Integrated Pharmacotherapy Teaching and OSPE

Pharmacotherapy Internship with approach of

Guide to Good Prescribing-WHO

Abraham Simatupang, Lili Indrawati, Hertina Silaban,

Agus W Nugroho, Mulyadi Djojosaputro

Faculty of Medicine - Universitas Kristen Indonesia

[email protected]; [email protected]

[email protected]

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Introduction: Faculty of Medicine at a glance

Competence

Activities Examination & Evaluation (OSPE)

Faculty of Medicine: at a glance

• Established in 1962, located in east Jakarta.

• Present: 24 Departements, with faculties/academic staff ca. 110; student body ca. 1,250

• 4 research institutes:

• Tropical medicine

• Neuroscience

• Herbal medicine

• Traumatology

Competences of UKI’s Medical Doctor

• 7 (seven) areas of competence based on the Indonesian Doctor Competence Standard issued by Indonesian Medical Council:

1. Effective Communication

2. Basic And Biomedical Science

3. Behavior Medicine, Basic Clinical Skills

4. Health Problem Management

5. Appraisal Competence, Self Awareness

6. Care Personal Development

7. Professionalism and Moral Ethics

Learning Phase • Phase I : Foundation of Medicine offered through semester 1 to 2; • Phase II : Transition from theory to practice offered through semester 3

to 7; • Phase III : Doctor in practice (Clinical Clerkship) offered through

semester 8 to 11. • Degrees: • Sarjana Kedokteran (SKed.) or Bachelor degree after finishing 25 Blocks

(7 semesters) • Medical Doctor (dr./MD) or Professional degree after finishing 3

semesters

Lectures on basic pharmacology (etc. PK and PD) & special pharmacology (etc. Hormones, RAA System)

See slide on Pharmacotherapy internship

Learning Methods

• Problem based learning

• Seven jump (David et all, 1999): • STEP 1 : CLARIFICATION OF WORDS/TERMS

• STEP 2 : IDENTIFICATION OF PROBLEM

• STEP 3 : ANALYSIS OF PROBLEM (BRAINSTORMING)

• STEP 4 : ESTABLISHMENT OF HYPOTHESES

• STEP 5 : DEFINING LEARNING OBJECTIVES

• STEP 6 : INFORMATION GATHERING AND INDEPENDENT STUDY

• STEP 7 : INFORMATION SHARING AND DISCUSSION ON INDEPENDENT STUDY PRODUCT

Pharmacotherapy Internship

• Pharmacotherapy is one of the competencies every medical doctors should do in their daily practice

• Patient safety, health insurance, development of biomedical science (evidence based medicine, patient-centered medicine)

• Four important things for pharmacotherapy or giving prescription: efficacy, safety, suitability and cost.

• This competency should be taught as early as possible

• This internship is given after the student reached their Bachelor degree (25 Blocks) for 5 weeks

Main competence

After finishing the internship students are:

• be able to prescribe rationally

• be able to prepare some pharmaceutical preparations, such as:

• Powder

• Suspension

• Cream/paste

Activities in pharmacotherapy internship

• Practice of pharmacy (Praktikum): 1. Writing and reading prescription 2. Preparing pharmaceutical preparations • Internship: 1. Case-based (polyclinic/out-patient and in-patient) 2. Students observe cases in poly-clinic and in-patients 3. Students write a therapy-plan (non-pharmacotherapy &

pharmacotherapy) 4. Discuss the therapy-plan among them and with the doctors and

academic staff of Dept. of Pharmacology & Therapy

Therapy cycle

1. Define problem(s)

2. Define aim of therapy

3. Check for P-Therapy

4. Start therapy

5. Information:

drugs, application,

warnings

6. Monitor (stop?) therapy

Guide to Good Prescribing from WHO

Sources: 1. Teacher’s guide to good prescribing (2001). WHO

Essential Drugs & Medicines Policy 2. Guide to Good Prescribing. A practical Manual (1994).

WHO Action Programme on Essential Drugs. Geneva

Problem & Aim of Therapy

Patient 1: A 4 y.o. child with mild had diarrhea no throw-up for 3 days. He has

not urinated for the last 24 hours. Physical Exam: Temp. 36,8 oC, pulse quick and

weak, skin turgor weak.

• Problem (?): (severe) dehydration

• Aim of therapy: rehydrate

Patient 3: Mr. P 40 y.o, complained for headache and muscle-ache at the back of

head. Physical exam.: Blood press.: 145/100 mmHg, Pulse: 80 x/minute. Lung,

heart, liver and kidney: normal. BodyMass Index (BMI): 28. Working Diagnosis:

(esensial) hypertension grade 1.

Problem (?):

Aim of therapy: Prevention of end-organ failure, other (?)

1. Define the diagnosis Angina pectoris stabil yang disebabkan oleh penyumbatan parsial a. koronaria

2. Define the aim(s) of therapy Overcome the attack as soon as possible. Reduce myocardial demand for oxygen by

reducing the pre-load and afterload , heart-rate also its contractility.

3. List a prospective medicines that suit to the

pathophysiology of the diagnosis

NItrates

Beta blockers

Ca channel antagonists

4. Select the prospective medicines in accordance to

efficacy, safety, suitability and cost Efficacy Safety Suitability Cost

Nitrates + ± ++ +

Beta blockers + ± - -

Ca channel antagonists + ± - -

5. Select the P-therapy Efficacy Safety Suitability Cost

Glyceril trinitrate (tablet) + ± + +

Isosorbid dinitrate (tablet) + ± + -

Isosorbid dinitrate (inhalation) + ± (+) ±

Isosorbid mononitrat (tablet) + ± + ±

6. Conclusion

Active substance, preparate Isosorbid dinitrate, tablet 5 mg, sublingual

Dosage 1 tab. , if it is needed 1-3 menit if the pain persists

Therapy program In accordance to the guidelines

(P)ersonal therapy

Examination & Assessment

Objective Structure Pharmacotherapy Examination (OSPE)

Basically OSPE is developed with a model of Objective Structured Clinical Examination (OSCE), but OSPE focuses more in pharmacotherapy and its challenges. The students should firstly explain what is her/his therapy aim to the given case and afterwards she/he writes prescription. The students will be asked by the examiner: the aim of therapy and its background, the efficacy, safety (adverse events, drug interactions) and suitability of the medicine they prescribed. The scoring: Each competence-item has a score from 0 to 3 and weighted 2 or 3. The max score is 33 which is equal to 100 The final score will be calculated from pharmacotherapy score and practice (praktikum) which is weighted to 60:40, respectively. The student passed the examination if the final score achieved minimum 65 (range from 0 to 100).

Example of Case

Rubric of OSPE

ASSESSMENT FORM of OSPE

Pharmacy practice (praktikum)

Objective Structured Pharmacotherapy Examination (OSPE)

Students’ Exam Papers

Case IPD_01 Hypertensi-on

Name/NIM Name/NIM Name/NIM Name/NIM Name/NIM

Pandu H Jatmiko

Maria

Linggar Pratiwi

Diana

Nubatonis

Florida Linawati AS

Sri

Sukmalestari

Weight 09-198 Score & Weight

09-196 Score & Weight

09-197 Score & Weight

09-189 Score & Weight

09-186 Score & Weight

Item Penilaian 0/1/2/3 0/1/2/3 0/1/2/3 0/1/2/3 0/1/2/3

Aim of therapy 2 1 2 2 4 3 6 3 6 3 6

Prescription 3 2 6 1 3 2 6 2 6 2 6

Indication Contra indication

2 2 4 2 4 2 4 2 4 2 4

Adverse events 2 1 2 0 0 1 2 2 4 2 4

Drug interaction

2 0 0 0 0 1 2 0 0 1 2

Score 14 11 20 20 22

Assessment of OSPE

Some ad-interim results of our survey on students’ perception of the internship*

• Students are active to look upon text-book of pharmacology, journal, guidelines and EBM during internship.

• Mean of points (0-100) 67,94 ± 7,56 (range: 60-81).

• Most of the students are happy with the approach and the internship is needed for their coming internship (surgery, internist, pediatric, etc.) and for their future career as medical doctors

* The students are asked through online survey which is developed in Google.docs form

Prescription writing

Medication preparation

Lectures and discussion on pharmacy

General views of students on the pharmacotherapy internship

Students’ perception survey

Pria 23%

Wanita 77%

Jenis Kelamin

N=13

Note: Likert scale: 1 not good, 5 very good

dr. Agus wiyanto N, SpFK

dr. Lili Indrawati, MS

dr. Hayati Siregar, MS dr. Grace Bolang

dr. Hertina Silaban, MSi.

Dr. med. Abraham

Simatupang, dr., MKes.

Academic staff of the Dept. of Pharmacology Therapy

Social media: Facebook

Research Activity & Miscellaneous Topics At the moment the Dept. of Pharmacology and Therapy has programs: • Clinical Trial (patient recruitment) under Neuroscience Research Center

Piperine nigra (black pepper) as add-on therapy for epilepsy • Cooperation with Institute for clinical Chemistry & Clinical Pharmacology Uni-Klinik Bonn 1. Atheroindonesia Project: Cholesterol, precursors of sterols, oxysterols and plant sterols levels in patients and non-patients of Germany and Indonesian. 2. Online survey: Prescription pattern of Indonesian and German doctors (Vergleich der Verschreibungspraxis zwischen deutschen und indonesischen Ärzten) Backgrounds: rational prescribing, integration of pharmacology & clinical pharmacology into daily practice of medical doctors, relationship between MDs and Pharmacists/Apotheker/inen comparative study between German & Indonesian MDs

• Development of cooperation with respect to integration of pharmacology and clinical pharmacology into internship is highly appreciated!

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Terima kasih Mauliate Matur nuwun Bujur Hatur nuhun Abrigado Thank you Makaseh