Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Currents in Pharmacy Teaching and Learning

journal homepage: www.elsevier.com/locate/cptl

Experiences in Teaching and Learning

Evaluation of pharmacy students' knowledge and perceptions of

pharmacogenetics before and after a simulation activity
⁎
Radha V. Patel , Melissa Chudow, Teresa T. Vo, Erini S. Serag-Bolos
Department of Pharmacotherapeutics and Clinical Research, University of South Florida, College of Pharmacy, 12901 Bruce B. Downs Blvd, MDC 30,
Tampa, FL 33612, USA

AR TI CLE I NF O AB S T R A CT

Keywords: Background and purpose: The purpose of this study was to evaluate students’ knowledge and
Simulation perceptions of the clinical application of pharmacogenetics through a simulation activity and to
Pharmacogenetics assess communication of pharmacogenetic-guided treatment recommendations utilizing stan-
Standardized patient dardized patients.
Counseling
Educational activity and setting: Third-year students in the four-year doctor of pharmacy
Curriculum
(PharmD) program at University of South Florida College of Pharmacy completed a pharmaco-
genetics simulation involving a patient case review, interpretation of pharmacogenetic test re-
sults, completion of a situation, background, assessment, recommendation (SBAR) note with drug
therapy recommendations, and patient counseling. Voluntary assessments were completed before
and after the simulation, which included demographics, knowledge, and perceptions of students’
ability to interpret and communicate pharmacogenetic results.
Findings: Response rates for the pre- and post-simulation assessments were 109 (98%) and 104
(94%), respectively. Correct responses in application-type questions improved after the simula-
tion (74%) compared to before the simulation (44%, p < 0.01). Responses to perception ques-
tions shifted towards “strongly agree” or “agree” after the simulation (p < 0.01).
Discussion and summary: The simulation gave students an opportunity to apply pharmacogenetics
knowledge and allowed them to gain an appreciation of pharmacists’ roles within the pharma-
cogenetics field.

Background and purpose

Pharmacogenetics information is present in the Food and Drug Administration (FDA) approved product labeling of over 150
medications. This labeling outlines the impact of genetic variations on pharmacokinetics, pharmacodynamics, and/or clinical out-
comes, but provides little guidance on how that information should be implemented.1 The Clinical Pharmacogenetics Implementation
Consortium (CPIC) has developed guidelines for select drug-gene pairs to empower clinicians with an understanding of how to use
labeled pharmacogenetics information in a clinically meaningful way.2
With ongoing research and initiatives aimed at personalizing patient care by integration of pharmacogenetic information into the
clinical decision-making process as well as growing public interest, pharmacists, as pharmacotherapy experts, are expected to have a
working knowledge-base of pharmacogenetics to address questions from the lay and medical communities.3–6 As a way to address this
growing need, pharmacogenetics is a required element of the didactic doctor of pharmacy (PharmD) curriculum as indicated by the

⁎
Corresponding author.
E-mail addresses: [email protected] (R.V. Patel), [email protected] (M. Chudow), [email protected] (T.T. Vo),
[email protected] (E.S. Serag-Bolos).

http://dx.doi.org/10.1016/j.cptl.2017.09.012

1877-1297/ © 2017 Published by Elsevier Inc.

Please cite this article as: Patel, R.V., Currents in Pharmacy Teaching and Learning (2017),
http://dx.doi.org/10.1016/j.cptl.2017.09.012
R.V. Patel et al. Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

Accreditation Council for Pharmacy Education (ACPE) “Standards 2016”.7 However, pharmacogenetic instruction varies from less
than 10–60 hours content exposure, delivered through various methods, including didactic lectures, laboratory exercises, and patient
care skills courses.8–10 The guidance document published by the American Association of Colleges of Pharmacy (AACP) pharma-
cogenomics special interest group provides examples of pharmacogenetics content and assessment methods throughout PharmD
curricula and how they align with the Center for the Advancement of Pharmacy Education (CAPE) Educational Outcomes 2013. The
document concludes with a call to action for incorporation of pharmacogenetics into the clinical pharmacy core curricula.10,11
Previously published studies have demonstrated that an active learning exercise involving personal genetic testing enhanced
knowledge of pharmacogenetics concepts among medical and pharmacy students.12–14 Moreover, a clinical pharmacogenetics ro-
tation experience for pharmacy students, residents, and fellows provided opportunities to interpret and apply genotype-guided
therapy for the management of warfarin.15 Knoell et al.9 described a pharmacogenetic exercise that consisted of a counseling session
where students obtained consent to perform a deoxyribonucleic acid (DNA) swab, interpreted the results, and created a plan. While
the use of simulation-based activities has been shown to increase knowledge, confidence, clinical performance, and critical thinking
skills, the application and communication of pharmacogenetics in a simulated clinical environment with standardized patients (SPs)
is limited in the literature.9,16
The goal of our simulation was to mimic a clinical scenario a student may encounter during advanced pharmacy practice ex-
periences (APPEs) while continuing to strengthen both written and verbal communication skills. Specific objectives of the simulation
included: interpretation of pharmacogenetic results utilizing the CPIC guidelines, completion of a written situation, background,
assessment, recommendation (SBAR) note detailing therapeutic recommendations, and patient counseling on the purpose of the
pharmacogenetic test, results, and treatment plan. The objective of the research component of this activity was to evaluate students’
knowledge and perceptions of the clinical application of pharmacogenetics through the simulation activity and to assess written and
verbal communication of pharmacogenetic-guided treatment recommendations utilizing SPs. We hypothesized that students’ ability
to utilize course content would increase critical thinking skills through a patient case and students’ understanding of pharmacists’
roles in pharmacogenetics would be enhanced.

Educational activity and setting

This was an online non-randomized, voluntary, unpaired pre- and post-assessment study assessing students’ knowledge and
perceptions of pharmacogenetics before and after a pharmacogenetic simulation activity. During the fall 2015 semester, 113 student
pharmacists in their third professional year (P3) were concurrently enrolled in two 16-week three-credit required courses, transla-
tional pharmacogenomics and the pharmaceutical skills V course at the University of South Florida College of Pharmacy (USF COP) in
Tampa, Florida. Pharmaceutical skills V is part of a longitudinal patient-care laboratory course comprised primarily of simulations
with the use of SPs and interprofessional activities during the P3 year.
Specific pharmacogenetics content for the simulation was developed by the coordinator of the translational pharmacogenomics
course, who is also a post graduate year 2 (PGY-2) trained pharmacogenetics clinical pharmacist. The simulation was focused on
cytochrome P450 2C19 (CYP2C19) genotype-guided antiplatelet therapy given the availability of CPIC guidelines.2 Student were
lectured on this topic during week 8 and tested on this material during week 11 of the semester. In order to reinforce application, the
simulation was conducted during week 13 of the semester. By the time of the simulation, the students had lectures on the phar-
macogenomic applications of all major therapeutic areas with CPIC guidelines, including a primer in basic genetics. Genetics is also a
required prerequisite for the college. Students had previously participated in similar simulations not related to pharmacogenetics
earlier in the semester. Hence, the students were very familiar with the format and expectations of the simulation.
One week prior to the simulation, students were notified via an announcement in the Pharmaceutical Skills V course's learning
management system to review the cardiology-related pharmacogenetics materials prior to the activity and were also provided with an
electronic slide presentation regarding appropriate techniques for counseling patients on pharmacogenetics test results. Students
were also notified the activity would be completed within their pre-assigned academic team (five to six students per team) and to
bring their laptops/tablets.
The pharmacogenetics simulation was conducted in October 2015, during week 13 of the semester, at the Center for Advanced
Clinical Learning (CACL) within the USF COP. The CACL is a state of the art simulation center with 12 clinical examination rooms
equipped with digital video monitoring and a closed circuit computerized evaluation system, on the USF Health campus. Computers
are located both inside and outside the room for student use, and all rooms are linked to master video monitoring within the
simulation center control room. Each exam room also has a double-sided mirror that allows evaluators to view and hear the live
encounter outside of the room. The CACL also oversees the SP program for university. The program recruits lay people through the
Office of Curriculum and Medical Education at the USF Morsani College of Medicine. The SPs are trained using a pre-developed
curriculum focused on role-playing and providing written and verbal feedback to students focusing on communication and inter-
personal skills. Scripts are provided for specific activities in order to allow the SP to role play clinical encounters with the goal of
training student learners. This well-established program provides approximately 60,000 SP encounters each year at USF Health.
The simulation only required two faculty members to orient and guide the students to their assigned rooms. On the day of the
activity, each team arrived at the simulation center during their assigned time. The simulation was divided into three rounds of
40 min in order to accommodate all 20 academic teams during the three-hour class period. Prior to beginning the simulation, students
received a 15-min orientation and were invited to individually complete a non-randomized, voluntary, anonymous pre-simulation
assessment. The assessment was built in Qualtrics® (Provo, UT) and consisted of eight multiple-choice questions and four Likert scale
questions (1 – “strongly disagree” to 5 – “strongly agree”). Three of the multiple-choice questions collected demographic information

2
R.V. Patel et al. Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

(age, gender, preferred learning styles), and five of the multiple-choice questions were knowledge-based and corresponded with
material previously taught in the translational pharmacogenomics course and directly related to the content of the simulation. The
Likert scale questions aimed to assess students’ perceptions of their individual and team's ability to interpret and provide drug therapy
recommendations based on pharmacogenetics results. The first page of the assessment included a waiver of informed consent.
Students who were absent on the day of the simulation and those who did not complete the assessment were excluded from the study.
Participation in this study did not impact the student's grade for the activity or the courses.
After the pre-simulation assessment, each academic team was given 40 min to complete the simulation experience involving a
patient with acute coronary syndrome who had undergone a percutaneous coronary intervention with stent placement. During the
first 25–30 min of the simulation, each academic team was given a patient case (available to the reader upon request) along with the
pharmacogenetic test results. The team was asked to interpret the results and provide their written recommendation to the attending
physician regarding antiplatelet therapy in the form of a SBAR. Teams were permitted to utilize guidelines and other drug in-
formation resources to complete the SBAR. Once completed, one note per team was submitted electronically through the course's
learning management system.
The second part of the simulation consisted of one to two students from each team taking the lead on counseling the SP to explain
why the pharmacogenetics test was ordered, what the test result meant, and how the test result would impact the selection of
antiplatelet therapy. Rubrics (available to the reader upon request) were used to evaluate the written SBAR (14 points) and patient
counseling sessions (50 points). In order to minimize variability in the grading of the simulation, one study investigator evaluated all
of the written SBAR notes and one study investigator evaluated all the recorded patient counseling sessions. At the end of the
simulation, students were invited to complete the post-simulation assessment that contained the same questions as the pre-simulation
assessment. After the students completed the assessment, an informal 10-min post-simulation debrief session was held to gather
verbal feedback from the students.
Data were analyzed using IBM SPSSv18. Nominal data, such as gender, preferred learning style, and responses to multiple-choice
questions on the pre- and post-simulation assessments, were analyzed using the chi-square test. Ordinal data, including responses to
the perception questions using the Likert scale, were analyzed using the Wilcoxon-Mann-Whitney test. All p-values were two-sided
with an alpha level set at 0.05 for statistical significance. Assessment data and team scores from the written SBAR and patient
counseling rubrics were analyzed using descriptive statistics. This study was approved under expedited review by the USF
Institutional Review Board.

Findings

Of the 111 students that completed the simulation activity, 109 (98%) and 104 (94%) students completed the pre- and post-
simulation assessments, respectively. Differences in gender in the pre-simulation assessment, female (46%) and male (54%), com-
pared to the post-simulation assessment, 45% (female) and 55% (male), were not statistically significant, p = 0.93. The majority of
students completing the pre- and post-simulations assessments were less than 30 years of age (95% and 97%, respectively). A large
portion of students indicated their preference towards a combination of learning styles (52% versus 56%) followed by visual learning
(28% versus 27%), kinesthetic learning (16% versus 13%) and auditory learning (4% versus 5%). Although a majority of students
favored a combination of learning styles, this was not statistically significant, p = 0.88.
Results from the knowledge questions are summarized in Table 1. More students answered the knowledge-based questions
correctly after the simulation. There was no statistically significant difference seen in recall type questions, such as basic drug
interaction questions. On the other hand, a statistically significant difference was seen in responses for questions that focused on
guidelines and application of knowledge when presented as a patient case. Additionally, changes in student perceptions regarding
their comfort level in formulating a patient-specific plan based on pharmacogenetic results, the team's ability to document re-
commendations, and the role of the pharmacist in clinical practice as related to pharmacogenetics were statistically significant

Table 1
Pre/post-assessment knowledge question responses.

Answered Correctly

Pre (N = 109) Post (N = 104) p value

n(%) n(%)

Assessment Questions
What is the CYP2C19 phenotype of a patient carrying two loss of function alleles? 103 (95) 103 (99) 0.06
Clinical Pharmacogenomics Implementation Consortium developed guidelines for using CYP2C19-genotype 51 (47) 63 (61) 0.04a
guided antiplatelet therapy for which of the following indications?
A past medical history of stroke is a contraindication for the use of which of the following antiplatelet 48 (44) 76 (73) < 0.01a
medications?
Which of the following proton pump inhibitors should be used with caution or avoided in patients prescribed 98 (90) 97 (93) 0.38
clopidogrel?
Which of the following medications may be influenced by a patient's CYP2C19 genotype? 50 (46) 60 (58) 0.07

CYP, Cytochrome P450.

a
Chi Square test, p < 0.05 significant.

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Table 2
Pre/post-assessment perception question responses.

Strongly Agree Agree Neutral Disagree Strongly Disagree

Pre n Post n Pre n Post n Pre n Post n Pre n Post n Pre n Post n p value
(%) (%) (%) (%) (%) (%) (%) (%) (%) (%)

Assessment Questions
I feel comfortable formulating a patient-specific treatment plan based on a patient's CYP2C19 7 (6) 38 (37) 45 (41) 55 (53) 44 (40) 8 (8) 9 (8) 1 (1) 4 (4) 2 (2) < 0.01a

4
genotype.
I believe my team will be able to make a group decision regarding drug therapy 28 (26) 46 (44) 65 (60) 48 (46) 14 (13) 8 (8) 1 (1) 1 (1) 1 (1) 1 (1) < 0.01a
recommendations based on pharmacogenetic results.
I believe my team will be able to provide written communication to the healthcare provider 23 (21) 48 (46) 71 (65) 48 (46) 11 (10) 6 (6) 1 (1) 1 (1) 2 (2) 1 (1) < 0.01a
regarding drug therapy recommendations based on pharmacogenetic results.
I understand the role of pharmacogenomics testing and associated pharmacist's roles in clinical 24 (22) 43 (41) 69 (63) 53 (51) 11 (10) 5 (5) 2 (2) 1 (1) 3 (3) 2 (2) < 0.01a
practice.

CYP, Cytochrome P450.

a
Wilcoxon-Mann-Whitney test, p < 0.05 significant, shift towards strongly agree/agree in the post-assessment.
Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx
R.V. Patel et al. Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx–xxx

(p < 0.01) favoring “agree” or “strongly agree” in the post-simulation assessment compared to the pre-simulation assessment. Table 2
outlines the results of student responses to the perception questions.
The average written SBAR and patient counseling grade among the 20 academic teams was 13.5 out of 14 (range 12–14) and 48.6
out of 50 (range 45–50), respectively. Additional verbal feedback gathered from the post-simulation debriefs and course evaluations
suggests that the majority of students enjoyed the hands-on approach of the activity and the opportunity to work within their
academic teams to collectively reach a recommendation. Few students expressed the desire to complete such simulations individually
to ensure adequate competence. Students also provided positive feedback that they gained a deeper appreciation for the pharmacist's
role in the therapeutic decision-making process based on a patient's genetic profile.

Discussion

Pharmacogenetics is deemed by ACPE as an element of the didactic pharmacy curriculum, and is one of the four pillars at the USF
COP.7 This emerging aspect of pharmacy practice allows for personalization of therapeutic modalities based on a patient's genetics to
maximize effectiveness and reduce adverse effects of medications as well as enhances overall safety.
This simulation allowed for integration of other essential pharmacist skills such as critical thinking and verbal and written
communication skills. The simulation can be mapped to several CAPE outcomes such as 2.1 (patient-centered care), 3.1 (problem-
solving), and 3.6 (communication). In addition, the simulation incorporated several components of the communication domain, such
as written (SBAR) and verbal communication (team work and patient counseling).11
Students reported favoring visual and kinesthetic learning styles over auditory, which is consistent with the literature regarding
adult learning theory.17 Moreover, students’ reported preference for a combination of learning styles correlates to findings on the
knowledge-based assessment questions. Transformative learning changes the way learners consider their environment and involves a
shift in awareness.17 This is supported by the statistically significant increase in knowledge on the application type questions on the
post-simulation assessment. Based on the post-assessment, students demonstrated they may be able to retain concepts that involve
knowledge of guidelines or case-based questions when it is directly related to a simulation activity. However, long-term retention was
not assessed as part of our study.
Overall, students performed well on the written SBAR and verbal patient counseling sessions. This may be attributed to the
purposeful reiteration of these communication skills throughout the curriculum and especially in the P3 year, where students en-
counter multiple cases that align with content from other courses. Students were familiar with the rubrics used in this simulation,
which were only modified with regards to point values for each section.
Strengths of this simulation include enhanced application of knowledge acquired through the didactic curriculum as demon-
strated by the knowledge assessment results. Curricular alignment is a key focus at the USF COP to enhance content delivery in a
coordinated manner and provide an appropriate stepwise approach for mastery of skills. The use of trained SPs also allows for a more
real life application of patient interaction and counseling instead of using faculty members or other students as patients. The
pharmacogenetics simulation serves to prepare students for other scenarios, such as during APPEs, that may require patient-specific
treatment recommendations based on pharmacogenetic results. Tasking the students with reviewing a case, completing an SBAR, and
counseling the SP within a 40-min time period also provided the students the ability to utilize their time wisely and expose them to
what they may experience on APPEs or during clinical practice. Feedback from students was overall positive with specific mention of
the hands-on approach and the ability to work and learn as a team. Such feedback suggests that students recognize the value of team-
based learning.
In development, faculty intentionally avoided certain challenges by allowing students to work in teams in order to reduce costs
associated with hiring SPs that also minimized time needed for grading and providing feedback. Furthermore, the ability to video
record the counseling sessions eliminated issues with inter-rater reliability since one faculty member graded all of the assignments by
watching the patient counseling sessions and reviewing the written SBAR notes at a later time.
The study is not without limitations. The pre- and post-simulation assessments were not paired, which limits the ability to assess
individual students’ change in knowledge and perceptions. Even though the majority of students preferred completing the simulation
within their academic teams, this limits the ability to assess each member's contribution to the team. One way to overcome this
limitation could be through the use of self and peer evaluations and incorporating this as a component of the overall simulation
grade.
The authors do not anticipate barriers to acceptance of a similar pharmacogenetics simulation at other institutions. Content of
didactic lectures would need to be aligned in order to adequately prepare students for the activity. It is appreciated that many colleges
and schools of pharmacy may not have the resources or funds to support the use of a simulation center and/or SPs. This activity could
be replicated with the use of small break out rooms and patients could be role-played by faculty members or APPE students.
Counseling sessions could be recorded through the use of personal recording devices. The approach of using personal recording
devices should be carefully considered in order to ensure it is in compliance with the Family Educational Rights and Privacy Act
(FERPA) and program policies.18 Another alternative would be to conduct live grading, which may require more evaluators during
the activity.
Based on the positive student feedback, future directions involve development of a pharmacogenetics elective course as well as
enhanced internship and research opportunities in this area. Future modifications for this simulation activity under consideration
include incorporation of a practice component where students perform obtaining the sample through a buccal swab as well as
utilizing self and peer evaluations. Furthermore, the simulation may be modified to allow an interprofessional component with
medical and nursing students. This would further raise awareness and enhance the team-based approach when it comes to application

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of pharmacogenetics in clinical practice.

The evolving field of pharmacogenetics poses a unique opportunity for the academy and pharmacy curricula to develop new and
innovative ways to integrate pharmacogenetics within the PharmD curriculum. This study could be used as an example of an in-
novative teaching approach to enhance pharmacogenetic application within the pharmacy curricula that could be replicated by other
institutions. In addition, to our knowledge, this is the first pharmacogenetic simulation activity to utilize SPs.

Summary

The pharmacogenetics simulation provided students a unique opportunity to apply pharmacogenetics knowledge to a patient case
in a simulated clinical environment. Curricular alignment and strategic integration of key pharmacogenetics concepts with an em-
phasis on written and verbal communication allowed for deeper understanding and application of materials. There was an im-
provement in correct responses for the application-based questions in the post-simulation assessment compared to before the si-
mulation. The results of the post-simulation assessment suggest a favorable shift in perceptions regarding the role of the pharmacist as
it relates to pharmacogenetics.

Acknowledgements

The authors would like to thank the CACL staff involved with facilitating the simulation.

Conflicts of interest

None.

Financial disclosures

None. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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