning students over with Kahoot! Game‐based learning. J Nurs Educ. 2018;57(5):320. [DOI] [PubMed] [Google Scholar]
- 57. Gudadappanavar AM, Benni JM, Javali SB. Effectiveness of the game‐based learning over traditional teaching–learning strategy to instruct pharmacology for phase II medical students. J Educ Health Promot. 2021;10:91. 10.4103/jehp.jehp_624_20 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 58. Hasamnis AA, Arya A, Patil SS. Case‐based learning: our experience in clinical pharmacology teaching. J Pharm Bioallied Sci. 2019;11(2):187‐189. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 59. Tayem YI. The impact of small group case‐based learning on traditional pharmacology teaching. Sultan Qaboos Univ Med J. 2013;13(1):115‐120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 60. Kaur G, Rehncy J, Kahal KS, et al. Case‐based learning as an effective tool in teaching pharmacology to undergraduate medical students in a large group setting. J Med Educat Curri Develop. 2020;7:2382120520920640. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 61. Baheti Tushar C, Gajanan D, Gaurav C, Vishal K. Student perception & effectiveness of case based learning in pharmacology. Pravara Med Rev. 2020;12(4):4‐10. [Google Scholar]
- 62. Chiranjeevi UK, Gedela V, Rao GH. A comparative study of case‐based learning with conventional teaching in undergraduate training of pharmacology. Nat J Physiol Pharm Pharmacol. 2022;12(5):712‐716. [Google Scholar]
- 63. Gupta K, Arora S, Kaushal S. Modified case based learning: our experience with a new module for pharmacology undergraduate teaching. Int J Appl Basic Med Res. 2014;4(2):90‐94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 64. Kumar A, Aslami AN. Introduction of “case‐based learning” for teaching pharmacology in a rural medical college in Bihar. Natl J Physiol Pharm Pharmacol. 2016;6(5):427. [Google Scholar]
- 65. Jain S, Paliwal A, Kashyap G, Shoaib M. Case based learning vs traditional didactic lectures as a teaching‐learning method in pharmacology. J Popul Ther Clin Pharmacol. 2023;30(18):425‐432. [Google Scholar]
- 66. Meira MB, Maioli EC, Souza RM, Camargo MS, Mistro S. Case‐based learning for teaching pharmacology to pharmacy students. Revista Brasileira de Farmácia Hospitalar e Serviços de Saúde. 2022;13(3):775. [Google Scholar]
- 67. Taesotikul T, Watana S, Nawanopparatsakul S, Nuntharatanapong N, Chinpaisal C, Phuagphong P. Case‐based learning for better understanding in pharmacology: an experience with pharmacy students. 2023 IEEE 12th International Conference on Educational and Information Technology (ICEIT). Institute of Electrical and Electronics Engineers (IEEE); 2023:87‐90. [Google Scholar]
- 68. Özdener F, Özbaykuş AC, Yavuz M, Sürsal A, Narter F, Koç D. Case based learning versus conventional lecture in clinical pharmacology education and its relation to learning styles. South Clin Ist Euras. 2020;31(3):208‐213. [Google Scholar]
- 69. Jalgaonkar SV, Sarkate PV, Tripathi RK. Students perception about small group teaching techniques: role play method and case based learning in pharmacology. Edu Med J. 2012;4(2):e13‐e18. [Google Scholar]
- 70. Kantar LD, Sailian S. The effect of instruction on learning: case based versus lecture based. Teach Learn Nurs. 2018;13(4):207‐211. [Google Scholar]
- 71. Picard J, Sutcliffe R, Kinobe RT. Utilisation and evaluation of cooperative case‐based teaching for integration of microbiology and pharmacology in veterinary education. Health Prof Educ. 2020;6(2):211‐221. [Google Scholar]
- 72. Vora MB, Shah CJ. Case‐based learning in pharmacology: moving from teaching to learning. Int J Appl Basic Med Res. 2015;5(Suppl 1):S21‐S23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 73. Rajasekaran SK. Effectiveness of the hybrid model of case‐based teaching in medical pharmacology. Med Sci Educator. 2009;19(4):160‐166. [Google Scholar]
- 74. Chacko TV. Emerging pedagogies for effective adult learning: from andragogy to heutagogy. Arch Med Health Sci. 2018;6(2):278‐283. [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data discussed in the manuscript are publicly available in the articles cited.