The research described in this thesis was carried out under the supervision of Charlotte Mbali and Julie Botha from the University of KwaZulu Natal. The dissertation also includes an analysis of the quantitative assessment according to the cognitive categories of Bloom's Taxonomy, as well as qualitative data collected from interviews with students, which revealed the understanding of prescribing skills that prevailed at different Bloom's cognitive levels for different students.
INTRODUCTION
Although an attempt was made to link these topics to one of the problems in the PBL curriculum, they often did not fit well with the problem at hand. The first aim was to assess students' level of confidence in their prescribing judgments to determine whether a lack of prescribing confidence was a general problem.
LITERATURE REVIEW The Goal
Students who think of learning a topic in a limited way (such as learning by heart to increase knowledge quantitatively) are unlikely to take a deep approach to learning the specific topic. Teaching therapeutics using the p-drug process shifts the perspective of learning from one where only product (ie, the outcome, such as an appropriate drug for a specific problem) is important.
CONCEPTUAL FRAMEWORK AND CORE CONCEPTS Conceptual framework
Phenomenography is the study of the limited number of qualitatively different ways in which a phenomenon is experienced. The emphasis is on differences, resulting in a partial description of the experience of a phenomenon that does not include ways of experiencing the phenomenon that are common to the group.
IMPLEMENTATION Study design
Examples of the types of stimulus materials we used were graphs (two questions), treatment guidelines (one question), a print advertisement graphic (one question), clinical scenarios (six questions), a clinical scenario with diagram (one question), and a clinical scenario with treatment instructions (one question). The main limitation of the 'think aloud' method is that not all thoughts can be articulated.
ANALYSIS Pre-intervention test
Appropriate treatment was given by two out of ten students for case A (asthma), and by one out of ten students for cases C (statin-induced myalgia) and D (knee osteoarthritis). Two students, who ranked seventh and eighth on the test, considered efficacy, safety, suitability and cost when making their treatment decisions. In the following category, disease was conceptualized as having levels of severity and treatment decisions depended on the level of severity with which the patient presented.
In the fourth category, we expanded the concept of prescribing from the selection of drugs to the selection of treatment that included. Many of the students who did not attend were unable to do so because it was scheduled during the holidays when they were traveling home far from Durban. On the day of the assessment, 79 students (46% of the entire class) were present in the class.
Strengths of the course highlighted included student-faculty relationships, group work and time on task: some students liked the intense and focused block of time. Several students reported that they felt that the lessons were not graded as a weakness. Most often, they requested that these exercises be conducted as part of the curriculum at the beginning of the students' training.
DISCUSSION AND CONCLUSION
The number of students interviewed was small, so this finding should not be considered representative of the entire class. Turning our attention to the problems highlighted by students (Table 10), the comments reveal something of the students' understanding of learning itself. The category 'gap in prescribing strategy' shows some understanding of the evaluative skills required to prescribe competently.
My approach to the analysis of the transcripts differed from Denig et al (2002). In addition, an understanding of the patient's role seems to change as the performance develops. In the first category, the student was interested in giving an inhaler to induce bronchodilation in the smooth muscle of the lung, her consideration of the patient limited to the level of the organ in question.
The understanding that the student in the fourth category shows is of the patient as an individual linked to a context (in this case, a work situation that can aggravate asthma symptoms). At the last level, the patient perception in relation to the prescribing process has again changed. The student who falls into this category has recognized that optimal prescribing also depends on the patient's ability and motivation to follow the prescribing decision.
This experience also helped me to appreciate and focus more on the qualitative research component of the study. She believes it is probably due to the after-effects of the sinus infection she recently had.
Pre-and Post-Intervention Questionnaire
Please refer to advert Question 1 in the Appendix
In a patient who contracts malaria while taking appropriate malaria prophylaxis, symptoms are initially less severe and complications are delayed. The family should be advised to report flu-like symptoms that develop during their stay and approximately two months thereafter. As you reassure them that the condition is self-limiting and no intervention is needed, she mentions "It's ok if I started a bit late with my pack of Femodene®, isn't it?" and takes the packet of contraceptives out of her handbag to show you which pills she missed.
She took all the red tablets from the previous pack and then, with all the worry of a sick child, forgot to start the white tablets from the new pack for two days.
The placebo tablets should be left out at the end of Mrs Jacobs' new pack and she should instead start with the active tablets in the new pack. Once a patient has responded to antidepressant treatment, treatment should be continued for 6-12 months after a single episode to prevent relapse. The weather is hot and after a day of digging in the garden she is feeling unwell, probably from mild dehydration, and her osteoarthritis knee has become painful.
The pharmacist should explain that metoclopramide can act as an agonist at dopamine receptors in the extrapyramidal system. Dopamine deficiency accompanied by an overload of acetylcholine in the extrapyramidal system can cause extrapyramidal symptoms. Dr Pillay should be advised to switch Ms Ndlovu's medication to a 5HT3 antagonist such as ondansetron.
Diet, exercise and weight loss are extremely important in the management of type 2 diabetes as they lower blood glucose concentrations and reduce coexisting risk factors for heart disease. With her current treatment, Mrs Karlsen has a greater than 10% risk of myocardial infarction over 10 years. Agents of the protease inhibitor class (eg, indinavir, lopinavir, and ritonavir) should be reserved for second-line therapy, when the first treatment regimen fails.
Student Evaluation Questionnaire
Do you think your understanding of graphics has changed as a result of the holiday lessons? How well do you think you understood the arithmetic steps in forward dose calculations. Do you think your understanding of the arithmetic steps in dose calculations has changed as a result of the holiday lessons?
Do you think your understanding of the counseling skills involved in the prescribing process has changed as a result of the holiday guides. How well do you think you were able to critically analyze the company's communications (e.g. advertisements, presentations by pharmaceutical representatives) before the holiday exercises. Do you think your ability to critically analyze corporate communications changed as a result of the holiday guides?
Paper published in the SA Journal of Higher Education
The sample was stratified to ensure representation of each of the following groups of results: 30±. Students who had participated in (part of) the intervention were then asked to evaluate the program during a standard lecture session. Lack of trust was a common theme raised by interviewees. Table 3 (see next page) provides an overview of the interviewees' treatment decisions.
Several students reported that they felt that the lectures were not graded as a weakness. Understanding the arithmetic steps involved in dosage calculations Understanding the counseling skills involved in the prescribing process. The test results before the intervention were poor, less than a third of the students scored 50 percent.
Of the short-answer questions, the worst answer was a dosage calculation question (average 5 percent.) The question required students to retrieve dosage information from a package insert and explain the steps for proper dosage. Taking into account students' confidence about their answers, an analysis of the true/false question with the best answer (the insulin question) shows that for two of the five parts of this question, students who answered correctly had a significantly higher credibility rating than those who did not. The subject strengths articulated in the student evaluation questionnaire are compared to some of the qualities highlighted in the 7 Principles for Good Practice in University Education (Johnson Foundation 1987).
Paper submitted to Medical Teacher
MEDICAL
Undergraduate medical students' reasoning with regard to the prescribing process
Details of this assessment as well as the design and evaluation of the intervention have been previously published. Bloom (1956) developed lists of the abilities graduates need for developing competence in their chosen field. The implications of the neglect of therapeutic teaching in the undergraduate curriculum are far-reaching.
Next, the portion of the student interview transcripts related to two of the prescribing problems (related to asthma and otitis media) was reviewed. The lack of students' skills in higher cognitive domains should be seen in light of the fact that the spread of test questions was uneven. The phenomenographic part of the analysis provides an overview of students' conceptions of the prescription process.
In the first category, the student's attention to the patient was limited to the level of the organ in question. In the last category, the student recognized that optimal prescribing also depends on the patient's participation and motivation in the prescribing decision. Details of the pharmacological topic within each skill can be found in Harries et al.2006.
