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Clinical Pharmacist Education of Meijo University
with Clinical Training in Affiliated University Hospital

1. Development of a practical education of clinical pharmacy at affiliated medical schools

-- an education system model for private pharmacy schools without medical schools --

Until recently, Japanese pharmacist training stood by itself as an independent health care field and incorporation of rigorous practical training in medical settings was slow. Increased public demand for advanced health care services, however, has led pharmacy schools in Japan to take corrective measures toward health care more. In April 2003, Meijo University's graduate pharmacy program was reorganized into two majors: Clinical Pharmacy and Pharmaceutical Sciences. Paralleling basic research courses for Clinical Pharmacy, a course of Clinical Pharmacy Skills was incorporated into Clinical Pharmacy Course and offers practical training in advanced clinical pharmacy practices. This course focuses on practical, clinical pharmacy education and offers instruction in medical settings. It continues and develops a one-year course of clinical pharmacy practices with individualized pharmacy practice instruction that had been offered at Meijo University for 28 years.

The graduate school's new educational philosophy emphasizes the importance of pharmacotherapy at clinical sites where pharmacists take responsibility for medications and learn how to interact with patients. Almost two-thirds of the two-year graduate curriculum involves practical training in clinical settings. As they study individual cases, students become skilled in problem finding and solving. Practical training is also enhanced as students engage in self-directed learning through Problem Based Learning (PBL) tutorials and study communication skills.

Since Meijo University does not have its own medical facility, it turned to the medical school at neighboring Fujita Health University for assistance in the clinical training of pharmacy students, and with their cooperation both universities formed an affiliated medical-pharmaceutical graduate school. Pharmacy graduate students at the Meijo University are now part of the medical care teams at Fujita Health University Hospital and are able to participate in their daily activities. They are guided and instructed by both of the medical faculties and pharmacy faculties and have broadened their education. With the entire hospital as their workplace, students can expect a thorough training in clinical pharmacy skills. Interdisciplinary education is very important, and this inter-university approach provides a nationwide model that shows other private pharmacy schools without medical schools how they can train clinical pharmacy skills to their undergraduate pharmacy majors and graduate student pharmacists (Figure 1).

Pharmacy graduate students at the Meijo University attend a Satellite Classroom set at the Fujita Health University. Pharmacy graduate students at the Meijo University attend a Satellite Classroom at the Fujita Health University. Here, pharmacy students participate in clinical conferences, and medical faculties and pharmacy faculties exchange ideas with students. Because of the satellite classroom's many benefits, further expansion like cooperation between clinical medicine and pharmaceutical science may be expected in future. This successful affiliated program is a model for other private pharmaceutical colleges without a medical school.

2. Improving skills with an expanded clinical pharmacy education

Meijo University's objective of clinical pharmacy skills training in clinical settings originated in its one-year course. Its goal was to comply with public requests and provide education that allows pharmacists to improve their performance by participating in a medical team. In April 2003, the graduate clinical pharmacy major was revised and expanded, and a specialized course in clinical pharmacy skills was developed to allow pharmacists to work alongside medical students and interns in bedside training. A distinguishing feature of the clinical pharmacy skills course is that undergraduates who take "medical ethics", "knowledge of clinical medicine", and "drug information practice" are trained in Master's course for two years as clinical pharmacists specializing in pharmacotherapy support services. The course teaches them to understand the physician's medical plan for the patient's condition and support it with appropriate pharmacotherapy. Special features are:

• (1) Students learn important communication skills that are necessary for gathering illness-related information from patients.
• (2) Students work with PBL tutorials and practice "active learning" as they study important related topics such as "advanced topics in clinical pharmacotherapy" and "advanced topics in clinical pharmacokinetics".
• (3) Students complete fifteen months of clinical training at the hospital of the affiliated university.

To summarize: clinical training provides a total of fifteen months in eight hospital departments, hospital pharmacy, and nursing field. Students are trained alongside medical students and interns in the wards and outpatient areas, and are instructed by senior medical staff.

Figure 2 summarizes the schedule for the clinical pharmacy skills course curriculum. In the course, we intend to train clinical pharmacists with a high level of knowledge and skills in pharmacotherapy. Particular emphasis is placed on the nurturing of pharmacists who will play a leading role in the health care field. The other curriculum contents are as follows;

• Drug information practice (30hours),
• Statistics/Pharmaco-epidemiology (30hours),
• Clinical laboratory data analysis (30hours),
• Pharmacokinetics/Prescription analysis (30hours),
• Therapeutics by lecture and PBL (30hours),
• Herbal medicine (30hours),
• Communication skills/Medical ethics (30hours),
• Medical english (30hours),
• 15-month of clinical clerkship including hcspital pharmacy practice training,
• two weeks of oversea clerkship under cooperation of Samford University and University of Southern California in the US,
• and one week of Nursing skill training.

3. Clinical communication skills and the introduction of OSCE

It is very important that graduate students take "advanced topics in clinical communication." In the course, students interview simulated patients, and identify themselves with them psychologically and make effort to get accurate information of patient's condition. Simulated medical interviews allow pharmacists to learn many skills in the work setting. Good patient skills are essential in a clinical setting and a well-conducted medical interview can yield valuable understanding of an illness. Students learn these important skills as they role-play pharmaceutical/medical interviews.

At the end of the course, OSCE (Objective Structured Clinical Examination) is used to evaluate the students. OSCE is now universal in school of medicine now, and the school of pharmacy finds now OSCE invaluable as a means of assessing specialized pharmaceutical knowledge, communication skills and attitude. To ensure the test's objectivity, it is administered and evaluated by faculty staff from other universities in a third-party review, and results are made available publicly. At the test site, the graduate student assesses the standardized patient (SP) and makes an appropriate response. The response is evaluated by the pharmacy and medical school examiners and immediately discussed with the student. Once he/she passes the test, the graduate student moves on to clinical training in clinical setting (Photo 1).

4. The introduction of PBL tutorials and the development of resources

Problem-based learning is a well-known and especially effective skill for integrating medical information from a patient in clinical field, finding problems and solving them. Meijo University introduced PBL tutorial education to clinical pharmacy education in 2001. Much effort was invested in educating and training tutors and sending them to foreign and domestic conferences and seminars. Faculty from fellow academic-exchange participants USC and Stamford University were invited to give talks and presentations on PBL learning.

Samford University in particular was highly supportive and provided access to the teaching materials it had developed on its own. PBL encourages individual participation in learning and is very effective in combination with traditional forms of learning. Meijo University graduate students find PBL a valuable resource that prepares them for real-life decisions as they work with patients during their clinical training. They learn to translate knowledge into practice and find/solve the problems that they encounter. By fostering such skills, PBL prepares students for their future lives as clinical pharmacists and the myriad of problems they will encounter. Face-to-face with the issues of the health care field, they will be grateful for their training.

5. Strengthening clinical training by working as part of a health care team at an affiliated medical-pharmacy graduate school

Meijo University does not have its own independent medical facilities or clinical training hospital. Through its contractual association with Fujita Health University, it has created an inter-university affiliation that provides clinical pharmacy education and advanced medical care. Meijo University graduate students are part of a health care team and learn to be pharmacists from this enhanced perspective. They have clinical training in the divisions of General Internal Medicine, Cardiology, Endocrinology, Gastroenterology, Respiratory Medicine, Hematology and Chemotherapy, Gastroenterological Surgery, and Emergency and Critical Care Unit.

The medical doctors who chair these hospital divisions hold concurrent posts as professors at the pharmacy school and share responsibility with the pharmacy school's faculty for the clinical training and education of its graduate students. The nursing division supervises the students in one-week of nursing experience and the pharmacy supervises their six-week training as pharmacists.

The clinical trainee is first assigned to the dispensing pharmacy at Fujita Health University Hospital and then to the nursing department and patient care. The student then moves to the seven internal medicine/surgery departments and the GICU, and is in charge of his or her own patients. The student learns on-the-job pharmacotherapy monitoring while working with interns and medical students under a doctor who has primary responsibility. Under the cooperative supervision and instruction of the doctor, the head of the hospital pharmacy department and the pharmacy school instructor, the student is part of a medical team and learns the duties of a pharmacist.

6. The satellite classroom for clinical pharmacy

The graduate clinical-pharmacy majors in the clinical skills course work with doctors, patients and nurses in the hospital wards. There they learn the role and responsibilities of pharmacists as they study pharmacotherapy and drug prescribing intention for patient.

The satellite classroom is located within the medical school. Meijo University's clinical pharmacy satellite-classroom brings together the disparate fields of medicine and drugs, and is the first in Japan to provide a clinical pharmacy education in another university's medical facilities. The classroom serves multiple functions in the students' education. It provides a setting for the faculty of both institutions to meet and study, and provides space for clinical conferences, seminars, resource research and independent study. The pharmacy school faculty share rotating responsibility for the classroom, deal with any problems and ensure a smooth interface with the school of medicine.

The pharmacy school faculty sees the classroom as an excellent opportunity to get out of their studies and laboratories, interact with the medical faculty, and find fresh material for their undergraduate classes. Pharmacy faculties who participate in clinical conferences at the satellite classroom renew their knowledge of clinical training. The clinical skills course provides an opportunity for the on-duty pharmacy faculty to talk with graduate students and medical school faculty. As they attend the combined medical-pharmacy clinical seminars and other events, the pharmacy faculty broadens their viewpoint. Pharmacy faculties often find that their specialized fields cast a fresh light on a clinical pharmacy issue, and they leave the classroom with a heightened sense of appreciation. With the new setting, they faculty has been given a wonderful opportunity to create "a clinical field for pharmacy" for their own field of specialization.

The long-standing distance between "medical" and "pharmaceutical" has lessened, but there is still much to be done. This interaction between the two fields serves Japan well. As part of the future transition to a six-year program, an increasing shift to clinical training is desirable. With all of these benefits, the satellite classroom has shown how well it can provide a clinical education to students of a pharmacy school without its own medical school. Clinical pharmacy is an interdisciplinary field, and use of the satellite classroom opens up new avenues of medical and pharmaceutical interaction (Photo 2).

7. International Exchange

Clinical pharmacy originated in the United States in the 1960s as a new field that would equip pharmacists with broader skills. Clinical pharmacy education trains pharmacists to provide doctors and patients with safe and correctly used medications, and it differs from Japanese traditional basic pharmaceutical research focusing on the development of new drugs.

Since 1975, Meijo University has promoted and developed clinical pharmacy education by encouraging study abroad and sending students and faculty to the University of Southern California's progressive pharmacy program. The University concluded academic exchange agreements with USC, Los Angels California in 1993 and Samford University, Birmingham Alabama in 1997. In line with its new program and global emphasis, the graduate school now offers overseas clinical training as part of its curriculum. Second-year Master's students spend approximately two weeks in the overseas clinical training program. Their objectives are

• a) participation in clinical training with American pharmacy students in professional grade 4,
• b) an understanding of how medical teams function,
• c) training in patient communication, and
• d) participation in clinical pharmacy lectures, seminars and other activities.

In addition, the exchange program allows faculties of USC and Samford University to alternate with the medical faculties and give seminars in the satellite classroom at Fujita Health University. Both of University faculty is invited to visit Meijo University and participate in the satellite classroom and other clinical training activities.

On these occasions, Meijo University graduate students benefit greatly from the clinical conferences and discussions that reflect current clinical practice, from the participation of the medical preceptors and from the chance to hear specialized English. US students can now receive Clinical Clerkships through the Meijo University- Fujita Health University graduate program. Planning is also underway for clinical training exchanges between Japanese and American students. Overseas training is another benefit of the inter-university approach.

8. Future prospects: clinical training for practicing pharmacists

Medical care is making remarkable advances and the clinical pharmacy skills course has vitalized the connection between medical field and pharmaceutical field. Meijo University has the opportunity to open the door for practicing pharmacists to learn new pharmaceutical skills and understand many issues whose resolution will benefit society. Education will keep pharmacists abreast with the increase in specialized knowledge. The various issues that pharmacy practitioners confront in the health care arena must be research materials for pharmacy scientists. Their solutions will be research subjects for pharmacy scientists in School of pharmacy.

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