Evaluation of the Inverted Classroom Approach in a Case-Study Course on Antithrombotic Drug Use in a PharmD Curriculum: French Monocentric Randomized Study

Introduction

The French Regional Centers of Pharmacovigilance recently revealed that 8.5% of hospital admissions of 141 short-stay specialist medical wards randomly selected in 69 public hospitals, were related to adverse drug reactions [Laroche ML, Gautier S, Polard E, et al. Incidence and preventability of hospital admissions for adverse drug reactions in France: a prospective observational study (IATROSTAT). Br J Clin Pharmacol. Jan 2023;89(1):390-400. [CrossRef] [Medline]1]. Antithrombotic drugs were involved in 11.6% of the cases, placing them in second place right behind antineoplastic drugs. Some of the adverse drug reactions (mainly bleeding) were considered to be preventable because the drugs had not been used per the summary of product characteristics or guidelines [Réseau Français des Centres Régionaux de Pharmacovigilance [Website in French]. URL: https://www.rfcrpv.fr/ [Accessed 2025-03-25] 2]. In the French health care system, antithrombotics are mainly available in pharmacies, and for some also on websites but under the responsibility of a pharmacist. Pharmacists, particularly community-based pharmacists, are easily accessible health care professionals [Kehrer JP, Eberhart G, Wing M, Horon K. Pharmacy’s role in a modern health continuum. Can Pharm J (Ott). Nov 2013;146(6):321-324. [CrossRef] [Medline]3]. They are experts in drug therapy use, assessing each patient through observation, dialogue, and consideration of clinical indicators. They are involved in monitoring the patient’s compliance with treatment as well as their response to drug therapy through regular follow-up. This allows for the early detection of adverse effects or drug misuse. Therefore, pharmacist intervention should have a positive impact on the management of patients on antithrombotic therapy. All the above reasons makes the optimal use of antithrombotic drugs of utmost importance to learn for pharmacy students to prevent iatrogenesis.

In France, the PharmD (Doctor of Pharmacy) curriculum consists of a 6-year course. Three teaching models are used mainly: the lecture-based classroom, the case-study class, and the practical session. Case-study class is a hands-on approach to learning that involves presenting realistic scenarios and helps students to apply theoretical knowledge in clinic-like settings and attain a high-order cognitive level per Bloom’s taxonomy [Krathwohl DR. A revision of Bloom’s taxonomy: an overview. THEORY Pract. Nov 1, 2002;41(4):212-218. [CrossRef]4]. The instructor asks students to participate in the case study analysis and discussion. This method favors the development of a deep understanding of the subject and avoids passive note-taking in students. However, this objective is not necessarily always reached. Since its introduction in 2000, the inverted classroom (IC) approach, switching away from the traditional educational approach for the lecture-based classroom, literally inverts the focus per Bloom’s taxonomy: the bottom parts of the taxonomy (ie, understand and memorize basic concepts) are reserved for student self-instruction through readings, short recorded video, audio lectures, etc, while the class time is focused on the upper parts of the taxonomy (ie, analyze, justify a stand, and create original work). The IC approach has been increasingly studied in health professions students’ education including pharmacy school [Roth MT, Mumper RJ, Singleton SF, et al. A renaissance in pharmacy education at the University of North Carolina at Chapel Hill. N C Med J. 2014;75(1):48-52. [CrossRef] [Medline]5-Youhasan P, Chen Y, Lyndon M, Henning MA. Exploring the pedagogical design features of the flipped classroom in undergraduate nursing education: a systematic review. BMC Nurs. Mar 22, 2021;20(1):50. [CrossRef] [Medline]17]. These studies reported a positive impact of this approach on students’ knowledge and skills in most of the cases in comparison to lecture-based courses [Ferreri SP, O’Connor SK. Redesign of a large lecture course into a small-group learning course. Am J Pharm Educ. Feb 12, 2013;77(1):13. [CrossRef] [Medline]8-Persky AM, Dupuis RE. An eight-year retrospective study in “flipped” pharmacokinetics courses. Am J Pharm Educ. Dec 15, 2014;78(10):190. [CrossRef] [Medline]11,Edginton A, Holbrook J. A blended learning approach to teaching basic pharmacokinetics and the significance of face-to-face interaction. Am J Pharm Educ. Jun 15, 2010;74(5):88. [CrossRef] [Medline]13,Crouch MA. An advanced cardiovascular pharmacotherapy course blending online and face-to-face instruction. Am J Pharm Educ. May 27, 2009;73(3):51. [CrossRef] [Medline]14,Hess R, Hagemeier NE, Blackwelder R, Rose D, Ansari N, Branham T. Teaching communication skills to medical and pharmacy students through a blended learning course. Am J Pharm Educ. May 25, 2016;80(4):64. [CrossRef] [Medline]18-McLaughlin JE, Roth MT, Glatt DM, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. Feb 2014;89(2):236-243. [CrossRef] [Medline]24]. It has been introduced into various courses including pharmacotherapy, pharmacokinetics, pharmaceutical calculations, pharmacy practice, and others [Bossaer JB, Panus P, Stewart DW, Hagemeier NE, George J. Student performance in a pharmacotherapy oncology module before and after flipping the classroom. Am J Pharm Educ. Mar 25, 2016;80(2):31. [CrossRef] [Medline]7,McLaughlin JE, Gharkholonarehe N, Khanova J, Deyo ZM, Rodgers JE. The impact of blended learning on student performance in a cardiovascular pharmacotherapy course. Am J Pharm Educ. Mar 25, 2015;79(2):24. [CrossRef] [Medline]12,McCabe C, Smith MG, Ferreri SP. Comparison of flipped model to traditional classroom learning in a professional pharmacy course. Educ Sci. 2017;7(3):73. [CrossRef]25-See S, Conry JM. Flip my class! A faculty development demonstration of a flipped-classroom. Curr Pharm Teach Learn. Jul 2014;6(4):585-588. [CrossRef]32]. That said, the added value of the IC approach has rarely, if at all, been tested for case-study courses in pharmacy education. Hence, we sought to conduct a monocentric study investigating the added value of an IC approach in a case-study course during the PharmD curriculum at Paris Cité University. In this IC approach, students received the course material before the in-class session and were asked to prepare it and assume the role of the instructor on the target day. We aimed to assess knowledge acquisition, preclass workload and students’ self-assessment of their stress, empathy, and global satisfaction. It was hypothesized that the IC approach would lead to improved outcomes compared to the traditional question-and-answer educational approach.

Methods

Ethical Considerations

This study was approved by the Institutional Review Board and Ethics Committee of Paris Cité University (00012023‐20) and all procedures were performed per the Helsinki Declaration. Students were completely free to participate or not in this study. They were informed that neither participation nor nonparticipation in this study would influence their passing of this course or their grades. The participants were also informed about the option to withdraw from this study at any time. Informed consent was obtained from all the students who participated in this study. They were not paid for their participation. Collected data were anonymously analyzed.

Participants

We conducted this study at the faculty of Pharmacy of Paris Cité University in March 2023 (2022/2023 academic year). The participants were in the spring semester of the third year of the PharmD curriculum. At the beginning of the semester, students had basic courses on hemostasis (physiology and pathology) and thrombosis. During the month preceding the case-study course, they also had 3 lecture-based courses for a total of 4 hours on antithrombotic drugs. The recordings of the lectures were then available on a teaching platform (“Moodle”). The 90-minute case-study course on antithrombotic drug use entailed 16 groups consisting of about 20 to 22 students each, which were randomly assigned to the groups by the office of student affairs of the faculty of Pharmacy without any influence from the instructor. Therefore, a randomized assignment can be assumed. Students were highly required to respect their group assignment. Each time, 2 groups assisted simultaneously in one course, thus the course was repeated 8 times by the same instructor. Participants were assigned to 2 major groups: the control group and the IC group (Figure 1). Attendance was not mandatory.

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Study Design and Procedure

Three weeks before the case-study course, the instructor informed all the students about the concept of the IC approach and this study’s process in addition to the importance of their engagement in the learning process. A summary of the process was also posted on Moodle. Students were informed that half of them would be assigned to the IC group where they would receive the course material for preparation 1 week before the in-class session to take the role of the instructor on the target day. The course material was delivered as a PDF document of a PowerPoint (Microsoft Corp) presentation (encompassing 63 slides) file via Moodle. The same course material was used in both approaches. The courses took place on Monday and Tuesday. One week separated the courses of the control from the IC groups.

Six cases concerning various clinically relevant scenarios were included in this course in addition to some incorporated slides to review and emphasize selected foundational concepts. They were centered on the most relevant aspects of antithrombotic drug use in different clinical settings: (1) treatment of pulmonary embolism associated with proximal deep vein thrombosis in a posttrauma patient aged 63 years; (2) prevention of thrombotic events postelective knee replacement surgery in patient aged 78 years; (3) treatment of pulmonary embolism that occurred under combined pill contraception in a woman aged 20 years; (4) prevention of thrombotic events in an acutely ill medical patient aged 80 years; (5) prevention of stroke and systemic embolism in a patient aged 82 years with atrial fibrillation and renal insufficiency; and (6) antithrombotic treatment of myocardial infarction in a patient aged 54 years. Each case was accompanied by a set of standardized questions about antithrombotic treatment decisions and adequate monitoring. Students in the control group attended a case-study course carried out by the instructor with a traditional question-and-answer approach, whereas students in the IC group took on the role of the instructor and were able to recall basic concepts or add details to the course material freely. Two to three students were randomly asked to present and discuss 1 of the 6 cases on the target day. By doing so, students were able to draw on each others’ knowledge and understanding. The instructor added details, provided guidance, clarity and feedback whenever required during the progress of the students’ presentation and summarized the main features at the end of each case. The classes in the control and IC groups were conducted by the same experienced instructor who is familiar with the content and organization of the case-study course to guarantee the consistency of the teaching content and objectives in the 2 educational approaches. This study’s design and progress are illustrated in Figure 1.

Data Collection

On the target day, students in both control and IC groups were asked to complete a pretest (ie, at the beginning) and a posttest (at the end) survey (

Multimedia Appendix 1

Pre- and postclass multiple-choice questions.

Statistical Analysis

The distribution of the data was evaluated using the Shapiro-Wilk test. The percentage of participation was compared between groups and sexes using a 2-way ANOVA followed by the 2-stage setup method of Benjamini, Krieger, and Yekutieli [Benjamini Y, Krieger AM, Yekutieli D. Adaptive linear step-up procedures that control the false discovery rate. Biometrika. Sep 1, 2006;93(3):491-507. URL: https://www.math.tau.ac.il/~yekutiel/papers/KBY%20--%20adaptive%20FDR.pdf [Accessed 2025-03-26] [CrossRef]36] for multiple comparisons. The results of the pre- and posttest MCQs were compared for statistically significant differences using the nonparametric Wilcoxon matched-pairs signed rank test. The preclass workload was compared between the 2 groups using the Mann Whitney test. The data relative to the empathy and stress self-assessment were compared between both groups using chi-square test whereas those relative to satisfaction were analyzed using the Fisher exact test. Error probability with a P value less than .05 was considered significant. Statistical analysis and graphical representation were performed using GraphPad Prism (version 10.0.2, GraphPad Software, Inc).

Results

Participants Characteristics

In this study, 346 third-year adult students (women: n=213, 62%; men: n=133, 38%) were randomized. As attendance is not mandatory, only 46% (n=158) attended the in-class session. All of them took part in this study. Ninety-three (women: n=70, 75%; men: n=23, 25%) were in the control group whereas 65 (women: n=40, 62% women; men: n=25, 38%) were in the IC group (Table 1). A significantly higher participation rate was observed in the control group (93/171, 54%) compared to the IC group (65/175, 37%; P=.002). Women (110/213, 52%) participated more than men (48/133, 36%; P=.002) in the case-study course no matter the allocation group. No other demographic information regarding the students was collected.

Pre- and Postclass Knowledge Survey

On the target day, the in-class session started for both groups with a 5 MCQ survey for 5 minutes to assess the students’ readiness to discuss cases and stimulate the recall of knowledge learned before the case-study course. Questions were on the “take-home messages” related to antithrombotic drug use in real-life clinical settings. These MCQs also help students to identify their possible misconceptions at the beginning of the course. The mean and SD of the prescore (out of 5) did not differ between the control group (1.17, SD 0.66) and the IC group (1.24, SD 0.72; Figure 2). To evaluate the students’ short-term knowledge retention, the same survey was completed immediately after the class. The mean score improved from the prescore (P<.001), in both the control group 2.45 (SD 0.61) and the IC group 2.35 (SD 0.73; Figure 2). Knowledge improvement was comparable in students from both groups.

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Stress Self-Assessment

Apart from the preclass knowledge assessment survey, students in both groups completed a stress survey at the beginning of the class during 5 minutes. Questions related to sleep disorders, nervousness, fear, panic, and annoyance during the week preceding the in-class course were completed (Figure 3). Although approximately 50% of the students reported sleep disorders and a feeling of fear during the week preceding the in-class session, no significant difference was observed between the 2 groups for any of the above-mentioned parameters. Likewise, students care for their appearance on the target day did not differ between the control and the IC groups.

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Preclass Workload

Students of both groups were asked to provide the number of hours spent preparing for the course, their perception of the preclass preparation difficulty in comparison to the other educational approach as well as the self-assessment of the required skill level. Preclass workload was estimated at 1 (IQR 0-2) hour in the IC group as a median, which was significantly higher (P=.02) than in the control group, 0 (IQR 0-2) hour (Figure 4A). While 38% of the students in the IC group considered that they had been preparing harder for the case-study course than it would have been if they were in the control group, 27% of the latter considered that as such it resulted in no significant difference between both groups (Figure 4B). Approximately half of the students in each group considered having a knowledge level adapted to the case-study course content. No difference was observed between both groups (Figure 4C).

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Empathy Self-Assessment

Student empathy for their instructor favors engagement and learning behavior in class, hence 3 related questions rated by a 7-point Likert scale were completed by students of both groups at the end of the course (Figure 5). Although only students in the IC group assumed the role of the instructor within the class, students’ opinions were quite similar between both groups. Approximately 30% of the students considered that it is hard for the instructor to perceive things as the students while 50% confirmed the importance of the sense of humor of the instructor in enhancing students’ performance and of reading the students’ minds through nonverbal communication and body language. These results did not differ between both groups.

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Global Satisfaction Assessment

The students’ global satisfaction was evaluated at the end of the course using a 6-item questionnaire (Figure 6). While more than 80% of the students were satisfied with the content of the course material in both groups, the satisfaction survey revealed that the IC approach was not well received among the students. Indeed, 18/65 (28%) of the students found that the objectives of the case-study course not clearly defined and 13/65 (20%) considered that they were not achieved, in comparison to 10/93 (11%; P=.006) and 2/93 (2%; P<.001) in the control group, respectively. A total of 20/65 (30%) of the students in the IC group were not satisfied with the in-class progress of the course versus 7/93 (8%) in the control group (P<.001). While 91/93 (98%) of the students in the control group considered this case-study course on antithrombotic drug use important for pharmacy education, only 47/65 (72%) did so in the IC group (P<.001). When it came to the question of the overall satisfaction of the educational approach, 88/93 (95%) of the students in the control group were satisfied versus (36/65) 55% in the IC group (P<.001).

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Discussion

Principal Findings

Education methodology is increasingly shifting from a teacher- to student-centered learning approach [Naing C, Whittaker MA, Aung HH, Chellappan DK, Riegelman A. The effects of flipped classrooms to improve learning outcomes in undergraduate health professional education: a systematic review. Campbell Syst Rev. Sep 2023;19(3):e1339. [CrossRef] [Medline]37]. In this context, we sought to assess whether applying an IC approach for a case-study course has an added value for conveying optimal antithrombotic drug use skills to pharmacy students. Such an educational approach would increase the communication, critical-thinking, problem-solving, and self-learning skills of pharmacy students. Our study revealed that while the IC approach did not increase student stress, it did not enhance their short-term knowledge retention or their empathy for the instructor. It increased the preclass workload and was not well received among the students. Of note, the case-study course on antithrombotic use was the first on this topic in the PharmD curriculum.

For any educational method to be considered successful, there must be evidence that student learning is enhanced. Many small-scale studies showed enhanced student learning following flipping lecture-based pharmacy courses [Roth MT, Mumper RJ, Singleton SF, et al. A renaissance in pharmacy education at the University of North Carolina at Chapel Hill. N C Med J. 2014;75(1):48-52. [CrossRef] [Medline]5-Persky AM, Dupuis RE. An eight-year retrospective study in “flipped” pharmacokinetics courses. Am J Pharm Educ. Dec 15, 2014;78(10):190. [CrossRef] [Medline]11,McLaughlin JE, Roth MT, Glatt DM, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. Feb 2014;89(2):236-243. [CrossRef] [Medline]24]. Here, the IC approach applied to the case-study course was not associated with an enhanced preclass knowledge level and did not improve the students’ short-term knowledge retention. This was also the case in the Everly and Cochran study in which no significant differences in examination question performance between students in the lecture-based section and the flipped format section were observed [115th Annual Meeting of the American Associaton of Colleges of Pharmacy, Grapevine, TX, July 26-30, 2014. Am J Pharm Educ. Jun 2014;78(5):111. [CrossRef] [Medline]9]. That said, MCQ and examination scores are often used as a proxy measure for learning; however, the ultimate goal is for students to be able to apply classroom learning to real-life situations, which is more difficult to assess. Perhaps we need to examine other nonquantitative student characteristics outcomes following the IC approach in case-study courses (such as intellectual curiosity, personal responsibility, reasoning skills, etc) to identify pharmacy students most likely to succeed.

A recent systematic review including 45 studies with a total of 8426 students from various health professional pathways showed that implementing flipped classes may improve academic performance, and may support student satisfaction, yet the certainty of the evidence is low [Naing C, Whittaker MA, Aung HH, Chellappan DK, Riegelman A. The effects of flipped classrooms to improve learning outcomes in undergraduate health professional education: a systematic review. Campbell Syst Rev. Sep 2023;19(3):e1339. [CrossRef] [Medline]37]. A second systematic review and meta-analysis including 11 randomized controlled Chinese studies enrolling 1200 participants suggested that flipped classroom pedagogy enhances students’ learning enthusiasm, self-learning ability, thinking and communication skills as well as cooperative ability [Peng W, Xiong Y, Wei J, et al. Flipped classroom improves student learning outcome in Chinese pharmacy education: a systematic review and meta-analysis. Front Pharmacol. 2022;13:936899. [CrossRef] [Medline]38]. Although, another systematic review focusing on students in pharmacy education, incorporated 6 observational studies with 1395 participants. No overall significant difference in final academic performance between the 2 educational models was reported [Gillette C, Rudolph M, Kimble C, Rockich-Winston N, Smith L, Broedel-Zaugg K. A meta-analysis of outcomes comparing flipped classroom and lecture. Am J Pharm Educ. Jun 2018;82(5):6898. [CrossRef] [Medline]39]. An important heterogeneity of student perspectives from flipped classrooms has emerged in the literature, ranging from positive [Wong TH, Ip EJ, Lopes I, Rajagopalan V. Pharmacy students’ performance and perceptions in a flipped teaching pilot on cardiac arrhythmias. Am J Pharm Educ. Dec 15, 2014;78(10):185. [CrossRef] [Medline]10,McLaughlin JE, Roth MT, Glatt DM, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. Feb 2014;89(2):236-243. [CrossRef] [Medline]24,White PJ, Larson I, Styles K, et al. Adopting an active learning approach to teaching in a research-intensive higher education context transformed staff teaching attitudes and behaviours. HERD. May 3, 2016;35(3):619-633. [CrossRef]40-Anderson HG Jr, Frazier L, Anderson SL, et al. Comparison of pharmaceutical calculations learning outcomes achieved within a traditional lecture or flipped classroom andragogy. Am J Pharm Educ. May 2017;81(4):70. [CrossRef] [Medline]42] to negative [Chen KS, Monrouxe L, Lu YH, et al. Academic outcomes of flipped classroom learning: a meta-analysis. Med Educ. Jun 25, 2018;52(9):910-924. [CrossRef] [Medline]21,Gillette C, Rudolph M, Kimble C, Rockich-Winston N, Smith L, Broedel-Zaugg K. A meta-analysis of outcomes comparing flipped classroom and lecture. Am J Pharm Educ. Jun 2018;82(5):6898. [CrossRef] [Medline]39,Missildine K, Fountain R, Summers L, Gosselin K. Flipping the classroom to improve student performance and satisfaction. J Nurs Educ. Oct 2013;52(10):597-599. [CrossRef] [Medline]43,Kugler AJ, Gogineni HP, Garavalia LS. Learning outcomes and student preferences with flipped vs lecture/case teaching model in a block curriculum. Am J Pharm Educ. Oct 2019;83(8):7044. [CrossRef] [Medline]44] and mixed [McLaughlin JE, White PJ, Khanova J, Yuriev E. Flipped classroom implementation: a case report of two higher education institutions in the United States and Australia. Comput Sch. Jan 2, 2016;33(1):24-37. [CrossRef]45] perceptions. These differences are potentially due to the different contexts in which these studies were carried out as well as different student populations, backgrounds, sample sizes, and outcome measures. Apart from that, some instructors may be more effective teachers than others regardless of the teaching modality. Research evaluating which elements contribute to the efficacy of an IC approach in pharmacy education is still needed. Moreover, it is still unclear if there is a particular area or topic that is better suited for the use of the IC approach in the PharmD curriculum. Besides, with the increased use of the IC method, it is important to consider the impact on students when this approach is incorporated into multiple concurrent courses. Determination of the ideal amount of preclass preparation time across the curriculum would provide helpful guidance to pharmacy faculties implementing such teaching methods.

One of the major limitations of the IC approach is its high dependence on the attendance to class time and on student engagement and discipline for reading and preparing the preclass material as previously emphasized [White PJ, Naidu S, Yuriev E, Short JL, McLaughlin JE, Larson IC. Student engagement with a flipped classroom teaching design affects pharmacology examination performance in a manner dependent on question type. Am J Pharm Educ. Nov 2017;81(9):5931. [CrossRef] [Medline]26]. As the class time attendance is not obligatory in our faculty, only 46% of the students were present in the antithrombotic drug use case-study course. The percentage of attendance was more important in the control group than in the IC group. A more elaborate strategy for students’ motivation should thus be implemented to obtain a higher engagement and adherence to our case-study courses in general, and to such IC experience if it shall be repeated. Providing clear expectations to students, keeping the preparation tasks focused, and explicitly linking preparation activities to in-class active learning could be some key methods for instructors to increase the proportion of students who prepare for classes. Future research should also be devoted to assessing the potential effect of sex, gender, socioeconomic background, and age on the outcomes of such an approach in the PharmD curriculum.

Preclass preparation could be considered as a considerable “extra” work [Wong TH, Ip EJ, Lopes I, Rajagopalan V. Pharmacy students’ performance and perceptions in a flipped teaching pilot on cardiac arrhythmias. Am J Pharm Educ. Dec 15, 2014;78(10):185. [CrossRef] [Medline]10,Gloudeman MW, Shah-Manek B, Wong TH, Vo C, Ip EJ. Use of condensed videos in a flipped classroom for pharmaceutical calculations: student perceptions and academic performance. Curr Pharm Teach Learn. Feb 2018;10(2):206-210. [CrossRef] [Medline]29,Cotta KI, Shah S, Almgren MM, Macías-Moriarity LZ, Mody V. Effectiveness of flipped classroom instructional model in teaching pharmaceutical calculations. Curr Pharm Teach Learn. Sep 2016;8(5):646-653. [CrossRef]30,Akçayır G, Akçayır M. The flipped classroom: a review of its advantages and challenges. Comput Educ. Nov 2018;126:334-345. [CrossRef]46]. Indeed, students in the IC group of our study reported an increased preclass workload which might take up an amount of their spare time leading to negative feedback on this approach. It is to be mentioned that the course materials made available beforehand should not be too complex to be understood by the students on their own. We did our best to include 6 uncomplicated cases issued from real-life settings and incorporate few slides to recall knowledge learned in the three lecture-based courses during the month preceding the case-study course.

Case-study courses with an IC approach are probably important in pharmacy education as they would help students promote higher-level critical-thinking skills, foster analyzing, and improve their communication skills therefore improving their motivation and attitudes [Freeman S, O’Connor E, Parks JW, et al. Prescribed active learning increases performance in introductory biology. CBE Life Sci Educ. 2007;6(2):132-139. [CrossRef] [Medline]47]. Assisting them in learning how to think and communicate like a graduated pharmacist will prepare them for their future beyond pharmacy school. Communication skills are required to ensure patient understanding and compliance [Ranjan P, Kumari A, Chakrawarty A. How can doctors improve their communication skills? J Clin Diagn Res. Mar 2015;9(3):JE01-JE04. [CrossRef] [Medline]48,Maguire P, Pitceathly C. Key communication skills and how to acquire them. BMJ. Sep 28, 2002;325(7366):697-700. [CrossRef] [Medline]49]. If a patient does not understand the purpose of the antithrombotic treatment, adherence will likely be low. Communication training in pharmacy students is thus mandatory to improve their later effectiveness as future health professionals. Although third-year students were overall not satisfied with this experience, such an approach is worth being retested with “older students,” from the fourth to the sixth year of the PharmD curriculum. Successful pharmacy students are expected to have the ability to manage their learning and adequately communicate their knowledge. Self-learning skills are particularly crucial to achieving effective lifelong learning in pharmacy, where scientific knowledge is continually evolving. Consequently, pharmacy students should be trained to be effective self-learners. Antithrombotic drug use assessed using a case-study course is an application-based activity, while the material taught previously is mostly a knowledge-based presentation. Therefore, third-year students may have significant difficulty in providing an application-based activity when their skill level may have been still on a much lower level of Bloom’s taxonomy [Krathwohl DR. A revision of Bloom’s taxonomy: an overview. THEORY Pract. Nov 1, 2002;41(4):212-218. [CrossRef]4] which may explain the low postclass knowledge scores in both groups. They will complete 2 additional learning years where it is anticipated they will gain more knowledge, clinical experience, and communication skills through their traineeships in community-based and hospital pharmacies as well as clinical laboratories. That said, many students were very interested in participating in this pedagogical study and found the experience to be innovative and enjoyable.

From the instructor’s perspective, the IC approach might be more challenging than a traditional session with a question-and-answer approach due to the risk that students’ presentation and case discussion activities create an unsettled classroom, thus a chaotic environment in which students may feel lost, and the fear that students may be unable to deliver the course adequately. However, the IC approach makes student engagement in the course easier and empowers them as active participants in their learning in comparison to the traditional educational approach. It allows the instructor to guide students in deeper learning processes as previously shown [Peng W, Xiong Y, Wei J, et al. Flipped classroom improves student learning outcome in Chinese pharmacy education: a systematic review and meta-analysis. Front Pharmacol. 2022;13:936899. [CrossRef] [Medline]38,Akçayır G, Akçayır M. The flipped classroom: a review of its advantages and challenges. Comput Educ. Nov 2018;126:334-345. [CrossRef]46]. A more interactive teaching strategy may be more attractive than the IC approach, such as the adventure game recently developed by Perrin et al [Perrin J, Meeus A, Broseus J, et al. A serious game about hematology for health care workers (SUPER HEMO): development and validation study. JMIR Serious Games. Feb 13, 2023;11:e40350. [CrossRef] [Medline]50]. It is a video game in which the player assumes the role of a protagonist in an interactive story driven by exploration and problem-solving tests. Briefly, the pharmacy student assumes the role of a hematology superhero named SUPER HEMO. SUPER HEMO can meet 5 unwell characters in 5 different steps. The player must answer their questions and find the best way to diagnose and cure them. At the final hematology evaluation, students who played SUPER HEMO had a slightly better (but not statistically significant) median knowledge score than those who did not [Perrin J, Meeus A, Broseus J, et al. A serious game about hematology for health care workers (SUPER HEMO): development and validation study. JMIR Serious Games. Feb 13, 2023;11:e40350. [CrossRef] [Medline]50]. The value of such an innovative strategy for case-study courses on antithrombotic drug use in the PharmD curriculum remains to be established. Team-based learning is another educational approach that provides structure, defined timeframes, and formative assessment opportunities. It was previously shown to develop students learning enthusiasm, self-study, and thinking abilities as well as communication skills [Lang B, Zhang L, Lin Y, Han L, Zhang C, Liu Y. Team-based learning pedagogy enhances the quality of Chinese pharmacy education: a systematic review and meta-analysis. BMC Med Educ. Jul 29, 2019;19(1):286. [CrossRef] [Medline]51]. Therefore, it might be considered as an alternative approach for improving case-study courses in the PharmD curriculum, and thus is worth being assessed.

One possible limitation of our study is that the long-term effect of our IC approach on knowledge retention and skill application was not assessed. The question relative to this course was deliberately not included in the final exam in order not to create any lack of equity among the students of both groups. We did not complete any postclass knowledge survey 3 to 6 months later, nor did we assess the acquired skills through, for instance, an objective structured clinical examination. This remains to be specifically investigated. Second, we did not collect data on how many students effectively accessed the course material before the in-class session, although it might be feasible via the information technology service. As the preclass results of the students in the IC group were not better than those of the control group, we hypothesized that a lot of students had not read the course material before the target day. Noteworthily, it is hard to control whether students had effectively read and prepared the course material before the in-class session. Students might only click on the material folder without reading it or read parts of it. Also, several students might have accessed the material via 1 student user ID. We also did not ask students in the presurvey questionnaire whether they had read the assignment. However, they would, most probably, have not told the truth. Third, ideally, students in the IC group should have been asked to prepare the course material by themselves, yet this was not the case to avoid a high level of absenteeism as in-class attendance is not mandatory according to Paris Cité University policy. Despite this, a relatively small number of students effectively participated in this study. Fourth, in-class sessions with the traditional approach were completed 1 week before those with the IC approach to prevent students in the former group from having access to the material course from those of the latter group before the in-class session. Consequently, we cannot rule out the possibility that some students initially assigned to the IC group had changed their group assignment to get the case-study course at an early date. Finally, our findings cannot be generalized to other contexts, particularly to students in other year cohorts or to other specialties. This remains to be specifically investigated.

Conclusions

Our study showed that an IC approach does not appear to be suited to the case-study course on antithrombotic drug use in the third-year PharmD curriculum. While no additional gain in short-term knowledge was observed using this approach in comparison to the traditional educational approach, we perceived significantly lower student satisfaction. However, the increased instructor-student and student-student interactions are still convincing arguments to try this pedagogical approach. Hence, additional research in this field is still needed to implement innovative educational approaches aiming at improving the knowledge and skills of our future pharmacists.