Abstract and Introduction
Abstract
Objective. To introduce pharmacy students to a patient-centered mnemonic to aid them in remembering the most important parameters when assessing a patient's drug therapy and to determine whether use of the device improved students' clinical examination scores.
Design. Second-year pharmacy students were randomized to an intervention group or a control group. A 30-minute presentation on the rationale of the mnemonic and how to apply it to clinical scenarios was given to the intervention group and then a case-based multiple-choice clinical examination was administered. Students in the control group completed the same examination first and then were given the mnemonic.
Assessment. Ninety-five students completed the examination. Examination scores of students in the intervention group were 6% higher than those of students in the control group (p = 0.04). A 6-question survey instrument was administered to both groups and the majority of students agreed that they would use the mnemonic when assessing patients during their upcoming practice experiences. One-hundred percent of the students stated that the mnemonic definitely or probably helped them (or would have helped them) think critically when assessing the patient cases.
Conclusions. Pharmacy students who used a mnemonic device for pharmacotherapy assessment exhibited better decision-making skills and made fewer errors than students who did not use the mnemonic.
Introduction
The pharmacist's role continues to expand and now includes therapeutic decision making for individual patients. The outcomes created by the Center for the Advancement of Pharmaceutical Education (CAPE) strongly emphasize pharmacy students being able to provide patient-centered care. Similarly, the Accreditation Council for Pharmacy Education (ACPE) requires that pharmacy graduates be competent to provide patient-centered care and have the ability to design, implement, monitor, evaluate, and adjust pharmacy care plans that are patient-specific. In doing so, graduates are expected to minimize drug misadventures and optimize patient outcomes.
When pharmacy students start their advanced pharmacy practice experiences (APPEs) they need to be able to think critically and feel confident in their decisions. The transition from classroom lectures to experiential learning is difficult. One of the fundamental challenges encountered by pharmacy students is applying knowledge learned in the classroom to specific patients, even if the students received excellent grades in therapeutics courses. To list all of the side effects and contraindications of lisinopril, for example, a student must recall memorized information. However, to determine whether a particular patient should receive lisinopril, a student must be able to assimilate previously learned knowledge and apply it to a unique clinical situation through reasoning and critical thinking. Students often struggle with making drug therapy recommendations for specific patients because they are afraid of making a critical mistake.
To maximize sound decision making and minimize errors, a systematic tool, such as a flowchart, checklist, or mnemonic, can be used. In their development of a flowchart for therapeutics integration, Winslade and colleagues stressed that pharmacy students must have a problem-solving decision-making framework to follow to help ensure that they consider all of the important information when assessing a patient's drug-related problems. "Adverse drug reaction," "excess dose," and "drug interaction" are decision points along the multiple-branching algorithm that must be considered as potential causes for a drug-related problem. By following the flowchart, students are less likely to overlook an existing or potential problem related to 1 of these 3 causes.
Similar to an arborization strategy such as a flowchart, a checklist offers a systematic and comprehensive method of outlining criteria that should be considered when undertaking a particular process. Hales and colleagues assert that checklists are "important tools to condense large quantities of knowledge in a concise fashion, reduce the frequency of errors of omission, create reliable and reproducible evaluations and improve quality standards." Not only do checklists simplify information processing, they have the potential to improve the quality of patient care. For example, implementation of a 19-item World Health Organization safe-surgery checklist resulted in decreased rates of death and complications among patients.
Similar to a flowchart or checklist, a mnemonic device can be used to navigate through a complicated clinical decision-making process. One unique advantage of mnemonic devices is that they can be remembered easily. Numerous examples of medical mnemonics exist. For example, the mnemonic "GOLD MARK" was introduced in a paper published in Lancet to describe the possible causes for an anion-gap metabolic acidosis (Glycols, Oxoproline (Tylenol overdose), L-lactate, D-lactate, Methanol, Aspirin, Renal failure, Ketoacidosis). Two other examples of mnemonics include "SAFE," which was developed by members of the American College of Allergy, Asthma and Immunology and the American College of Emergency Physicians to remind physicians of the 4 basic action steps suggested for the care of a patient with anaphylaxis (Seek support, Allergen identification and avoidance, Follow-up for specialty care, and Epinephrine for emergencies) and "AIRESMOG" to assess contributors to poor asthma control (Allergy and adherence to therapy, Infection and inflammation, Rhinitis and rhinosinusitis, Exercise and error in diagnosis, Smoking and psychogenic factors, Medications, Occupational exposures, Obesity and obstructive sleep apnea, Gastroesophageal reflux disease). In each of the previous examples, the mnemonic is used to prompt the user to conduct a thorough assessment of the topic, decreasing the chance that any important parameters are overlooked during assessment.
The mnemonic that we devised, "I ESCAPED CPR" is a patient-centered tool that offers a simple method to remember the most important parameters when assessing drug therapy for a patient and is the first mnemonic proposed for use in pharmacotherapy decision-making. The mnemonic, as shown in Figure 1, can be used to analyze current therapy and potential therapy being considered. It was our objective for pharmacy students to use the mnemonic I ESCAPED CPR to improve their scores on a case-based clinical examination. We hypothesized that students who learned the mnemonic would be more skilled at systematically approaching drug-therapy decisions for a particular patient, while minimizing the risk for errors. It was not our intention to test students' recollection of memorized facts, but rather to test the success of a tool to increase students' abilities to systematically organize their thoughts, resulting in safe, effective, and appropriate patient-specific decisions about pharmacotherapy.
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Figure 1.
"I ESCAPED CPR" Mnemonic.