|ORIGINAL RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 1 | Page : 46-51
Development of active learning modules in pharmacology for small group teaching
Raakhi K Tripathi1, Pankaj V Sarkate2, Sharmila V Jalgaonkar2, Nirmala N Rege3
1 Associate Professor, Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
2 Assistant Professor, Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
3 Professor and HOD, Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||31-Jul-2015|
Raakhi K Tripathi
Associate Professor, Department of Pharmacology and Therapeutics, College Building, 1st Floor, Seth GS Medical College and KEM Hospital, Acharya Donde Marg, Parel, Mumbai - 400 012
Source of Support: None, Conflict of Interest: None
Background: Current teaching in pharmacology in undergraduate medical curriculum in India is primarily drug centered and stresses imparting factual knowledge rather than on pharmacotherapeutic skills. These skills would be better developed through active learning by the students. Hence modules that will encourage active learning were developed and compared with traditional methods within the Seth GS Medical College, Mumbai. Methods: After Institutional Review Board approval, 90 second year undergraduate medical students who consented were randomized into six sub-groups, each with 15 students. Pre-test was administered. The three sub-groups were taught a topic using active learning modules (active learning groups), which included problems on case scenarios, critical appraisal of prescriptions and drug identification. The remaining three sub-groups were taught the same topic in a conventional tutorial mode (tutorial learning groups). There was crossover for the second topic. Performance was assessed using post-test. Questionnaires with Likert-scaled items were used to assess feedback on teaching technique, student interaction and group dynamics. Results: The active and tutorial learning groups differed significantly in their post-test scores (11.3 ± 1.9 and 15.9 ± 2.7, respectively, P < 0.05). In students' feedback, 69/90 students had perceived the active learning session as interactive (vs. 37/90 students in tutorial group) and enhanced their understanding vs. 56/90 in tutorial group), aroused intellectual curiosity (47/90 students of active learning group vs. 30/90 in tutorial group) and provoked self-learning (41/90 active learning group vs. 14/90 in tutorial group). Sixty-four students in the active learning group felt that questioning each other helped in understanding the topic, which was the experience of 25/90 students in tutorial group. Nevertheless, students (55/90) preferred tutorial mode of learning to help them score better in their examinations. Discussion: In this study, students preferred an active learning environment, though to pass examinations, they preferred the tutorial mode of teaching. Further efforts are required to explore the effects on learning of introducing similar modules for other topics.
Keywords: Active learning, group dynamics, intellectual skills, pharmacology tutorial, small group teaching, student interaction
|How to cite this article:|
Tripathi RK, Sarkate PV, Jalgaonkar SV, Rege NN. Development of active learning modules in pharmacology for small group teaching. Educ Health 2015;28:46-51
| Background|| |
Teaching in medical colleges in India is undergoing a transition from traditional passive classroom teaching to active, patient oriented and skill-based teaching. The intended outcome of this change is for students to be able to apply clinical reasoning and be a more competent health care professional.  The Medical Council of India's Vision 2015 has focused on active and skill-based learning and outcomes to produce an effective and competent "Indian Medical Graduate." 
Second year undergraduate medical students in their 3 rd , 4 th and 5 th semester are exposed to pharmacology, which in our institute is taught in accordance to the curriculum defined by the Maharashtra University of Health Sciences (MUHS).  The skill expected of students in pharmacology is to be able to prescribe rational drug therapy based on disease and patient characteristics. At present, teachers in the institute impart factual information and highlight the clinical applications of the topic during teaching sessions. The theory assessment pattern is also subjective including short and long answer questions, which ask for direct recall only and not application case-based questions. Thus, emphasis is mainly on students receiving information rather than developing the ability to prescribe rational and personalized drug therapy depending on the particular presentation of the disease. Hence it is important for the student to be exposed to various disease scenarios and to develop clinical reasoning and learn how to prescribe rationally. To achieve this, after providing basic drug information to students, they should be exposed to various disease specific case scenarios "Case scenarios" through active learning techniques to develop attitudes of self-learning, critical clinical thinking and good prescribing practices. 
The Pharmacology Department at the Seth GS Medical College, Mumbai, runs tutorial programs for students each semester. Tutorials, coupled with group discussions, are an interactive mode of small group teaching. The present study was planned to evaluate the introduction of active learning techniques into our school's regular teaching sessions of pharmacology. We did not find any published literature evaluating students' perceptions and performance with active learning strategies in pharmacology. The authors did not find any published literature evaluating students' perceptions and performance with active learning strategies in pharmacology. We compared students' feedback on the acceptability and short-term performance with the interactive versus traditional, less interactive teaching/learning strategies. In both tutorial and active learning approaches, student-to-student and student-with-teacher interactions play vital roles in teaching/learning, so these too were assessed under both active learning and traditional teaching approaches.
| Methods|| |
For the study, a prospective, 2-arm, comparative, crossover design was used. Institutional Ethics Review Board permission for the conduct of the study was obtained. A total of 180 second year undergraduate medical students entering their third semester in August 2010 in our institute were eligible for participation in the study. Out of these, 90 students who voluntarily agreed and consented to participate were included in the study. These students were randomized into two major groups; those who participated in an active learning exercise and the others who participated in a more conventional tutorial exercise .
Based on the Active learning modules available in literature,  three modules on a given topic in pharmacology were developed as follows:
- (Module 1) Case scenario; A case of the given disease was described and students had to discuss the pharmacotherapy giving rationale for the use of drug and write the correct prescription
- (Module 2) Critique appraisal of prescriptions; An incorrect prescription for the given disease for a specific patient was written. Students had to identify and explain the inaccuracies and then write the accurate prescription
- (Module 3) Drug identification; On basis of the pharmacokinetics, pharmacodynamics and adverse effects of a particular drug presented as drug autobiography, students had to identify the drug giving justification.
The topics selected as part of small group teaching were anemia and hypertension. The authors developed three different modules for these two topics, which were critically evaluated and refined by internal pharmacology experts (n = 6). The expected answers to the modules were also presented, which were revised by internal pharmacology experts and then forwarded to external pharmacologists (n = 4) for opinion. The final model answer copies were then given to the teachers conducting active learning modules.
Teachers (n = 6) were identified from the department and randomly assigned to active learning group or tutorial group. In addition, the selected teachers for active learning mode were given separate training session (4 h) on active learning principles, group dynamics and resource materials on how to be good facilitator. The teachers were briefed about the topic wise specific learning objectives for both the groups. The authors presented the session plan and the type and sequence of the probable questions to be asked for both the groups. Doubts posed by the teachers were clarified. The teachers conducting active learning modules were provided with the copies of answers to the modules.
Teaching learning activity
Active learning and conventional learning groups were further divided into three sub-groups of approximately 13-15 students each. During the first phase of the project, three of the six sub-groups were taught anemia management as a tutorial, while the remaining three sub-groups were taught using active learning modules. During the second phase of the project, there was crossover of teaching methods. The three sub-groups that were initially taught in tutorial mode were taught hypertension management using active learning modules and vice versa. All students attended the theme lectures on anemia and hypertension.
In the tutorial group, the sessions were conducted in oral question-answer format. If any student had difficulty he/she asked the teacher and questions were answered. The session was conducted for 1.5-2 h.
All the students were given orientation lectures on active learning techniques and videos were shown to demonstrate the teaching-learning techniques, which was also attended by the sub-group teachers conducting these sessions. Subsequently, the active learning group students came to the department and the facilitator (sub-group teacher) gave the case-based therapeutic problem/incorrect prescription/drug identification problems on the given topic.
During these active learning sessions (1.5-2 h), after reading the problems the students had to identify unfamiliar terms and seek clarification with each other/take help of medical dictionary. All students had to participate, identify the learning objective and discuss to achieve the correct answer for the problems. The facilitator guided the discussions. If students were able to solve the problem then one of them summarized the answer at the end of the session. If students were unable to come to the correct solution to the problem, then the session ended with a "wrap-up," both to discuss the progress of the session completed and to clarify objectives to be completed. The next meeting was scheduled as per the convenience of the students after 5-7 days. In the second meeting, students would discuss and present the correct answers.
All the students in the active learning group gave a pre-test (maximum 20 marks) consisting of therapeutic problem (5 marks), critique appraisal of prescriptions (10 marks) and drug identification (5 marks) on the given topic before the session. Similarly students in the tutorial group gave pre-test (maximum 20 marks) before the session, based on brief questions: Question 1 on classification and mechanism of action (5 marks), Question 2 on rationale for use of the drug (10 marks) and Question 3 on adverse effects and drug interactions (5 marks). All the students also gave post-tests (similar to pre-test) after 2 months. The authors had developed model answers to the pre-test and post-test with mark distribution which were given to the sub-group teachers to correct the answer sheets.
At the end of each phase, students' perceptions of the given teaching-learning approach were assessed with a 14-item questionnaire with closed-ended questions, responses scored on a Likert scale (5 - strongly agree, 4 - agree, 3 - neutral, 2 - disagree and 1 - strongly disagree), and a "comments" section for the perceived advantages, disadvantages and suggestions. At the same time, a second 11-item questionnaire was administered to students to receive feedback on interactions and group dynamics. This questionnaire too had fixed-response questions, some scored on a similar Likert scale, as above and "comments" section.
The pre-test and post-test scores of the two groups (intergroup analysis) were compared by Student unpaired t-tests; within group comparisons of scores were done by paired t-test. For all tests, two tailed P value of < 0.05 was considered statistically significant. The response of the feedback questionnaires on a given teaching-learning technique, student interaction and group dynamics was analyzed using descriptive statistics and the response to each item of the questionnaire for both the teaching approaches was compared using Chi-square test. A score of 4 or 5 on the Likert scale to each item of the questionnaire was considered as a positive response.
| Results|| |
Pre-test scores were 5.2 ± 1.4 for the active learning and 4.9 ± 1.2 for the conventional tutorial groups (P = 0.122) [Table 1] and [Table 2]. Post-test scores were statistically higher than pre-test scores for both groups (P < 0.0001). However, post-test scores were higher for students in active learning group than in the tutorial group (15.9 + 2.7 vs. 11.3 ± 1.9; P < 0.001).
|Table 1: Pre-test and post-test score of students exposed to active learning exercise|
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|Table 2: Pre-test and post-test scores for students exposed to tutorial mode of teaching learning|
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More students felt that active learning modules were interactive (77% vs. 41%; P < 0.0001), provoked self-learning (45% vs. 16%; P < 0.0001) and enhanced knowledge and clinical reasoning skills, which would help them in future clinical practice (43% vs. 28%; P = 0.042) than in the traditional tutorial learning group. More students participating in active learning exercises believed that their teaching-learning approach aroused their intellectual curiosity, helped them achieve good understanding and brought clarity about clinical applications, but these differences did not reach statistical difference.
In contrast, more students in the conventional tutorial group than in the active learning group reported that they were very comfortable with the teaching/learning approach (94% vs. 56%; P < 0.0001) and satisfied with their approach (82% vs. 59%; P = 0.001). In addition more students in the tutorial group than in the active teaching group expected to score better in their formative and summative assessments (61% vs. 38%; P = 0.002) and felt that all pharmacology topics should be taught in the manner they participated in (58% vs. 36%; P = 0.004). Thus, in the 14-item student feedback questionnaire, three items statistically favored active learning strategies while four items favored the tutorial mode of teaching learning: There were no statistical differences for the remaining seven items [Table 3].
|Table 3: Positive responses to various statements about active learning and tutorial mode of teaching|
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In the "comments" section of the questionnaire, 16 students stated that the active learning modules gave them more opportunity to discuss topics with their fellow students, and 14 students felt that this enriched their knowledge through the varying points raised that made for more complete answers. In contrast, 20 students stated that the active learning approach was more time consuming.
Similarly students stated on student interaction and group dynamics questionnaire. A total of 71% students stated that question-answering skills improved concept clarity when exposed to active learning techniques (vs. 28% students in tutorial mode; P < 0.0001). In addition, active learning strategies provoked every student to participate was felt by 87% students (vs. 45% students in tutorial mode; P < 0.0001). In the students' feedback on student interaction and group dynamics during the two teaching approaches, 10 out of 11 items statistically favored the active learning strategy, but 33% students had also stated that in sessions using active learning strategy the contents had gone haywire [Table 4].
|Table 4: Positive responses to various statements about student and group interactions during the active learning and tutorial mode of teaching|
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In the "comments" section of this questionnaire, 21 students stated that everyone within the active learning groups was given an opportunity to express themselves and that there was a friendly atmosphere that helped individuals arrive at correct answers. Seven students stated that if students had not completely read the topic being discussed they were less interactive and this hindered discussion.
| Discussion|| |
Active learning is defined as instructional activities involving students in doing things and thinking about what they are doing. , Demonstrated benefits of active learning include better problem solving, capable to perform higher-order thinking tasks as analysis, synthesis evaluation, and critical reasoning.  To engage students in this higher order thinking tasks, the questions/problems given to students must be based on applied knowledge, which can channelize the reasoning process.
Pharmacology is a vast and vital subject for the medical students to become competent, skilled and effective health care professional. Students are often wary of this subject and consider it as one of the most dull and boring subject. Training in intellectual skills of drug prescription can be achieved if topics are taught with focus on clinical applications and students themselves discuss and reason out the answers rather than passive knowledge transfer. Thus enriching the learning environment through incorporation of active teaching-learning techniques, in and out of the classroom can yield enhanced reasoning skills and a competent pharmacologist.
Active learning encourages motivation, improves critical thinking and helps students score higher in evaluations than peers exposed to traditional learning. ,, In this study, students perceived the benefits of interactivity, self-learning, achieving good understanding, improving topic clarity, arousing intellectual curiosity and reasoning of clinical applications but felt that this mode of teaching-learning did not help them in scoring higher in examinations.
In contrast, more students felt comfortable and were satisfied with the tutorial mode of teaching than with active learning strategies. This might be explained by students' greater familiarity and thus comfort with the tutorial mode of teaching, as this is the principal form of teaching-learning from their first year in the medical curriculum. For students exposed to active learning, this technique was novel with its focus shifted from the teacher to the student. Students were forced to put in more effort with less readymade solutions provided by the sub-group facilitators. In addition students felt that all pharmacology topics should be taught as tutorials might be due to the perceived advantages of small group teaching, that it better addressed how exam questions were oriented and students' comfort with this mode of learning.
In the tutorial groups, discussions center around answers given to brief questions. In formative and summative theory examinations of the University, students are asked for short answers, accounting for nearly 56% of the total marks. Thus, students taught in the tutorial approach can feel that the teacher was exposing them to the material in a similar format that they will be assessed. In contrast, students that participated in active learning approaches through case discussion can believe that actively discussing disease management may help in their future clinical practice but not provide immediate short term benefits in terms of school marks.
Students' less than favorable perception of active learning approaches can be expected of students exposed to a new teaching technique, as students prefer to learn in familiar ways. There is general student resistance  to non-lecture teaching for students familiar with lecture-passive mode of teaching and familiarization to any novel teaching technique is important for its acceptance.
Student interaction and cohesive group dynamics are key to successful active learning strategies. In this study, student-student interaction was perceived to be greater in active learning approach and students appreciated asking questions, learning from others and being able to draw their own conclusions to arrive at the correct answer.
But more students within the active learning group approaches reported that there was distracting cross-talking and that the content of discussions went awry. In tutorials, teachers asked questions of students, and there was more student-teacher interaction rather than student-student interaction. In active learning approaches, facilitators need to be trained to channel effective discussions.
Prescription writing was better in the active learning group than tutorial group. Therapeutic problems and drug identification type of questions were focused in active learning modules, which do not appear in their theory examinations. Critique appraisal of prescriptions does feature in practical examinations in pharmacology accounting for nearly 18% of the total marks. In active learning approach not only was the teaching technique new but the performance test also included format of questions to which students were unaccustomed. Thus for active learning techniques to be effective, the examination pattern also needs revamping  wherein questions are posed as therapeutic problems that involve critical thinking, applied knowledge and reasoning skills in contrast to mere recall type of short/brief/long questions.
Published educational assessments involving active learning approaches in pharmacology subject in India are lacking. However, similar educational assessments have been published for other pre-clinical subjects like physiology,  where better student performance and more favorable perceptions are shown for active learning.
It was challenge for the authors to develop and implement such applied pharmacology specific problems and make students learn the topic using these problems with active learning techniques. Development of patient oriented case/therapeutic problem, which must trigger higher order, complex thinking, was also challenging. Similarly, to inculcate in students (who are naïve to principles of active learning) the active learning techniques with the resultant development of reasoning skills and critical reflective thinking is also a challenging task. We had to conduct dummy run sessions coupled with videos for students explaining active learning techniques prior to exposing them to actual project sessions.
The other barriers to implementing active learning exercises were increase in commitment of faculty time for meeting students, as they were expected to provide necessary guidance and address students' initial confusion on the exercises and teamwork issues. The faculty also faced challenges in assessing how much work each student contributed to the various assignments.
| Limitations|| |
The study was conducted in 90 students who consented to participate, which may have been too small to uncover some group differences. Long-term student performance was not assessed in this study. In addition, questionnaires were only validated for content by local experts and not externally validated. Feedback from the facilitators about active learning approach was also not collected. Given the study's findings, a more detailed orientation program-perhaps 6-8 weeks-to active learning strategies for both student and faculty may have seen better acceptance and a change in students' perceptions.
| Conclusion|| |
Our students appreciated the conventional tutorial mode of learning as they were comfortable with it and it fits the education and testing approaches of their University. Students perceived the benefits of active learning strategies in helping them gain clarity on the topic, arousing intellectual curiosity, promoting student interaction and yielding effective learning. Further efforts will be needed by faculty to sensitize and familiarize them to active learning strategies. We plan to implement similar active learning modules for other topics and skills in pharmacology, coupled with appropriate assessment strategies.
| Acknowledgements|| |
The authors thank the efforts taken by the faculty of the Department of Pharmacology and Therapeutics, Seth GS Medical College, Mumbai, India.
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[Table 1], [Table 2], [Table 3], [Table 4]
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