The purpose of the present study was to assess the current status of physiology education in US Doctor of Pharmacy (PharmD) programs. A survey instrument was developed and distributed through SurveyMonkey to American Association of Colleges of Pharmacy (AACP) Biological Sciences section members of 132 PharmD programs. Survey items focused on soliciting qualitative and quantitative information on the delivery of physiology curricular contents and faculty perceptions of physiology education. A total of 114 programs responded to the survey, resulting in a response rate of 86%. Out of 114 schools/colleges, 61 programs (54%) offered standalone physiology courses, and 53 programs (46%) offered physiology integrated with other courses. When integrated, the average contact hours for physiology contents were significantly reduced compared with standalone courses (30 vs. 84 h, P < 0.0001). Survey respondents identified diverse strategies in the delivery and assessment of physiology contents. Eighty percent of the responding faculty (n = 204) agree/strongly agree that physiology is underemphasized in PharmD curriculum. Moreover, 67% of the respondents agree/strongly agree that physiology should be taught as a standalone foundational course. A wide variation in the depth and breadth of physiology course offerings in US PharmD programs remains. The reduction of physiology contents is evident when physiology is taught as a component of integrated courses. Given current trends that favor integrated curricula, these data suggest that additional collaboration among basic and clinical science faculty is required to ensure that physiology contents are balanced and not underemphasized in a PharmD curriculum.
- pharmacy education
- PharmD integration
- basic sciences
after decades of product-orientated and dispensing focus, the pharmacy practice has undergone a transformation with regard to its role, its status, and the provision of key services within the healthcare system (16, 25, 26). Over the past few years, the profession has focused on optimizing drug therapy outcomes through patient-centered care (16, 49). Accordingly, pharmacy education has strived to emphasize the roles of pharmacists as clinicians and medication therapy experts (6). The purpose of pharmacy education is to train competent Doctor of Pharmacy (PharmD) graduates who provide medication therapy management and develop or modify protocols to address unpredictable or unique patient care situations. Basic biomedical science remains the cornerstone of pharmacy education, particularly as it relates to the provision of evidence-based practice. Because of an increasing reliance of clinical practice on the latest scientific discoveries and advancements, the relevance of biomedical sciences to pharmacy practice becomes even more apparent (18).
Recently, pharmacy curriculum reforms focusing on outcome-based, patient-centered clinical education (with significant emphasis on pharmacy practice, social and administrative sciences, and experiential education) have resulted in noticeable reductions in the teaching of basic pharmaceutical and biomedical sciences (43, 58). Additionally, these changes have been accompanied by an increasing trend whereby the basic and clinical sciences have been integrated in pharmacy curricula throughout the US (29, 30). Although curricular integration offers contextual learning by connecting the relevance among different disciplinary concepts (48, 54), balanced integration of basic and clinical sciences remains an ongoing challenge for curriculum planners (10, 20). A significant concern among biomedical science educators is that integrated curricula are often created at the expense of disciplinary depth, resulting in content dilution (44).
Although pharmacy is an applied science, the importance of basic sciences in pharmacy education and training has long been recognized (14, 43). Physiology is one of many basic biomedical science components among PharmD programs. It provides the foundation for understanding pathophysiological processes and mechanisms of drug action. Physiology course contents include anatomy/histology, biochemistry, biophysics, cell biology, clinical medicine, neuroscience, pharmacology, genomics, and proteomics. As such, among basic sciences, physiology is the most relevant to clinical practice (4, 42). A fundamental knowledge of the human body is necessary for successful clinical reasoning and decision-making (18). As new drugs have rapidly appeared on the market, an explosion of new scientific knowledge has emerged. These scientific advances, coupled with a better understanding of the human genome, require the current cadre of graduating healthcare students to understand molecular, cellular, and organ system physiology.
Given the importance of physiology to PharmD curricula, there is a significant impetus to survey physiology instruction among US colleges and schools of pharmacy. Here, we provide an assessment of the current status of physiology instruction for pharmacy students, the extent of integration of physiology with clinical science content, and the instructional design and assessment of physiology courses/components in the curriculum. Our study presents information regarding the impact of curricular changes on physiology education and may inform curricular revisions as pharmacy educators engage in the curriculum review process.
A 31-item survey instrument was developed and focused on soliciting qualitative and quantitative information on the delivery of physiology contents and faculty perceptions of physiology education in US PharmD programs. The survey instrument was divided into three sections. Three questions in the first portion of the survey sought general perceptions of faculty regarding physiology education. In the second section, 21 survey items focused on evaluating the different types of physiology course offerings in the PharmD curriculum (standalone vs. integrated), including course design, implementation, and assessment. The last section of the survey instrument utilized seven survey items to collect demographic information of responding faculty and their respective PharmD programs.
Survey items were formulated by the authors, and as a pretesting process, the survey was reviewed by two independent pharmacy faculty members with biomedical sciences backgrounds who did not participate in the study. The survey instrument was revised based on their feedback regarding the clarity of survey questions and composition and whether the survey items adequately addressed the study objectives. To minimize survey fatigue, skip logic was employed to direct respondents to a different path in the survey based on their responses. An electronic hyperlink to the survey instrument was emailed to the physiology instructors of 132 Accreditation Council for Pharmacy Education’s (ACPE) accredited and candidate status PharmD programs in the US and its territories through the AACP Biological Sciences section member distribution list. SurveyMonkey (Portland, OR) was utilized to collect responses. The survey was configured to track responses from individual schools/colleges based on each respondent's e-mail address. The survey instrument was initially sent on December 8, 2014, followed by two subsequent reminders sent 4 wk apart. The survey was closed on February 16, 2015. An accompanying cover letter articulated the purpose of the survey along with assurance that participation was voluntary and that participant identity would remain confidential. To ensure confidentiality, all files were password protected and stored in a password-protected stationary computer in a locked office.
If multiple individuals from the same institution responded to questions, data were not combined when conflicting answers were chosen for nonperception questions (i.e, prerequisite requirement for admission, course design, and course credit/contact hours). To account for these isolated instances, an answer was selected based on the respondent individual’s position and/or rank, with preferences given to faculty members considered most likely to have the best understanding of the course (i.e., course coordinator/director, years of experience, and type of position). Data from multiple faculty of the same institution, particularly on teaching and assessment strategies and perception-based questions, were combined for analysis. Based on the survey instructions, we included all “single” responses (when only one faculty member responded from an institution) in the data analysis irrespective of the faculty member’s years of experience. For example, respondents were instructed to answer survey items 4–24 only if they were knowledgeable on physiology course structure and content.
Course credit/contact hours from quarter system programs were adjusted to semester credit hours. Credit hours for programs with three quarters rather than two semesters were multiplied by two-thirds to determine an equivalent number of semester credit hours. Credit hours for programs with four quarters rather than two semesters were multiplied by one-half to determine an equivalent number of semester credit hours. Statistical analyses were conducted using SigmaPlot (version 3; Systat Software, San Jose, CA). Unpaired Student’s t-test and one-way ANOVA were used to analyze data on course contact hours. For analysis of proportions or percent data from two sample populations, the z-test (2-tailed) was utilized. Survey items on faculty perceptions of physiology education were self-reported on a five-point Likert scale of 1 (strongly disagree) to 5 (strongly agree). Response rates were calculated as medians and interquartile range (IQR; 25–75%). Mann-Whitney U-test or Kruskal-Wallis test was used to assess statistical significance among independent variables (i.e., type of institution, years of existence of the program, etc.) and dependent variables (respondents’ level of agreement). Geographic locations of schools/colleges of pharmacy were collected based on nine divisions as defined by the US Census Bureau. This study was deemed exempt by the Institutional Review Boards of West Coast University and Lake Erie College of Osteopathic Medicine.
One-hundred fourteen of 132 ACPE candidate status and accredited US PharmD programs responded to the survey, yielding a response rate of 86%. The institutional response rates when calculated as the percentage of all public (n = 65) and private (n = 67) pharmacy programs were 80 and 92.5%, respectively. The demographic information of the programs and the faculty respondents are displayed in Table 1. Of the total respondents, the percentages of responding public and private programs were 46 and 54%, respectively. The age of the programs varied with 51% >20 yr, 13% of programs 11–20 yr, 20% of programs 6–10 yr, and 17% of programs ≤5 yr old. The class sizes for responding institutions varied with 4% reporting a class size of <50 students, 45% reporting 51–100 students, 27% with a class size of 101–150, and 16% with 151–200 students. Survey respondents were comprised of faculty members with pharmacology/toxicology (67.6%), physiology (22%), biochemistry (7.6%), and microbiology/immunology (2.8%) backgrounds who were involved in physiology instructions in PharmD programs. More than 50% of the respondents indicated having 10 yr or more of academic experience in pharmacy. Because skip logic was employed in the survey, variations were observed in response rates between survey items/questions. Notably, all survey participants responded to questions on the general perceptions of physiology education in pharmacy. The number of respondents for physiology course structure-specific questions was limited to those who were most knowledgeable about the physiology curriculum in their programs.
Figure 1 demonstrates the current status of physiology course offerings among US PharmD programs. Out of 114 programs, 71 programs (62%) require physiology as a prerequisite course for admission. Whereas 61 programs (54%) offer a standalone physiology course, 53 programs (46%) integrate physiology concepts with other courses, including pathophysiology (n = 29), pharmacology (n = 10), and medicinal chemistry, pharmacology, or therapeutics (n = 14). Next, respondents were asked to report the total credit hours/contact hours for their standalone physiology course or the physiology component of any integrated courses. Although 91 colleges/schools of pharmacy responded to this survey item, a large variation in contact hours was observed (Table 2 and Fig. 2). When physiology was offered as a standalone course, the semester credit hours ranged from 2 to 15 credit hours with a mean ± SD of 5.6 ± 2.3 semester credits (n = 61). Average semester credits for physiology standalone courses were higher in private schools compared with public school programs (P = 0.01). When integrated into other courses, however, average contact hours for physiology content (means± SD: 30.2 ± 32.6; n = 30) was significantly reduced compared with calculated contact hours for standalone courses (84.2 ± 32.7; n = 61) (P < 0.0001) (Fig. 2). In addition to reporting total physiology contact hours, respondents were asked to provide contact hour breakdown for selected topics in physiology (Table 3). When offered as a standalone course, 8.5–12.6 h are spent on topics that include cardiovascular, endocrine, renal and body fluids, and neurophysiology. Contact hours for additional topics such as respiratory, gastrointestinal, cell membrane, and muscle physiology ranged from 5.2 to 7.2 h. In integrated courses, the contact hours for any of the aforementioned topics were significantly reduced (range 2–4 h) compared with those reported in standalone courses (P < 0.05).
Respondents who indicated that physiology contents were integrated with other courses in their programs were asked to complete questionnaires on physiology content integration. As shown in Fig. 3, only 46% of respondents agreed/strongly agreed that the contact hour allocation for physiology contents in the integrated courses was adequate. However, 38% of the respondents agreed/strongly agreed that the depth and breadth of physiology contents are compromised in integrated courses. Faculty members with 1–5 yr of experience were more favorable to the statement than others with 6–10 yr of experience. The response rates as medians (IQR 25–75%) for the two above-mentioned groups (1–5 vs. 6–10 yr) were 4 (3–5) and 2 (2–3), respectively (P < 0.05). Seventy-five percent of the respondents indicated that physiology course contents were sequenced and aligned well with pathophysiology/pharmacology/therapeutics contents. Respondents’ levels of agreement on the above questionnaires did not vary with the faculty affiliations (private vs. public institutions), years of experiences in pharmacy education, or the age of respondents' program.
Table 4 shows the pedagogical and assessment methods employed in delivering physiology contents as standalone or integrated courses. The use of multiple pedagogical strategies was common among the responding programs. Commonly employed course delivery methods included lecture (90% standalone, 93.0% integrated), discussion/recitation (51% standalone, 48% integrated), and assignment (52% standalone, 41% integrated, P = 0.214). Audio response systems were also reported as a popular instructional tool in physiology courses, even with traditional lectures (standalone 63%, integrated 54%, P = 0.214). Additional strategies utilized self-directed learning, games, workshop, projects, journal club, problem-based learning (PBL), and team-based learning (TBL). It should be noted that the utilization of PBL and TBL as teaching strategies for physiology was higher in integrated courses than in standalone courses (P < 0.001).
A wide variety of formative and summative assessment strategies were employed in assessing students’ learning of physiology in both standalone and integrated courses (Table 4). In addition to multiple-choice questions, short answer questions (41% standalone, 51% integrated), matching questions (34% standalone, 51% integrated, P < 0.05), or assignments (29% standalone, 32% integrated) were utilized as tools for formative and summative assessments. The use of case studies as an assessment tool for physiology in integrated courses was more common compared with standalone courses (40 vs. 28%, P = 0.089). When asked whether assessment involved testing students’ abilities to integrate physiology concepts in clinical situations, 65% of respondents indicated that they assessed students’ abilities to integrate physiology concepts in clinical situations where the contents were taught in an integrated fashion. Only 53% of respondents indicated that the assessment strategies for integrated physiology courses were developed and reviewed by a collaborative team of faculty.
Survey respondents were asked about their general perceptions of physiology education (Fig. 4). Eighty percent of the responding faculty agreed/strongly agreed with the following statement: “With intensive clinical focus of PharmD curriculum, the importance of physiology is underemphasized.” The response rates favoring this statement were significantly high among faculty members with 1–5 yr of experience compared with those possessing 6–10 yr of experience. The medians (IQR 25–75%) for the two groups (1–5 vs. 6–10 yr) were 5 (3–5) and 4 (2–5), respectively (P < 0.05). Sixty-seven percent of the respondents agreed/strongly agreed that physiology should be taught as a standalone foundational course. When asked whether physiology as a prerequisite only is adequate for PharmD students, 65% of the respondents disagreed/strongly disagreed. There were no significant differences between respondents’ levels of agreement to the aforementioned survey items and their affiliations (private vs. public institutions), years of experience, or the age of the programs.
Physiology provides a framework for understanding perturbations of normal body functions (53, 57). With the identification of thousands of human genes associated with disease (37), there is an increasing need to understand physiology (22, 51). Thus, physiology is well suited to provide the foundation for many new advances in medicine (4). It is of critical importance that clinicians have a solid understanding of the physiological, pathological, and pharmacological mechanisms that underpin a successful diagnosis and clinical treatment (18, 54, 55). Clinicians often utilize biological science explanations when they are challenged with complex and unpredictable patient cases (39). Several studies have reported that preclinical medical students demonstrated positive attitudes toward the importance of physiology for their mastering of pathology and clinical medicine (31, 47). Perhaps even more impressive is that medical students strongly acknowledge physiology as the essential component for interpreting laboratory values along with disease signs and symptoms (47).
Our survey identifies a wide variation in the offering of physiology course content in US PharmD curricula. Of 114 colleges/schools of pharmacy, only 54% offer physiology as a standalone required course; however, the credit hours vary and range from 2 to 10 semester credit hours among programs. The remainder of programs has incorporated physiology content directly into existing courses, where the contact hours vary significantly and range from 2 to 60 h. Given the wide variation in physiology course credit/contact hours identified in our study, current PharmD programs may be providing an inadequate scientific knowledge base to prepare the current generation of pharmacists. It is well known that with the paradigm shift toward outcome-based, patient-oriented education (with a heavy emphasis on pharmacy practice and social and administrative science courses) in PharmD curricula, the emphasis on foundational basic sciences has declined (17, 43, 58). It has been reported that current pharmacy programs are generating pharmacists who are afraid of the basic sciences (5, 58). In addition to these findings, Austin and Gregory (7) reported that basic sciences in pharmacy curriculum were becoming devalued by curriculum planners, students, and practitioners.
The Accreditation Standards and Guidelines 2016 for the Professional Program in Pharmacy set forth by ACPE states that the biomedical and pharmaceutical sciences should be of adequate depth and breadth to provide the foundation for clinical objectives of the professional PharmD program (2). The standards also stress that biomedical sciences should provide the basis for understanding body functions in health and disease and how this scientific knowledge is crucial for clinical reasoning and the provision of appropriate drug therapy. However, unlike the standards articulated for clinical, social, and administrative sciences, accreditation requirements for pharmaceutical and biomedical sciences are vague and open to interpretation. Appendix I of ACPE Standards 2016 suggests that preprofessional requirements of some of the biomedical sciences (e.g., physiology) may fulfill the requirements of the professional curriculum (2). This recommendation essentially undermines the importance of biomedical science knowledge in PharmD education. Approximately 40% of students are admitted to PharmD programs without a 4-yr college education (1); thus, the rigor of their biomedical science education may be below that of students with a traditional, 4-yr undergraduate degree. This notion is supported by well-documented findings that demonstrate a 4-yr college degree as one of the major, significant predictors of academic success for first-year pharmacy students (12, 12a, 27, 40). Therefore, it is imperative for pharmacy academicians and admissions personnel to reevaluate scientific prerequisites and the pharmacy curriculum.
Our survey data reported that integration of physiology content with other courses (e.g., anatomy, pathophysiology, and pharmacology and therapeutics) resulted in a significant reduction in depth and breadth of physiology concepts. These data are surprising given evidence that integration creates relevance and meaning for new learning, improves knowledge retention and helps students apply learned knowledge in real-life situations (46, 54, 56). Our data reflect current faculty perceptions that physiology is poorly integrated into their respective curricula and that improvement should be made. Integration undoubtedly leads to a deep understanding and application of basic science principles in the appropriate clinical context (8, 21, 48). In medical schools, there is an increasing trend of integrating biomedical sciences both horizontally and vertically to enhance the application of basic science in clinical reasoning (19, 33, 45, 50, 52). Students experience the teaching of physiology as more exciting when they are integrated in organ system blocks with clinical bearings (15). However, the transformation of teaching physiology in an integrated system-based curriculum is associated with a number of challenges, including appropriate planning, determining the content depth and breadth, and careful oversight (24, 38). Challenges on how to structure or balance an integrated biomedical science and clinical curriculum in the absence of adequate direction remain (3). Considerable collaborative efforts, faculty appreciation, and understandings of the linkages between disciplines and careful and contextual selection of disciplinary depth and breadth contribute to the development of a truly balanced and integrated curriculum (10, 20, 45). It should be noted that integrated curricula are often designed and delivered at the expense of disciplinary depth; this approach contributes to content dilution and superficial learning (44). In our survey, 80% of the responding faculty agreed/strongly agreed that physiology is underemphasized in current PharmD curricula. Moreover, two-thirds of respondents agreed/strongly agreed that physiology should be taught as a standalone foundational course. Notably, the same proportion of respondents disagreed/strongly disagreed with the notion that physiology as a prerequisite is adequate for PharmD students.
Today’s pharmacy classrooms are comprised of an array of students of different ages, sexes/genders and ethnic and cultural backgrounds; this diversity undoubtedly helps students address health disparities present in our healthcare system. Although this diversity is welcomed, it also poses challenges to addressing a wide spectrum of learning styles among students and requires that a variety of learning approaches are used to engage different styles of learning (41). Active learning strategies benefit all types of learners in the visual, auditory, and kinesthetic schemes (34). It is encouraging that schools/colleges of pharmacy have adopted diverse teaching and learning strategies in the teaching of physiology contents. The use of multiple pedagogical strategies was common across pharmacy programs in the country. Commonly employed course delivery methods include lecture, discussion/recitation, assignments, audio response system, self-directed learning, games, workshop, projects, journal club, problem-based learning (PBL), and team-based learning (TBL). The use of PBL and TBL as teaching strategies for physiology was higher in integrated courses than in standalone courses. Several studies have described PBL as a means of integrating the delivery of basic and clinical science courses (11, 13, 36). In medical school education, case-based teaching and TBL formats have been reported to be effective approaches to help students analyze and apply new information in clinical practice (9, 32). The incorporation of clinical relevance or its application into biomedical science courses has been a burgeoning issue in pharmacy education for some time (23). From a basic science curriculum perspective, physiology may serve as a starting point to develop the clinical reasoning skills of the pharmacy student.
In the context of pharmacy education, physiology learning outcomes should reflect students’ sophisticated understanding of how physiological concepts relate to disease mechanisms and clinical practice. Several assessment and evaluation strategies such as use of multiple-choice questions based on patient scenarios (with a focus on contents from different disciplines), reflection questions, short or long essay questions, projects, assignments, case studies, etc., have been suggested in the literature (10, 23, 28). A series of studies have demonstrated that students who were taught pathology in an integrated approach, by linking physiology to clinical pathology, were better able to diagnose difficult clinical cases (55–57). Our survey results showed that 60% of the respondents who taught physiology in an integrated course frequently assessed the student’s ability to relate physiology concepts to a clinical problem through case-based assignments.
The importance of physiology in pharmacy curricula is irrefutable. Therefore, the academy must rigorously assess the effectiveness of current physiology teaching in prepharmacy/pharmacy curriculum. As a starting point, pharmacy curriculum planners should refer to the curricular reforms in medical education where the role and value of basic sciences in medical education is currently being reemphasized (18, 45). The results of our survey study indicate that the majority of science faculty members in pharmacy are in favor of increasing the rigor of physiology in the pharmacy curriculum. However, our study is not without limitations. Faculty from different disciplinary backgrounds involved in physiology teaching responded to the survey. We collected information on respondents’ total number of years of experience in pharmacy education. Although not inquired in the survey, understandings of the respondents’ extent of involvement in physiology instructions could have further strengthened the validity of their views and perceptions of physiology education. Although the number of colleges/schools that responded to the survey was high, in many cases only one faculty member from a given program responded to the survey. Respondents were asked to answer survey items on physiology course structure, contents, delivery, and assessment methods only if they were knowledgeable in the subject area. Thus, all “single” responses on course structure were included in the data analysis. We acknowledge that physiology instruction in multiple integrated courses requires multiple faculty; thus the response from one faculty member may not represent the full scope of physiology integration. Alternatively, the responses to our survey may reflect a low number of physiology faculty members present within schools/colleges of pharmacy.
A significant range in the depth and breadth of physiology course offerings in US PharmD programs exists. The reduction of physiology contents is evident when physiology is taught as a component of integrated courses. Since current pharmacy education trends appear to favor a more integrated curricula, our data suggest that physiology contents must be integrated appropriately with clinical sciences to ensure competence, expertise, and application. An increase in the collaboration among clinical and basic science faculty is needed to facilitate this integration, exchange ideas, understand and value each other’s perspective, and jointly teach tomorrow's pharmacists. Additionally, our data indicate that biomedical and clinical faculty also need to work together to ensure that physiology contents are balanced and not underemphasized within the PharmD curriculum.
No conflict of interest, financial or otherwise, are declared by the authors.
M.A.I., S.A.K., and R.M.T. conception and design of research; M.A.I. performed experiments; M.A.I. analyzed data; M.A.I., S.A.K., and R.M.T. interpreted results of experiments; M.A.I. prepared figures; M.A.I. drafted manuscript; M.A.I., S.A.K., and R.M.T. edited and revised manuscript; M.A.I., S.A.K., and R.M.T. approved final version of manuscript.
We thank Drs. Kyle Sousa and Gauri Sabnis for critically reading the manuscript.
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